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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Deerfield Rd. CD
Property Address 1
Ellen Grasso
Owner Owner's Name
information is required for every Osterville Ma" 02655 5/2/2017
�
page. Cityrrown State Zip Code Date of Inspection °
�s
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.
Impofrtant:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Paul Martin
use the return Name of Inspector
key.
Cape Cod Septic Services
v�I Company Name
350 Main St
Company Address
W.Yarmouth MA 02673
City/Town State Zip Code
508-775-2825 S15016
Telephone Number License Number .
B. Certification
I certifyrthat 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 16.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
a -. 5/4/2017
Inspedor'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•3/13 We 5 official lirispacbm Forth:Subsurface Sewage Disposal System•Page 1 of 17
atd
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is Osterville Ma 02655 5/2/2017
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System in working condition.
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):
M
t5ins•3/13 Title 5 official Inspection Forth:Subsurface sewage Disposal system•Page 2 d 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is Osterville Ma 02655 5/2/2017
required for every
page. cityrrown 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(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
t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 3 or 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2/2017
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 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
Y Pa Y � Pe rY
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 1/day flow
t5ins•3/13 Title 5 official Inspection Form:Subsurface Swage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
'upTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is Osterville Ma 02655 5/2/2017
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® 'Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
` laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes'or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water.supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department
t5ins•3113 Title 5 Official kmpecbcn Fwr(c 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
.:'` 45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2/2017
page. Citylrown 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.
Were as built plans of the system obtained and examined?(if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS,'located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum? .
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems? '
The size and location of the Soil Absorption System(SAS)on the site has r
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): 110x3=
330gpd
t5ins-3M 3 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
45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy- Current
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:
t5iru-3113 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
45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is Osterville ` Ma 02655 5/2/2017
requir9e. for every Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: No records
Was system pumped as part of the inspection? ❑ Yes 0 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/Altemative 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-3113 Title 5 official Inspection form:Subsurtace Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Deerfield Rd.
Property Address
Ellen Grasso
Owner owner's Name
requinform
r on is Osterville Ma 02655 5/2/2017
requiredd for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed (if known)and source of.information:
1989 Per BOH records. ,
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
0'1
Distance from private water supply well or suction line: +
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Line checked with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
Septic Tank(locate on site plan): ,
27,E
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate). ❑ Yes ❑ No
Dimensions: 1250
Sludge depth: 6-8"
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts ,
�3 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cont)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 2-31'
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Estimated
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1250Gal tank in good structural condition. PVC tees in place and clean. Tank at normal operating
level. Inlet cover 6" below grade with outlet 27" below grade.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2/2017
page. Ckyrrown " State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal El fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons:
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 7
Commonwealth of{Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;
45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is required for every Osteryille Ma 02655- 5/2/2017
page. City/Town State Zip Code Date of Inspection '
D. System Information (cont.) .
Distribution Box(if present must be opened)(locate on site plan):
off
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.):
H-10 DB-5 with 1 line in and 1 line out in fair condition. Box is intact. Some solids carryover. No sign
of overloading or hydraulic failure.
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.):
*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•3/13' Title 5 Official Inspection Fong:SuWudace Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Forma
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.' 45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2/2017
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cunt.)
Type:
Cl leaching pits number:
❑ leaching chambers number.
❑ leaching galleries number:
® leaching trenches number, length:
1-3'x40'x16"
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
1-3'x40'x16"leach trench with perforated pipe and stone. No standing effluent in line at time of
inspection. No sign of overloading or hydraulic failure.
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-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'e 45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is Osterville Ma 02655 5/2/2017
Sue. for every Citylrown
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.):
z }
t5ins•3113 Title 6 Official Inspeclion 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
'< 45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is required for every Osterville Ma 02655 5/2/2017
page. Cityfrown 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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewap Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
45 Deerfield Rd.
Property Address
Ellen Grasso
Owner Owner's Name
information is Osterville Ma 02655 5/2/2017
required for every
page. Cityfrown State Zip Code Date of inspection
D. System Information (cunt.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water. +10'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local.Board of Health-explain:
❑, Checked with local excavators, installers-('attach documentation)
❑ Accessed USGS database explain:
You must describe how you established the high ground water elevation:
Hand auger to 10'with no water encountered. Max bottom of leaching is 6'
Before filing this Inspection Report,please see Report Completeness Checklist on next page. .
t5ins•3113 Title 5 Official I nspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Ngw Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments
,..' 45 Deerfield Rd.
