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HomeMy WebLinkAbout0020 CINNAMON LANE - Health 20 Cinnamon Lane y Osterville P A _ 165 109 n t; . • . ��5-ice " Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r— �M 20 Cinnamon Lane Property Address r"°a Robert Wilson ) Owner Owner's Name -0 information is required for every Osterville Ma 02655 - 7-9-2018 page. Cityrrown State Zip Code Date of Inspection " Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, , use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return key. Name of Inspector B&B Excavation 4:1 Company Name 374 Route 130 Company Address , Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-9-2018 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. k **""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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Cinnamon Lane Property Address Robert Wilson Owner Owner's Name information is required for every Osterville Ma 02655 7-9-2018 page. Cityrrown 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: The system was in working order at the time of 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. r 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 yy 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 20 Cinnamon Lane Property Address - Robert Wilson Owner Owners Name information is required for every Osterville Ma 02655 7-9-2018 page. City/Town 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): • M ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken'pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: El 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 d Title 5 official Inspection Form - Title Sewage Disposal System Form -Not for Voluntary Assessments M ,•''t 20 Cinnamon Lane Property Address Robert Wilson ` Owner Owner's Name " information is required for every Osterville _ Ma 02655 7-9-2018 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) , 2.'System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply welt. ❑ The system has aseptic 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: N 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 El ®, clogged SAS or cesspool ❑ a ® ' ` 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 s ❑ ® or clogged SAS or cesspool ' Liquid depth in cesspool is less than 6" below invert or available volume is less �. . ' ® than '/z day flow t5iris-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 20 Cinnamon Lane Property Address Robert Wilson Owner Owner's Name information is required for every Osterville Ma 02655 7-9-2018 page. Citylrown 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. 0 ® 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. E] ® 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 t ❑ ❑ 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 E] ❑° 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 117 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M o 20 Cinnamon Lane Property Address Robert Wilson Owner Owner's Name •. information is required for every Osterville Ma 02655 7-9-2018 page. Cityrrown State Zip Code Date ofInspection C. Checklist Check if the following have been,done. You must indicate"yes" or"no" as to each of the following: Yes No I [I ® Pumping information was provided by the owner, occupant, or Board of Health ❑ Z 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? E] ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system i® ❑ p y obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? -® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® • ❑. Existing information. For example, a plan at the Board of Health. :® ' Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(Actual) _3 330/GPD . DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Cinnamon Lane / Property Address + Robert Wilson Owner Owner's Name information ad fo is Osterville Ma 02655 7-9-2018 required for every page. CitylTown State Zip Code Date of Inspection D. System Information Y • 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.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� • Detail: 2016- 141,000gallons 2017- 106,000gallons .Sump pump? ❑ Yes ® No Last date of occupancy: Off and on Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: :Sins•3/13 S Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 F Commonwealth of Massachusetts ^ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Cinnamon Lane Property Address Robert Wilson Owner Owner's Name information is required for every Osterville Ma 02655 7-9-2018 ;page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Owner-date of last pump is unknown 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 •r Ej Tight tank. Attach a copy of the DEP approval. El 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 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Cinnamon Lane SV Property Address Robert Wilson Owner Owner's Name information is Osterville Ma 02655 7-9-2018 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) r Approximate age of all components, date installed (if known)and source of information: 1998 Were sewage odors detected when arriving at the site?- ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: t ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 8„ Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years a Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No i Dimensions: 1000gallons 3 Sludge depth: [Sins•3/13 :, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts '. W Title 5 Official Inspection Form �m Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 20 Cinnamon Lane Property Address Robert Wilson Owner Owners Name information is Osterville Ma 02655 7-9-2018 required for every page. Cityrrown 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 011 . Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle NS How were dimensions determined? r '. 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.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is not in need of pumping at this time but should be pumped every two years for maintenance. Grease Trap(locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness w Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments �M 20 Cinnamon Lane h Property Address- Robert Wilson Owner Owner's Name information is required for every Osterville Ma 02656 7-9-2018 page. Citylrown State: rt 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.): Tight or Holding Tank(tank must be pumped`at time of inspection) (locate on site plan): Depth below grade: 4 NA Material of construction: + ❑ concrete' c❑ metal #, ❑ fiberglass ❑ polyethylene ❑ other(explain): , + r Dimensions: - r Capacity: ' gallons x Design Flow: gallons per day Alarm present - ❑ Yes ❑ No. Alarm level: - Alarm in working order: El Yes ❑ No ` Date of last pumping:. Date ; • Comments(condition of alarm and float switches, etc.): :A a S . io '• - ,fir .. - - , Attach copy of current pumping contract(required). Is.copy attached?• ❑ +Yes ❑ No t5ms 3/13'F p Title 5 Official Inspection Form:Subsurface Sewage Disposal System x Page 11 of 17 . N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Cinnamon Lane Property Address ; Robert Wilson t Owner Owner's Name information is required for every Osterville Ma 02655 7-9-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) ; Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box is in working order at time of inspection with liquid level equal to outlet invert. D-box did not show signs of back up. 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 j * 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: t a t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Cinnamon Lane Property Address Robert Wilson Owner Owner's Name information is required for every Osterville Ma 02655 7-9-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) 500 gallon ❑ leaching galleries number. El leaching trenches number, length: . ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system.. Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.): Leaching was in working order at time of inspection with no sign of hydraulic failure. Leaching was full when viewed. i . Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): F Number and configuration NA 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 20 Cinnamon Lane „ Property Address Robert Wilson Owner Owner's Name information is required for every Osterville Ma 02655 7-9-2018 page. Cityrrown 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.): K Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): a Y I s r ' - _.. ~ �• '{ .� a •• ti _ ,f ' M ' e. •s F, , + / .tea ` � . ' ,fiii. � ... - 4 1 ♦. { t5ins•3/13 a Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Cinnamon Lane Property Address _ Robert Wilson Owner Owner's Name information is Osterville 4 Ma 02655 7-9-2018 required for every - page. Citylrown 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 REAR • -. B , C ' fir✓' , Al-3W B1-15' • C2-34' D2-40' C3-39' 133-39' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Cinnamon Lane Property Address Robert Wilson Owner Owner's Name information is required for every Osterville Ma 02655 7-9-2018' page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check celllar ®" Shallow wells ' Estimated depth to high ground water: No GW @ 12' 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: 7-8-98 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: Checked with local excavators,El Checked e ca ators, installers (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high groundwater elevation: Plan on file with BOH. 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 . I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . �M 20 Cinnamon Lane Property Address Robert Wilson , Owner Owner's Name information is OSterville required for every Ma 02655 7-9-2018 page. Citylfown State Zip Code Date of Inspection E. Report Completeness Checklist y ® 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 x46P lOr-Iq Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Roperly Ate ON ner rt um is avner's /} �` / DaZ S^ mquredforevery T C/�4el�y i ! �/ per. Cdyrrown State Zip Cod Date pm* Inspection results must be submitted on this form. Inspection forms may not be aMered in any way. Please see completeness checidist at the end of the form. A. General Informaiaon _ 16 74 6 CM the comer, use o*thetab 1. Inspects: key to nave yourcuisw-do not use the mtum Name of Inspector� ODnp8q Name49,41 Company Address ,9 OoG t, � • ZIPODde ayrtown� ago-2290 site C O Tt ptrone tuber License NwTW B. Certification 1 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 W40 of Tltie 5(310 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ feeds urther Evaluation by the Local Approving Authority Irispectee Ssat= o The sy em 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,OW.