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Home My WebLink About0033 EMILY WAY - Health 33 Emily Way Osterville P A = 118 126 a , I " , , r , a : , � III .a • P 7 7 =5�6 F j 1 , { c uq R Pl n'1 7 i 1 JUL. 2007 3 : 54PM N0, 818 P, 2 Town of Barnstable Health Inspector 7r+� Office Hours Regulatory Services $:30-- ):30 Thomas F. Geller,Director 1:00 2:00 a74AM Public Health Division _---- �;�o ° Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508490-630,t AMNESTY PROGRAM APPLICANT_SEPTIC QUESTIONNAIRE �. G-eueral Information: Size of Property: Map ,a �.4ddr..ss: Parcel �� ]'lame: � 121 �`�'�Z ZZ Phone#: �V, 0 ?.a_ How many bedrooms exist at your property now? 2b. Axe you planning to add any bedrooms?_ If yes,how many? 2c. How inauy bedrooms total are proposed at this property(including the amnesty unit)? 2d.Please include a copy of the floor plans for the entire property- showing the existing; rooms in the home plus the proposed amnesty apartment and/or addition. Please label 9:a.ch room clearly on the plans. 1 Is the dwelling connected to public sewer? YES or if the dwelling is connected to public sewer,skip questions#4 through#9 below. 1. Location of dwelling is .INSIDE or 0_ a Zone of Contribution to public supply well:.? i. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? i,. Is a disposal works construction permit on file? YES or _Ni) 6a. If yes,how many bedrooms were approved according to this permit? Dedrooins. 7. Were any building permits obtained for construction of additional bedrooms? YES or NO 3. 1s there m engineered septic system plan on file at the Health Division? i�Esl or NO Has tde septic system been inspected by a DEP certified inspector within the last two years? YES or NO ----------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. ^;pecial Conditions: �C f( re.�a i� r ��'Se w M Np ,:signed: : Date: 7 ��•1hec.lehlwp�les/amnesryapp McKean, Thomas From: McKean, Thomas Sent: Monday, March 12, 2007 8:22 AM To: Taylor, Madeline Subject: 33 Emily Way/ Hallett 1) We have no record of a permit for the septic system attached to the garage. What year was it installed and by whom? 2) The second floor"sewing room" has a door with privacy. Will you please ask the applicant to verify the 8 X 8 measurements of that room? 1 .. AP.R. 20. 2007 1 : 34PM N0, 490 P. 1 Town of Barnstable Health Inspector Office Hours Regulatory Services 9:30-9:30 .� Thomas F..Geiler,Director 1:00—2:00 Public Health Division FD Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862.4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT-SEPTIC QUESTIONNAIRE 1. General Information: A Size of Property: Z CL GEC:-2� Address: . y � /r.��,C Map Parcel Name: eZF1 E Phone r 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? 4Z(J If yes, how many? Z 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? 2d.Please include a copy of the floor.plans for the entire property -showing the existing w rooms in the home plus the proposed amnesty apartment and/or addition. ,Please laliel each room clearly on the plans. 3_ Is the dwelling connected to public sewer? YS or'',.) Q0- c_;, i If the dwelling is connected to public sewer,skip questions#4 through#9 below. ` 4. Location of dwelling is INSIDE or OUP a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an ONSHE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or NO 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 7_ Were any building permits obtained for construction of additional bedrooms? YES or NO 8_ Is there an engineered septic system plan on file at the Health Division? E or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES of NO ----,--------___-- _---o__—_— _ �r Kok OFFICE USE ONLY sion has no objection to bedrooms at this pr p�ertq 'ate Special Conditions: `T6 m ft y Q&0n0t)%—S . , 0.40A., ^ea. , � -7 'IF,r w O is Signed: —.____. Date: S/�5 f" Q,/health/wpftles/amn&Mapp 1' H� n 1�> O ,+ O �1 Dr- W L%Vo�VC RIM 1�,wnV c �,�► iz�9 k Clore74 AV # -�. A--117fPti O 0 a -o -ti 7b z 0 N O t O O W V - u C G Orr J6 W s i Town of Barnstable Health Inspector F1HE Office Hours do Regulatory Services 8:30—9:30 ; Thomas F.Geiler,Director 1:00—2:00 M * SARNSTABLE, � MASS.1639. ,�r Public Health Division AjFo ,tp Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE 1. General Information: F Size of Property: Address: Map ///i� Parcel Name: /l/(� ,�1� �� /`�'i9.L.�,C— T 7" Phone 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? 4Z6 If yes, how many? ' 2c. How many bedrooms total are proposed at this property (including the amnesty unit)? i 2d. Please include a copy of the floor plans for the entire property - showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. !Please label each room clearly on the plans. {R"d� 3. Is the dwelling connected to public sewer? Yo or-- 0-'- If the dwelling is connected to public sewer,skip questions#4 through#9 below. t ti 4. Location of dwelling is . INSIDE or �OU TSID a Zone of Contribution to p uplic supply wells? 1 5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or NO 6a. If yes,how many bedrooms were approved according to this permit? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms?. YES or NO 8. Is there an engineered septic system plan on file at the Health Division? Y✓ or NO 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ----=------------------------------------=---------------------------------=-------------------- ---- FOR OFFICE USE ONLY , ZOC> The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: Date: Q;/health/wpfiles/amnestyapp L rV`iV'G i A� i 1 L7�1114 �S 7 . � M r get i c�ilr�a� h Close McKean, Thomas From: McKean, Thomas Sent: Thursday, April 12, 2007 8:32 AM To: Taylor, Madeline Subject: THREE REQUESTS RE: 33 Emily Way-Yes I did receive it. I need someone from the Town to provide verification regarding the measurements of the "sewing room" and the L-shaped "walk-in closet" room. Are they both the same at 8 x 8? Re: 31 Old Stage - Donald could not get into the house at that first visit because nobody answered the door. He said that he would try to get into the house again. However, he was out sick yesterday and is out today again today as well. I don't have any up-to-date info on this now. RE: 2187 Main Street Barnstable The 1994 disposal works construction permit was approved for 4 bedrooms. The system consists of a 1,500 gallon septic tank, distribution box, and four galleys (4 X4)with two feet of stone (20 X 8). If the applicant requests five bedrooms,he/she would have two options: - Construct additional leaching area to the existing septic system (upgrade the system. A professional engineer must be hired to design the upgrade first. - Hire a professional engineer to determine what is the capacity of the existing septic system is to see if it could handle five bedrooms. -----Original Message----- - From: Taylor, Madeline Sent: Wednesday,April 11, 2007 4:15 PM To: McKean,Thomas Subject: RE: 33 Emily Way Did you get it? -----Original Message----- From: McKean,Thomas Sent: Wednesday,April 11, 2007 3:47 PM To: Taylor, Madeline Subject: RE: 33 Emily Way Okay, please do -----Original Message----- From: Taylor, Madeline • Sent: Wednesday,April 11, 2007 3:46 PM To: McKean,Thomas Subject: RE: 33 Emily Way Yes, I did. I can resend it if you need me to. -----Original Message----- From: McKean,Thomas 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE.OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 33 Emily Way Osterville, MA 02655 Owner's Name: David Hallett Owner's Address: Date of Inspection: September 15. 2007 Name of Inspector: (Please Print) James M. Ford , Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 �� t Telephone Number: (508) 862-9400 CERTIFICATION.STATEMENT I certify that I have personally,inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based{,on my training and experience in the proper,function and maintenance of on site sewage disposal systems. I am a-DEP r approved system inspector.pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes C nditionally PassesCni _ e ds Further Evaluation by the Local Approving Authority ? FailCo I CTs Inspector's Signature: Date: e ener 007 The system inspector shall sub) 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. Notes'and Cormnents **"This report only describes condition's at the time of inspection and under the conditions of use at that time. This inspection doe_s not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 " Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 kinily Way Osterville, MA Owner: David Hallett Date of Inspection: September 15, 2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any infonnation 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 EniilyWay Osterville, MA Owner: David Hallett Date of Inspection: September 15, 2007 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 CAM 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 Emily Way Osterville, MA Owner: David Hallett Date of Inspection: September 15, 2007 D. System Failure Criteria applicable to all systems: You must indicate either"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 cessP ool _ ✓ . Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow ✓. 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 asurface 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 coliform bacteria and volatile organic compounds indicates that the.well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No. (Yes/No)The system fails. I have detennined 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 33 Ennily Way Osterville, MA Owner: David Hallett . Date of Inspection: September 15, 2007 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping infonnation 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 nonnal flows in the previous two week period? ✓ . Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?.(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site. ✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with infonnation on the proper maintenance of subsurface sewage disposal systems The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 33 EmiL Way Osterville, MA Owner: David Hallett Date of Inspection: September 15, 2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_ n/a Number of bedrooms(actual): 4 Q in house, I above gara ems_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 1 Does residence have a garbage grinder(yes or no); n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry.system inspected(yes.or no): ` No Seasonal use(yes or no): Yes Water meter readings; if available:(last 2 years usage(gpd)): Unavailable Sump Pump.