Property Address
Ellen Grasso
Owner owner's Name
information is required for every Osterville Ma 02655 5/2/2017
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
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
e
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
III
F� Iir�j TOWN OF BARNSTABLE C�
LOCATION].. �C MtId Qa SEWAGE* �v��ql
5
VMLAGE Ostetu,A ASSE MORI MAP&LOT !GL 3,�?9
INSTALLER'S NAME&PHONE Nofiwx-see Irrvl�IZ� c . 5y�royN
SEPTIC TANK CAPACITY 1250
LEACHING FACIUTY4 tekHr�q TwQ (sire) qo x 3'x JG"
NO.OF BEDROOKS 7 PRIVATE WELL OR PUBLIC WATER ��kG
l$ $AmoSat 4t
BUILDER OR owNFR R R D Ghtt- Q�?�.unt—"- Yha. - --
DATE PERMIT ISSUED: 2
DATE COUPLIANCE ISSUED;__?+ — J/
VARIANCE GRANTED- Yes
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D fie A --�► — "' ---+
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates cost $30.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS
NAME in town (which you must do by M.G.L.- it does not give you permission to operate.) You must first obtain the, necessary
signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FL., 367 Main Street,
1 Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law.
a � �,•s ` � , ; � Fill in please: Date:
APPLICANT'S NAME: _-{ p /
YOUR HOME ADDRESS:
F N BUSINESS TELEPHONE # HOME TE_LELPHONE #:
NAME OF CORPORATION �2E'�Ft° Asti FID #
NAME OF NEW BUSINESS TYPE OF BUSINESS_,j11- e-F4 C
IS THIS A HOME OCCUPATION. �_ .YES NO � 5- — i(p(pr-0 7G�
ADDRESS OF BUSINESS S IJi, C� ;' � � : ce r t G�,� la-2-1 MAP/PARCEL NUMBER
(Assessing)
g)
When starting a new business there are several things you must do to be in compliance with the rules and regulations of the Town of
Barnstable. This form is to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. corner of Yarmouth
o th Rd.
& Main Street) to make sure you have the appropriate permits and licenses required to legally operate o� p q g y p your business in town.
1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of an permit requirements
y p q that pertain to this-type of business.
Authorized Signature**
COMMENTS:
2. BOARD OF HEALTH MUST COMPLY WITH ALL
This individual ha beei=z� �1 AT;^orme of the permit requirements that pertain to this type of business. HAZARDOUS MATERIALS REGUL �!^
_ . rrl�
Authorized Signature"*
COMMENTS:
\` 3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
Date:L
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: (,`e,,,, ( ,' n, JQ
BUSINESS LOCATION: ems— 04641 C-4e DS JZ-�_ WQ,INVENTORY
MAILING ADDRESS: , TOTAL AMOUNT:
TELEPHONE NUMBER:
CONTACT PERSON: ��
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS: e t l 4: ,,
INFORMATION/RECOMMENDATIONS: Fire District:
r
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels - T
(including chloroform;formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash XA
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS ?p�p—l�ric'Aant5/Sii6atu"re Staff's Initial
TOWN OF BARNSTABLE
LOCATION to f �I �tea SEWAGE # .v q/
O q
VILLAGE 0.5f•22U, A ASSESSOR'S MAP & LOT I C'o o �71
INSTALLER'S NAME PHONE NOfiwe'(yz-Ny'+tl65 fmc 5y�1 U1/I
SEPTIC TANK CAPACITY I sZ So 4N '
LEACHING BACILITY:(type) hQfll� 12�MG (si=e)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
-BUILDER OR OWNER R P I H y►tiow�h N'�U• .
DATE PERMIT ISSUED: 72 /
DATE COMPLIANCE ISSUED: � ?�
VARIANCE GRANTED: Yes No
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TOWN OF BARNSTABLE lwl()7cl
LOCATION h 0 1F" 1 J�J �-�/t zc,�t� SEWAGE #
VILLAGE 05 fQ2Vl!Ie - ASSESSOR'S NAP & LOT
INSTALLER'S NAME PHONE NO.&tuCc�sco7 yme5 ZAe.
SEPTIC TANK CAPACITY O'S
LEACHING FACILITY:(type) X e#Cwi� 7 4cA cd( (size) �o X 3 X Ito
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER �.2 wJ 1;� � �N, .►,, W�a
DATE-PERMIT ISSUED: d�`� ZZ'
DATE COUPLIANCE ISSUED: -!(v
VARIANCE GRANTED: Yes No +
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
_ 1
--.....T V.............OF...Os..T�..R.�.�LLB
Appliratinn for Disposal Works Tonstrnrtinn ramit
Application is hereby made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal
System at
N DEERFIEEL s �- l
..........................