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 K and copies sent to the buyer, if applicable, and the approving authority. • .el'Ki ** This report only describes conditions at the time of inspection and under the conditions of use C, at that time.This inspection does not address how the system will perform in the future unde '�- the same or different conditions of use. ' tft-3M3 Yf Tif50fWdIMPOOftFO=SUOsu=$9VMeOispasidSO= P09e1Of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DWial System Form-Not for Voluntary Assessments Q /N✓!cj W10 H /L Property Address I /.S o V7 kdormadon is cwner requiredv/ oa 6 S.� 3 a s forevtay drown State Zip Code Date of pecta B. Certification (cunt) Inspection Summary: Check A,B,C,D or E/a/wayscomplete all of Section D A) ni sses.ve not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ one or more system components as described in the'Conditional Pass'section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. . Check the box for`yes%'."no°or`not`determined'(Y,N, ND) for the following statements. 9'not determined,"please exVn. The septic tank is metal and over 20 years old'or the septic tank(whether metal or not)is stnichtrally unsound, exhibits substial infiltration orexfiltration or tank failure is imminent. System will pass inspection if the existirV tank is replaced with a complying septic tank as approved by the Board of Health. *A mewl 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): t5m•M3 T&e 50fbcW ImpeotiaeFort Subdriaw SmVeofsposd Sy.*m•FVe 20f 17 Commonwealth of Massachusetts Tide 5 Official Inspection Form Subsurface Sewage Disposal System Form 'Not for Voluntary Assessments Property Address � Owner Owner's Name / Cr fnform4ion is , re**edforevery Pam• Cky/Town State Zip Code Gate ca tion corgi. Cert�fi B. ) F ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpstalanns are repaired. , B) System Conditionally Passes(cunt.): Observation of sewage backup or break out or high static water level in the distribution boot 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): p broken pipe(s)are replaced ❑ Y [I N ND(Explain below): 0 YP. ❑ N ❑ ND(Explain below): p obstruction is removed . i leveled or replaced (D. Y ❑ N' a O' ND(Explain below): ❑ distribution box s PI 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 F ❑ Y Cl`:N .ND(Explain below): p .. obstruction is removed ❑ Y N ❑ ND(Explain below): r a, 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 1&303(1)(b)that the system is not functioning in a mannerwhich will protect.public health, . safety and the environment: p Cesspool or privy is within550 feet of a surface water , Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh 15ns•919 7ite5OM9 kspW Fare[S1 WWface SeWgemW=dFSyMM-PW 3017 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage 11sposal System Form-Not for Voluntary Assessments J' o Prop"Address o ✓I infom on is �"N oar's Name //,,,, & /�/� a 6L. 3 (�S' gar reedforevery (��7'�✓v! P Cylrawn State Zip Code Date of In pectic B. Cw ficatron (cons) 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 van 100 to 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 shy. ❑ 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 Anal coliform bacteria indicates absent and the presence of ammOnia nitrogen and nitrate rftMgen 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 "YesP or"No"to each of the following for a_N inspections: Yes No ❑ Backup of sewage into tacil'ity 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 Ie%el in the distribution box above outlet invert due to an overloaded ❑ or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow tars•WS, Title somw bspecreao Form SUbpjfeoe sWAQeDlsDosd SYdem-Pae 4of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth Not for•Voluntary Assessments �.0 G r/1✓ice✓'�o17 �- property Address Owner Owner's Name D� f��l 6 L-2)�o fss 0� inforrrta�On's Q requaedforevery State �Code Date of pec#i n Pa", C�y/fown -B. Certification`(cost.) 