(yes or no): No Last date of occupancy: Currently,occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available:. Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records . Source of information: The tank for the house was pumped after the inspection for maintenance Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: -gallons--How was quantity pumped deternined? .Reason for pumping:. TYPE OF SYSTEM 1(2) 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 33 Ennily Way Osterville, MA Owner: David Hallett Date of Inspection: September 15, 2007 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Cormnents(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 3'Onain house): 5"(gara eQ ) Material of construction: ✓ concrete _metal fiberglass polyethylene , _other(explain) If tank is metal list'age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 Qal.Onain house): 1000 gal. (garage) Sludge depth: 2"Onain house):2".garage) Distance from top of sludge to bottom of outlet tee or baffle: 30"Onain house): 30"garage) Scum thickness:. 2"Onain house); 0"(gara eR ) Distance from top of scum to top of outlet tee or baffle: . 6"Onain house): 6"(garage) Distance from bottom of scum to bottom of outlet tee.or baffle: 10"Onain house):10"( arage) How were dimensions determined:. Measuring stick(both) Comments(on pumping recommendations, inlet and outlet tee_or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.). There did not appear to be any signs.ofleakage. The tank for the main house was pumped after the inspection for inaintenance GREASE TRAP: None (locate on site plan) Depth below grade: 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: Cormnents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Emily Way Osterville,MA Owner: David Hallett Date of Inspection: September 15 2007 . TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _inetal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day. Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and.float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level_above outlet invert: Even Corrunents(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.): The D-box was level. No solids were present. PUMP CHAMBER: -- None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Corrunents(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Emily Way Osterville, MA Owner: David Hallett Date of Inspection: September 15 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'0000 gal.)w/stone leaching chambers,number: leaching galleries,number: leaching trenches,number,length:, .. leaching fields,number, dimensions: overflow cesspool,number: Innovative/alterriative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure;level of ponding,damp soil, condition of vegetation;etc.): In the original pit liquid was 1`below the outlet pipe A steel cover was to Qrade The on iQ pal pit overflows to the newer pit The newer pat was dry and the scum lane was 6"up front the bottom There did not appear to be any signs o�failua e CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding;condition of vegetation,etc.): PRIVY: None (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comrunents (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): 9 , Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property.Address 33 Emily Wav Osterville, MA Owner: David Hallett Date of Inspection: September 15 2007 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. G ArA.f t_ y a s a a� 3 3 cl9 30 10 s , . Y Page 11 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION (continued) - f Property Address: 33 Emily Way Osterville, MA Owner: David Hallett Date of Inspection: September 15, 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30'+1- feet + Please indicate(check)all methods used to.determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed: Observed site(abutting property/observation hole within 150.feet of SAS)' Checked with local Board of Health-explain: topoLi aphic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: . You must describe how you established the high ground water elevation: _Using Barnstable topographic and water contours maps, the7naps were showing approxinZately 30'+/-to ground water'at this site.. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report;is not a warranty or,guarantee that the system will function properly in the future. There have been no warranties or guarantees, either.expressed, written or implied, relating to the septic system, the inspection, this report and/or any components of the septic system which have not been located and inspected. ' ti , { Town.of Barnstable OF tae t � Regulatory: Services swxxsrns Thomas F. Geiler,Director MASS. 9$ATfD . A,�� Public Health Division .Thomas McKean,Director , 200 Main Street, Hyannis, MA 02601 Office:,5087862-4644 Fax:.508-790-6304 This septic system inspection report was-'completed by a private inspector who is certified by the State of Massachusetts,Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s'and'interpretations contained within this report. In addition,by receiving this-report the flown of Barnstable Health Division does not automatically approve the number of bedrooms,listed within this report: The actual number of bedrooms approved at a'particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. z t• '( Y st a L.1 FPO .