... ...... Q �.... ,
------------------------- PLY M ........._...........---•-•
ooLocation-Address or Lot
W Owner Address
a ..................... ........ ......_.....
Installer Address
UType of Building Size Lot..r0#.7-'7-c.......Sq. feet
Dwelling—No. of Bedrooms.....3..................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures -••.••• ------------------ ------------------------------------------------
---------=-------------
W Design Flow------..11.®..........................gallons per relay. Total dai�y flow.---•- - ®------••------•-•--.... ions
WSeptic Tank—Liquid capacityL gallons Length.?..6....... Width-_- y....... Diameter................ D h...'l
x Disposal Trench—No..................... Width_3.............. Total Length...... O....... Total leaching area....2.4---..sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (/) Dosing tank ( )
aPercolation Test Results Performed by.................................................I------------------------s� Date..........................
Test Pit No. 1......a-----minutes per inch Depth of Test Pit...J �...__._ Depth to ground water.._NIA...........
44 Test Pit No. 2.....�...... .
minutes per inch Depth of Test Pit. .............. Depth to ground water_AIA............
Description of S il... ------1' v a'w1L
x !4ru .�S P�?. = ..'.Tct�. 5�?j3So� .�.-� .`-� 'R .T.i_�1_F
U
DIvNIAJ --------------------------------------------------------------------------------------------------------------------
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 of the State Sanitary Code—The undersigned further agrees not to place/theysteoperation until a Certificate of Compliance has�beenid by the b of iealth.
Signed. ... -------------------------
Date
. ... ...........Application Approved B ... O ..
a �y
Date
Application Disapproved for the following reasons---------------------------------------------•---------------------------------------------....------------•...
-----------------------------------------------------------------------------------------------------
Date
PermitNo.......... -- /` •-----• Issue ---•---------------- --••-•----•------------•---•---
---� �J-----------• Issued_ Dale
„r
No.. 7 ......�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ . 1. .............OF... .. f l44..............................................
Applirotion for Disposal Works Tonstrurtion Errant
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
•---•-••---- ------57 -�'� --�.� ., ... ...�..................... .......................... - -•---- ...........
Location Address �m �p g�
or Lot PLY o f {”14, �;i A
gar
Owner Address
W
Installer Address
UType of Building Size Lod _1_1. '_......Sq. feet
Dwelling—No. of Bedrooms.... ...................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.............................. Showers ( ) — Cafeteria ( )
Other fixtures r ••--- . --•---•---••------ ---•-••------------•---•--•---------
W Design Flow_____ _._..._ ___ gallons pi er,-day Total ddapy flow_..... .......................gallons
WSeptic Tank—Liquid*capacity� gallons� ' Length-?.'. .._:_... Width..5® _ Diameter................ Depth
x Disposal Trench—No.......�............. Width. ......_...... Total Length..... ._...... Total leaching area...t�.___. ......sq. ft.
Seepage Pit No------------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box O Dosing tank ( )
Percolation Test Results Performed by......... ;----.-T------------------------ Date-------...._..-.---•----- ---••------..
a Test Pit. No. 1.._..± ..___.minutes per inch Depth of Test Pit_-1 _1--------
Depth to ground water_._? �...........
(_, Test Pit No. 2----- per inch Depth of Test Pit.................... Depth to ground water.l_.V; _ t.............
.
O D scri tion of oil.. 1 -!.. - �>-------[Qp t� "' 0IP� ��&� t � �� 3�1 __►'t�(�w" n d
-
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'ITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the ystem 'n
operation until a Certificate of Compliance has�been ' ed by the d of health.
-111r, -,( 'alz.lar�
Signed_ -.---- .- ---
Date
Application Approved By............... ----------------------------------------
Application Disapproved for the f olloanc, re as s:_d_........_ �___________________________
/U I1ate. G
...............................•---------•------.....---------......------••-----------•-•...----•-.......-
Date
PermitNo.......... _ ..y- -------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS _ ~
BOARD OF HEALTH
........... t..,.. OF.................... �.,...:,..,(�
(Irrtifiratr of Toutpliattir
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer /!
....................r _
has been installed in accordance with tl provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No........ 1 dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................... .' . '.." Q---------------------------- Inspector.................. ..................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�_.. OF.........� ! .. A,�-
No....................•--• x ..