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 I� 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. ❑ �7 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.] ❑ 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:acove 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%j hat will be necessary to correct the failure. E) Large Systems:,To be considered a large system the system must serve a,%CI ty 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 l ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑, ❑ the system is within 200 fleet 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 if of a public water supply well 9 you have answered yes'to any question in Section E the system is considered a signifrc W threat, or answered yes-in Section D above the large system has failed.The owner or operator of.arry large system considered a significant threat under Section E or failed under Section D shall upgrade the system in act with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Ism- 3 r4050fidgl ImpeCUMFam ytippafxeSerfigeDWpWd Sy5jem•Rage 66M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments C�o G�ovig"10 V Property Address IfforweMon is m o wforem C�y/Town State Zip� of Oate ' n Palms C. Checklist Check if the following Have been done.You must indicate"yes'or°no°,as to each of the following: Yes No ❑ ping information was provided by the owner, occupant, or Board of Health ;""�❑ Were any of the system components pumped out in the previous two weeks? ❑ 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 WA) 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? size and location of the Sore Absorption System(SAS)on the site has n determined based on: ❑ Existing information. For example, a plan.at the Board of Health. Determined in the field (d 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 (actual). ? Number of bedrooms (design): k DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t s-�13 rise50r5cWtmpzftFcrmSubsufaceSewage sYmm-Page W17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Roperty Address t'll o Owner Ow nets Name iftforfrelimis requirWforevey Ckyfrown State Zip Code me aF to spectio D. System Information Description: / /000 6z`/u,7 SP Tl C_ Tom►h lv 4"j a Tl 0-•1 Number of current residents: Does residence have a garbage grinder? J ❑ Yes C9" No is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes f No information in this report.) Laundrysystem inspected? ❑ Yes L`l No al- Seasonal use? Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: •Sump pump? � ❑ Yes No - Last date of occupancy: Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): - Gages per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No . Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: rf5 M-M 3 TAIe 50ffidal hspec6m Fort Subwf=9 Sw&W D4o8d Sy.hem-P.ge 70f 17 ' x ,f a • Massachusetts of Massa Commonwealth Title 5 Official Inspection Form menus Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ftpertyAd&M �A/l /So owner ow ner's Name VOA 66 J emfornnftn -�2�V/ -- Dare of P re**Wforevery c�yITown Stabs F� Paw D. system in on (cons.) Last date of occupancy/use:' •F' Date Other(describe below): x General inforrnabon Pumping Records: Source of information . Yes No was system pumped as part of the inspection? ❑ ❑ K yes, volume pm ermped: gaWns Howwas quan*pumped determined?, Reason for pumping: t Type of m. Septic tank, distribution box, soil absorption system„ a �.. Single cesspool 5 [� Overflow cesspool i Privy Y , es or no) (if yes, attach previoiu p Strayed system(yes inspection records,if any).r ❑ ;a Irinovative/AltemaUve 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 VA system by system operator under contact Y F ' Tight tantc.Attach copy of the DEP approval. 3 0 Other(descri be): g osSofftWkopecBm Form subwfaceSeaveD' SYSOm•FSP$of17*, 15=•3M3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a o �vq� �o� �. ftperty Address WAIso � . OwrerinforTrefim is OwnerS NWM . /Mow POP. forevery CRyfrown State Zip Code Oahe of D. System Information (cons) Approximate age of all components, date installed(if known)and source of information: l -- s Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer pocate on site plan): Depth below grade: feet Material of construction: , ❑ cast iron .40 PVC ❑ other(explain): �® T Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, e4dence of leakage, etc.): / Septic Tank(locate on site plan): Depth below grade: feet Material traction: C concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) itank is metal, list age: years is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: SM•M3 TWe5Oftd 1mPOcft Fcrm 8ubsuface SeaMeD7sposd SyMm•Fags M17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments R•o"Addness I kftrr� ON �'On's ner's ivarrte regtdred for every `S "'l�V! State Zip Code We — Pa". CRyfraam of D. System Information (coat.) Septic Tank(cant.) 1 to bottom of outlet tee or baffle Distance from top of sludge -::�C4 � 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 741e A How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition,stntctural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): A'L14 M 1✓1 AD C N L LI NG S !✓1 ' Oo ri `flvr �/ 7�10 4,< Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last purr ping: pate i. ISM•= rme 50fk at trspectiw Fare 9jbwfaoe Sewage Dispose)system•Page'lO d t7 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c;?,- G�O aV4,0 ol ftp"Aftm ly 0y ON rw ow Hers gameirdomuftn is pa�F requerrdforeverye Tip codGabe of n p atyfrown D. System Information (cons.) Commends(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): light 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: s Design Flow. gasm per day Alarm present: ❑ Yes ❑ No. Alamr level: Alarm in working order. ❑ Yes ❑ No Date of last humping: Date Comments (conddion of alarm andfloat switches, etc.): *Attach copy of current purr ping contract(required). Is copy attached? Ela Yes ❑ No Sas•3N3 True 5of dditpeetionForm SlbstrfewSw geWpwal Symm•Page 11 d 17 F' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Ow net ON rler's Warne 0� J �v` �a infornation is •ij/ ` ��� regr�ed for every ��own _-- Stste (de Date of ors ton Pam• D. System Information (coat.)