Disposal Works Tonotrur#ion rrutit
Permissionis'hereby granted..............................................................................................................................................
to Construct ( ) or Repair ( ) ann�Individual Se��a e Dispo al System
at No. r3 T /� •-� r ��.1!� 1; -4-4---'9 ,� --.-------•---•-•-----•--•-•------•--- -
i Street
as shown on the application for Disposal Works Construction Permit N j�•-GY. Dated.................. .....................
0(cn.
..............................
t�-•-•---••---------....------................-•------••-
Board of Health
DATE.............. ..."....�-'�- ',
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
MANHU-L :Ek r Fi
SHALL_ NUT BE MORE THi;',
FINISHED GRADE
dI T1 F04SFED GRADE [ MNi1FAUM SLOPE OVER SYSTEM )
t II,. "°t -t°t_II aarl `.I,. it^1 11Tt
r -1 t= 1, 1 tl
SCHEDULE 4" P ° -It.�i !�°/=i
UNPERFORATED ° I ° '
—.__ r_. _L _._._ ..
11 s
---°---1- 40 P.V.C. �r-- — .V.C. PPE- __ _ ° , ° . , o.,:? 12.. MIN. CLEAN FILL
_ l
e _ 10 ___ ___ I Q Z ,� + � 2" LAYER OF CLEAN PEA3Tt� Ile - 3/0 •��;:t .`., �•'t1 1.,
SLOPE 0.02 -- �- u ( — • O
3t� I?I57- O'7S=(), I° .v• ° • 3 �a.
It
I _— � is I•.°.�G�:pi {�.•'•.� CLEAN WASHE�`STONES 3/4- - I I/iL . o• a°• �•oQs
4'• P.V.C. I • • • ♦e , •• • o ♦: o ."o�_, o o - . ° 1' �° r• o e e
I SAX TEE, � 9 _ I I
v• , i D I S T R I 8 U T I O N B Q x 50TTOM TO BE LEVEL FOR ENTIRE '_EN6TH 3
" O/
- a MIN TEE LEACHING TRENCH
8AN TE
4' P.V.C. CROSS SECTION
± - -- i GROUND WATER TABLE
LOT �i -GALL ON SEPTIC TANK -
-->�-_iTT-_-�;;t � _ + _ ItI = II+ =� = I° ttt= lt+�It -
THE TANK IS $!O/��it ° �. ° �.. '.
MINI BREAKOUT 9y,a i .�" �YDL. - CLEAN FILL
i \ ELEV,. .'Jf. :,'si .. 2.. ?EASTONES 1/8" - 1/8-
q� 53 �6I FOR PROPER PERFORMANCE SEPTIC TANK Xo/ IS __
NHOENLD BE T E TOTALCTED ANNUALLY DEPTH OF SCUMAAND Cj�' ' '. •°"s •rj A' _T ,
(t SOLIDS EXCEECS 1/3 THE LIOUIC DEPTH / ��•^ _� °�°° ° "16 EAN WASHED STONES
f . OF THE T ANK IT SHOULD N FUMM. '°°', S� 4° ., o 1 _ D/4" 2"
t - �. TO PREVENT BREAKOUT:
Lo-T I ft�� y,..�- .s' ! a PEW. F V.C. Pm i
.TOP, SUBSUf� ANC OTHER DELETERIOUS
76- S 98-D) / I 6 0 97 MATERIALS WITHIN O FEET OF THE GRADE AWAY FROM SEPTIC SYSTEM WITH A MAXIMUM - -- 3' -- --
r LEACHING SYSTEM SHAD BE EXCAVATED.
T i BACKFIL- AS REOUIREL WITH CLF_AN COARSE SLOPE OF ONE FOOT VERTICAL (DROP) IN i o FEET
I� / f ( SAND AND GRAVEL, FREE FROM FMES, CLAY. HORIZONTAL, STARTING/S FEET FROM THE LEACHING 4, MIN
li`!
I ORCANI MATTER. AND LARGE BOULDERS AS STRUCTURE WITH A MINIMUM GRADE OF
tr BY REGULATION 2.17 OF TITLE 5, t GROUND WATER 7NLL
/� Ji r_kAMINATiONS AND PERC TESTS
415) CONDUCTED BY j3A�TER9NYE, 10C. y-ay-87
o t.1
Taa.83L CU4LOT a a.o a! F--� '. ... TEST HOLE 0 I TEST HOLE �/
ELEVATION 9� ELEVATION
PRo/�sea
9 GARAGE PROPOSED HovSE / 1 / _ ` 0
/ I Lo-r o< To SOIL IL
P `tom To ol� Sv��o►� i
r z z
I , 1
(48.g a9.r,T STRATIFIED STE�AJIFI1-D a 4 1
�I SAND ,
I � DRIVEWAY � S Af'�fl
--M-• — 1 I � 8 i I
r �, 97•�5) ' � ' � ��.,� /CoBBLtS
TNI > 10,
E
'" i }'� RESERVE 1 �-- 3.5•
h '
014
� _ , 3 yo —q—�I r. , z �4� 9
R—�0 - •�' \"M� I7 �OT 1 OM 1'F E%CAJATtMJ ~40T jOt� OF XCAVATf0�1 12 12 _
I �
70-90 l 1 1 v I 7fAl t: N4= ENcouNTen�D NO P_E r,jCAvNTEPED I
95 t70 o _ _ l 4 4' 4'
_ — - BEOCHMARK OESCRIPTIOK)
_ - ------ - l_____ ` -- -- ---
A,/yENT 97 l) TO OF W�'DRAN7 °� wc!TEi Ly coRN•" 7 00 f'ROR ---- -- '
�� P PERC TAKEN AT N A - - I•t-RC TAKEN A . N�A c•
— --�.— — A1,;,nc p ELEJAT totJ %OU.00
YtRC RATE tNIN I.JCI{ fkC RATE a.In+t+r ItiGN t
E E I\ F I ��IJ 1 \��� - I HATER ENCOON`ERF 4 ' L�Ln - WATEk ENCOUN7L RED Al N/A NA tr, f:w ._ It;
°^VENtNT ELEVATION SCHEDULE xx X ON A33UMED DATUM DESIGN CRITERIA WAGE
I
- _ _-- SE WAGE DISPOSAL L. A N
TOP OF FOUNDATION ELEVATION 100.00 { l 0 33
BASEMENT FLOOR ELEVATION -_-_ �a•s v,u AR6A�E GRIND I. N/A r C CFy D
- -- 96 11 C f L 1...
GARAGE FLOOR ELEVATION �. -15 D E R D-
SEWER INVERT AT FOUNDATION __ �S 7_5- TOTAL GALLONS/DAY REQUIRED = 33Q 'i-- MA
SEWER INVERT INTO SEPTIC TANK _- 9 ^ 3S I TRENCH : 40 L X 3'w X �'o 0 STER V I L-LE
SEWER INVERT OUT OF SEPTIC TANK 9S 30 �. . ,KEN 86 a.S ;2+5
SEWER INVERT INTO DISTRIBUTION BOX ?15-, /� 907TOM AREA- I10 I .0 Iao
SEWER INVERT OUT OF DISTRIBUTION BOX SCALE : 1" _ )Or DATE : 0CT0e E R
SEWER INVERT INTO TRENCHES 94, 90 TOTAL LEACHING AREA = dab s.f.
MAXIMUM GROUNDWATER ELEVATION S5.90 WITH A CAPACITY OF 335 G.P.D.
ZONING INFORMATION LEGEND 'JISIONS: -_-- -- --- ---
ZONE : ESI DENT 1 AL-C -. TEST HOLE •V
MINIMUM YARDS : FRONT ao SIDE 10 REAR 1-0- EXISTING CONTOURS ,NMFR'
R R ANo D 7PQ'-TIoN
ASSESSORS SHEET : 16� _ _ _ PROPOSED CONTOURS
a SAM�S�T sT. I
PLOT Q _ LOT ___J I EXISTING ELEVATION
c
--- FL.y M O U T V{ ) MA
PROPOSED ELEVATION
-- —_ _
I
t� of MA �ERTIF r THAW THE SEWAGE DISPOSAL
l� AALPHss . FACILITY IS DESIGNED IN ACCORDANCE WITH DESIGNED BY : DC RIM ENGINEERING COMPANY" NC. {
I• TITLE V Of THE STATE ENVIRONMENTAL
00±4
"` CODE AND THE REGULATIONS OF THE LOCAL DRAFTED BY :No 20225 150 NORTH MAIN STREET
" ^.ARD 'JF HFA!_TH. CHECKED BY :
($�IrlS% APPROVED BY R.I.M. IMANSFIELD MASSACHUSETTS
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.- T j'OG'R'r.'/�/iY T��-,EN Qy TiPgNd/T-,CT•oAtA w•srs Til+O
r ESS11"NAt- ENGIPIEE I-� UA i r..