` ; 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,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): o � Lem S Pump Chamber(locate on site plan): , R No*Pumps in wonting order Yes ❑ t E. 4 , Alarms in working order ❑ Yes ❑ No; . chamber, condition of pumps and appurtenances, etc,): Comments (rite condition of pump.. , , , If pumps or alarms am not in working order,system is a conditional pass. Soil Absorption System (SAS)(locate on site pion, excavation not required): - 9 SAS not located, explain why: o , , tomes-313 . TitlesoF6ew impW6W0mrt Subw0ace Sewage mposa son-Pap 12 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments LAll" Roperty Address L-A ©'vI info Om ners Nam �s- �,/l� �4 o� 6,ss 3ks-11-3 �forrmtiats reqtdredforevery frown Zip Code Gate of Me- Cly D. System Information (cont,) Type, S oo. 6�', 1/0�► ( �"►�,S s ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fief number, dimensions: ❑ overflow cesspool number ❑ innovative/aftemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): A/0 sl hs /'/67 I Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of lkpdd to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of cation Indication of groundwater inflow ❑ Yes ❑ No tree•3H3 Tive50t3dd hsp6C#WFam[submeme smoe mposd symm•Rve 13 d 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C_ 1✓�I�G v�o Z_ Ftoperty Addnos ON nor ON nees Nave m � �v� oozc,�s:. 3 as 1� forevery per— �y/T own State�i Zip Code Date oplopectionD. System Informadon (cont), Comments (note condition of soil, signs of hydraulic failure,:level of ponding, condition of vegetation, etc.): Pi Privy(locate on site plan): Materials of constriction: Dimensions Depth of solids v _ Comments (note condition of soil, signs of hydraulic failure;,level of ponding, condition of vegetation, etc.): ffis•ana 71sesomcid bspeeticnFamt sub%fffw9SnepDiV=W syssn•Page 14of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments o C(KV1 R via V1 Z-/f/ RopertyAddrew, �V/l 10 ON nor Om ner's N me infoml dfo is �s- e� requeedforevery page. Cky/rown State Zip Mode Date of n D. System Information (cons) Sketch Of Disposal System: Provide a view of the sewage disposal system, including ties to at least two anent reference landmarks or benchmarks. locate all wells within 100 feet. Locate where c water supply enters the building. Check one of the boxes below. hand ketch in the area below ❑ drawing attached separately C4/ • t /0 a S /T1 15es-W3 Tme50F§aalkspeoftFem[Subwface Sewage Disposal System•Page 15 d tt ' 4, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C Rq"Address e L'al)�Owner ON Ws Name leftmahm is /� requiredfaevery v f [�V�6 Ile— PICO. �Stpate Cty/Town "Zip Code We of 16speeft D. System Information (cons) Site Exam ❑ Check.Slope , ❑ Surface water. ! ❑ Check cellar ❑ Shallow wells , Yy Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record Nchecked, date of design plan reviewed: Date ❑ served site(abutting property/observation hole within 150 feet of SAS) Checked with jogo 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: • /I J �S /J Before filing this Inspection Report, please see Report Completeness Checklist on next page. tStS•3M3 TOO 50f5W 1MPW1CnFerm SAMOA=Sn%eDWpmd SyMm•fte iS cr 17 / r CommonweafEh of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Q Gt media✓"/o� .Lit/ a°aer Adam h/, /So✓� Owner OmndsNvre a OS-tev�,,4Ile Od 6,9 S/d&,b� mpiredp forway Cld'rown a ZIP Code Date of kn camp E. Report Completeness Checklist p' Nsp +Summary:A; B, C, D, or E checked 216-pection Summary D(System Failure Criteria Amicable to All Systems)completed EY's-lystern Idvmation—Estimated depth to high groundwater El Sketch of Sewage Disposal System either drawn on page 15 or armed in separate ft a , VW-ins rmesorWd trspeeamFa M SUbMt= SP"-RNP 17 of 17 y ' pfTKEro�,, Town of Barnstable Office: 508-862-4644 Fax: 508-790-6304 Regulatory Services Department Public Health Division ��y „As • Thomas A.McKean,CHO Arlo Mpg a 200 Main Street,Hyannis,MA 02601 Payment Receipt Septic Inspection Payment received: $25.00 (Check) on 4/14/2015 Permit number: 10760�� Check number: 1541 Check amount: $25.00 =Name on check: Robert M. Wilson Owner: ROBERT M TR WILSON Address: 20 CINNAMON LANE,Osterville Y, Y . it Y Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a_�_��✓1 a �dv� _�a��. Property Address Owner Owner's Name Information is ps-�e e, (2o &55 TM� � /j required for every page. City/Town. State Zip Code Date of Inspe n _ 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. p°'filling out t W fl hen A. General Information W forms onn th- ,computer,use 1. Inspector: ,M only the tab-key _ 1► / / �/ to move your cursor- use the do not Name of Inspector -- --------- ^ _~-- ----� ret key. _. Z/(/l��d I �Grn Nf I rr I 1 Company Name1y o �0<V Company Address L--�S �►a sM Oa 6 City/Town State —�� Zip Code Tel-P hone Numb -� ~� License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of "A ter. Title 5(310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails VIC ❑ Needs Further Evaluation by the Local Approving Authority cc Inspe'gtt6es Signa a 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-11/10 LT'M�0[5 VIF.:Subsurface Sw"DWpoael SyAn•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ` o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments z Property Address �/i•lSvh Owner Owner's Name required nIs O��rV1l/9- �� O�GsL /0/4 y d, required for J every page. CKy/Town State Zip Code Date 6f 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: 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•11/10 Title 5 Official Inspection Form:subsurface sewage Disposal system•Pape 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 7 "�'D / tooar 1ao Z-4 Property Address Owner Owner's Name / Information Is Os-4e�-v!`/�� told-y hat required for --- every page. Cityrrown State Zip Code Date of Inspeofion B. Certification (cont.) B) System Conditionally Passes (cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh W"•I M o TItN 6 Oftial Inspootlon Form:Subwdoee Sewage Disposal System•Papa 3 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments —),o. G,�1✓1G w►o� �_ Property Address Owner Owner's Name information is required for Ocs ' ` kV A� _ �%1 Qo�6 5..7 �O�oZ 114 _ every page. Citylrown State Zip Code Date ofAnsP ectl n B. Certification (Cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of'a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well", Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all Inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than'/day flow Ons•11/10 Tide 5 Official Inspecdon Form:Subsurraw$**a gs olgp l sye6em•Pep*4 off? Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property AddressOwner Owner's Name Inforrequired aeon Is rv,< `4- /j O� S J� /04 //0,)- everyrequired for �__ ,�T� ��/7 page. Cityrrown State Zip Code Date of I spectl n B. Celydfication (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: ❑ [t� 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. ❑ L� 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.] ❑ ❑/ he system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure, E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. tSins•11110 Title 8 Official 1 nspectlon Form:Subsurface Sewepe Dleposel SyeEarn•Pape 5 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments go C0V1G ��� Property Address Owner Owner's Name t information is !�S TC'►rlil ` l� 4 Op[ fo >� �0 02 required for ��• _. every page. Cfty/Town State Zip Code Date of(nspeco6n 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 ❑ L" Were any of the system components pumped out in the previous two weeks? ❑ 2 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? 1 ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) L"1 ❑ Was the facility or dwelling inspected for signs of sewage back up? L7 ❑ Was the site inspected for signs of break out? [7 ❑ 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 15.3O2(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): --- Number of bedrooms (actual): - -- 3.3a DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 61ne•11/10 TO 5 Official Inspection form:Subsurface Sewage Olsposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address Omer V_. Owner's Name / Information Is 0, 4e fl/j f ,o /�j oa 6 ss ld o)Yt �oZ required for _ Ton— every page, Clty/Town state Zip Code Date of Inspe on D. System Information �G�� -l.e,, Description: a SC Gallo ► Number of current residents: Does residence have a garbage grinder? ❑ Yes ff"No Is laundry on a separate sewage system?(if yes separate inspection required] ❑ Yes ET"'No Laundry system inspected? ❑ Yes [T�No Seasonaluse? Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump.pump? .�.._ .�.._._._�.__.....�_� ..�._.._.�...._ El Yes No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: - -------- Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes.❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t$lns-11/10 Us 5 OtAdal Inspection Form:Subsurface Swap Dle mi system-Pape 7 of 17 Commonwealth of Massachusetts WTitle 5 Official Inspection Form ,'?-0 614 Y7" -'1' Subsurface Sewage Disposal System Form• Not for Voluntary Assessments Property Address ("///I/S 0 0 Owner Owner's Name Information is required for _ /d Wo every page. CIWTown State Zip Code Date of Inspecti n D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: P 9 Source of information: - - ' Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of stem: 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): t5ln9.11n0 TO 3 QVWl ftpecft Form;auowrrace sewage system.Page a a» f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address ls� Owner owner's Name Information is required for every page. Cityrrown State Zip Code Data of thopectidn D. System Information (cont.) Approximate age of all components, date installed (if kno n) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes R-�o Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑other(explain): /O Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material construction: concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate ❑ Yes ❑ No Dimensions: Sludge depth: t5im•11/10 TM*6 Of dal MspecWn Form:Subsurface Sowapo DWpwW System•Pago 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address Owner Owner's Name - information is required for —.—— 4-�K 6L._.� /��4 Od 6,!5-3- /o/.2 every page. City/Town state Zip Code Date of I spection D. System Information (cont.) Septic Yank (cunt.)� 2�4 Distance from top of sludge to bottom of outlet tee or baffle -- Scum thickness Distance from top of scum to top of outlet tee or baffle it Distance from bottom of scum to bottom of outlet tee or baffle ea! /Lle . �a aL¢ How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels asrelated to outlet invert, evidence of leakage, etc.): P(-,(VVI 17 ak44, 41110JS Grease Trap(locate on site plan): Depth below grade: feet " Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum'to top of outlet tee or baffle — - Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t61ne 11l10 TWO$0mcial I nspoctlon Fan:Subewface Swvsp Dbposm System.Fape 10 of 17 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address Owner �_,__. W /•%(� Owner's Name information Is required for �� ✓(�` /�� ��6 J�J/• l� �� every page. City/Town State Zip Code Date of Inspectl6n D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: — Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day ` Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No tbins•11/10 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form•Not for Voluntary Assessments Property Address Owner Owners Name —1--_// requV dfo Is a` / �' �nlo2 t f `� required for b every page. Cityfrown State Zip Code Date of inspection D. System Information (cunt.) 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, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ISlns•+tNo Titlo 5 ORicial Inspodlon Fam:Subsurface Sewage Dks o System-Pop 12 a» Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form a Not for Voluntary Assessments c�z L10Y7A V$700 MOMMM IV Property Address Owner owner's Name /� Information is /��-1�r/�/� Ae a)6 SS G//0 required for v State Zip Code Dated in peotlon every page. CitylTown D. System Information (cont.) type:❑ leaching pits number: ❑ leaching chambers number: ❑ 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.): oo X<v S:)�f h 41-/N-e 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•I Wo TWO 5 OffxW Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Property Address Owner owner's Name / Information is A4Qp� ss �DId 9 required for ._.._ A z every page. City/Town State Zip Code Date ofinspeofon 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.): esns•11110 $@ i� Rvrrm: rlr � M1�arfi' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property Address / l bs Owner owner's Name / Information Is OS4eI�I/( l l� RY 6J required for every page. Cltyrrown State Zip Code Date of Ihipection D. System Information (cant.) 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: ❑ nd-sketch in the area below drawing attached separately Gf G Sins•t vs o TOO 5 oftiai Wapoebw Form:subturbw Swap DIsMW Sydwn.Popp 15 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments 7 Property Address G✓i S.o� Owner Owner's Name requir atlfo ist/vl `/e Al� oo)-G 5-r l0/C�'�required for ._._._.S/ _ every page. CitylTown state Zip Code Date of 1 ecdon D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells � � ��- Estimated depth to high ground water: -----------�--- -- 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 wdtb local Board of Health-explain: / 4-7S' ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe ow you es blished the high ground water elevation: t/I 'Aoki o Lo l vey,- loc c7t,, � , L as Before filing this Inspection Report, please see Report Completeness Checklist on next page. Sns-11/10 Tide 6 of Wal Inspeadon Fam:Subsuftee Sowape Disposal System-Pop 16 of 17 Commonwealth of Massachusetts fu In Title 5 Official Inspection Form Subsurface Sewage Disposal System Form•Not for Voluntary Assessments ug n � t pl;4 Ly l C✓pro H Property Address Owner Owner's Name ,,rr11 Information Is Q,-�✓(/1/ �/�� Dp2 6��^ 6� 02�f six required for every page. Cityrrown 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 V Sy m Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file thins•11H0 TM*6 Oftial Mspscdon Form:Subsurfaoa Sow"*D4poaal Sy*m•Papa 17 of 17 Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) e Property Address: 20 Cinnamon Lane,Osterville Owner: Vito DeBenedetto Date of Inspection: January 4,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. Cinnamon Lane Water service #20 30 ' 3a 40 15 ,•� 39 34 Co v-ev,-- 191e T41P S incnPntinn FnrrYt A/I VlMn 10 TOWN OF BARNSTABLI` LOCATION �.� �;,1✓I��oh Lei. SEWAGE #u�n5 P_c.�r'c9fe� VILLAG ASSESSOR'S MAP & LOT —Li cj9 INSULIIR4 NAME&PHONE NOtt'� SEPTIC TANK CAPACITY I ticsc� c� LEACHING FACELITY: (type) -dhe-m6-d'5 (size) 500 2CJ Y Z NO. OF BEDROOMS J BUILDER OROMM-R PERIvi DATE: ATE: Separation Distance Between the: 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'facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by qo 3� is G, TOWN OF BARNSTABLE LOCATION Q® CZ&E22246d ZAV SEWAGE # f VILLAGE,-Qm1fiah ASSESSOR'S MAP & LOT - O INSTALLER'S NAME&PHONE NO. � SEPTIC TANK CAPACITY loan 'LEACHING FACILITY: (type) . NO. OF BEDROOMS :off, � _ BUILDER OR OWNER C VCA AT PluzL PERMTTDATE: "Z COMPLIANCE DATE: I - to 49 Separation Distance Between the: 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 facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ., � 1 I 1 f � w - a � � � '��. u ` � �� � ~�f � i 1 .� � ���. r � - TOWN OF BARNSTABLE LOCATION d ,� A A Lk V)CASE WAGE # VILLAGE Q�: Fad ��t '� ASSESSOR'S MAP 6t LOTS CE INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY : LEACHING FACILITY:(type) (size) NO. OF BEDROOMS__J_PRIVATE WELL OR PUBLIC WATER '� . t, A BUILDER OR OWNER tNt Cjt DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ,� ;�_ � _� j S�� ��,, �O.� �� �� �� <� No. E Y Z f:«.. ,.? Fee ✓/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: t/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIPPrication for �Dioozaf *proem Construction Permit Application for a Permit to Construct( Vt Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. ad /t/�Or'!4/�/�j� Owner's Name,Address and Tel.No. Assessor's Map/Parcel ` Installer's Name,Address,and Tel.No. 1w� Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building o No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow .7.70 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 6"91zov � Description of Soil o l ' L Ohm I <f/4q ?�%� � Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Ti e 5 of th viro tal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued is Signed Date 7 el w Application Approved by _ Date 7,� Application Disapproved for the following reasons Permit No. Date Issued -7— %F } No. - Fee _ / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISr19N - TOWN OF BARNSTABLE, MASSACHUSETTS 21pplication for b !6pont *p.5tem Construction J)ertuit Application for a Permit to Construct( ( Repair( )Upgrade( )Abandon( ) O Complete System 0 Individual Components k Location Address or Lot No. Q0 Cl/a/4 0l41AI Owner's Name,Address and Tel.N �rrc��C.� Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Rr� yQ Designer's Name,Address and Tel.No. ao TREL TOPCzR, Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow � gallons per day. Calculated daily flow ✓.�� gallons. Plan Date Number of sheets I r. Reyisi'on,Date Title Size of Septic Tank 000 Type of S.A.S. ts? L s Description of Soil d—! ' L�f}/rl ?d.3 CLAGI TG!-Z <�ArSCO Nature of Repairs or Alterations(.Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and m 'ntenance of the afore described on-site sewage disposal system in accordance with the provisions of T' 5 of t v' o tal Code and not to place the system in operation until a Certifi= " cate of Compliance has been issued is e #d3 ar of Signed Date ^ 8 Application Approved by Date -7 r29'9 Application Disapproved for the following reasons Permit No. ' y Z Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance 4, . THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(I)Upgraded( ) Abandoned( )by 10641 Y077C-_ at a0 C—TAII kn OM IA1 has beenconstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �'� l/ dated 7— ! 9 Installer Designer The issuance of tqs lsemRsfiala tibt be construed as a guarantee that the system ill tion as designed. Date Inspector No. Z O „` ;' Fee THE'COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ligogar *pztem Congtruction Vermit Permission is hereby granted o Construct( )Repair t/)U grade( )Abandon( ) System located at Z U �� ''�R "-V%" ��+ O 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:'Constructtion must be completed within three years of the date of t ' ermit. Date: ( Approved r _Orr - r' f r + I 1119/97 NOTICE: This Form Is To Be Used For the Re' it Of Failed P yOnly. —� Se tic Systems t CERTIFICATION-OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT ENGINEERED PLANS) j a IJ ti I, 7) G / ,hereby certify that he application for disposal works construction permit signed by me dated 7-;Q-6 ,concerning the ' - meets all of the property located at a0 following criteria:IyV There are no wetlands located within 100 feet of the proposed leaching facility { r � r • 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 0 • 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 HW be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. ` Please 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 Di/ision well map) SIGNED: DATE: LICENSEASEPTIC M 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 f �y d •9. y , Ell G 31 d ' p ►� TOWN OF BARNSTABLE q LOCATION _Q0 !C /� L/t/, SEWAGE # l VILLAGE � UI// n' ASSESSOR'S MAP & LOT - O [�` INSTALLER'S NAME&PHONE NO. ,/9Y_ SEPTIC TANK CAPACITY LEACHING FACILrrY: (type) e�, • tl�� f ( �? S LAC NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: -g Y - COMPLIANCE DATE:_ `7 - I o Separation Distance Between the: 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 facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by