► S <'.y: •i ,x.•.sw. n',.' a. R 'S," ". ,� r'R° i , k LisF*"''a: }40, �s �SIR u Al ,r to ^ -f.. " A ! i`.t,t t. �• .M, " % t r A{xK-•— e`-..d V 0 g i i. V. • f.{. by 3 ; i "��R jj 4 4 ��ttYY k 3` Vs, '. $. � '}'i � �,��d�` e tx 4 5`N`x '�, ri • ��'�`tit r rrL � ax 2 �>� 'A. �,• ,� , � }s t±"a�'�. � �i,�i% as � T t ,UT -+y ,,y'�•rr�. 'd'.r� � :Flr��tr i°.qti'� s t�T. -'„,�� r ri ck9 3y ! '- �1!t:�k1ff� •, -.(�}gpFt. k�!t��t�l rs �^ �.,� tic i•� ��° r �.` �� ,.:,+ �. 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Hallett 33 Emily Way Osterville, MA 02655 NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.000 THE STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE The property owned by you located at 33 Emily Way, Osterville is being advertised by Frank Sullivan Real Estate as a 5 bedroom property. It is listed as "three bedrooms on the 2° floor"; "finished walkout basement...bedroom"; and "heated garage with separate guest quarters...bedroom" The following is a violation of the State Environmental Code: 310 CMR 15.214: Nitrogen Loading Limitations: 5 bedrooms are-being advertised for said property, which is located within a Zone 2, Wellhead Protection Area with less than one acre of land. On August 31, 1977, Septic permit 77-540 was issued for "2 + 1 future" bedrooms. You may have no more than three bedrooms total at said location. You are directed to correct the violation listed above within thirty (30) days of your receipt of this notice or prior to the transfer of property, whichever comes first. You are ordered to correct the violation by eliminating the two extra bedrooms so that a total of only three bedrooms are present at said location. The Town of Barnstable Health Department has a policy to eliminate the privacy of being considered a bedroom by installing a minimum five (5) foot cased opening with no doors, and no beds or people sleeping are allowed in the room. You and your realtor may only advertise the property as a 3 bedroom property. Please call Health Inspector David W. Stanton, RS to schedule an inspection of the property when the two extra bedrooms have been eliminated at (508) 862-4647. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date the order is served. r . Non-compliance will result in a fine of$100.00 per violation. Each day's failure to comply with an order shall constitute a separate violation. Q:\Order letters\Sewage violations\33 Emily Way.doc PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S. Director of Public Health Town of Barnstable Cc: Building Dept. Frank Sullivan RE. QAOrder letters\Sewage violations\33 Emily Way.doc COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS RlNiS TABLE DEPARTMENT OF ENVIRONMENTAL PR6,TI-,,MjgNAM 9, 01 �alltlSIGN TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 33 EnTily We Osterville. MA 02655 \� \ Owner's Name: David Hallett Owner's Address: Date of Inspection: April 16, 2005 Name of Inspector: (Please Print) James M.Ford Company Name: James M.Ford Mailing Address: P.O.Box 49 Osterville.MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper 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 Needs Further Evaluation by the Local Approving Authority. Fails Inspector's Signature: Date: April 19, 2005. The system inspector shall sub racopy 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. Notes and Comments ****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. w Title 5'Inspection Form 6/15/2000' page 1 a, Page 2 of 11 } OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 Emi.1y Wav Osterville, MA Owner: David Hallett Date of Inspection: April 16, 2005 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced_ ND explain: 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 obstruction is removed ND explain: 2 s Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 33 Emily Way _ Osterville.MA Owner: David Hallett Date of Inspection: April 16, 2005 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and. the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 r Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) , Property Address: 33 Emily Way Osterville, MA Owner: David Hallett Date of Inspection: April 16. 2005 D. System Failure Criteria applicable to all systems: You must indicate either"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''/z day flow 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that orie 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 System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No 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. 4 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 33 Emily Way Osterville. MA Owner: David Hallett Date of Inspection: April 16, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of.scum? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No ✓ 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(3)(b)]. . .5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 33 Emily Way' Osterville. MA Owner: David Hallett Date of Inspection: April 16, 2005 r FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): n1a Number of bedrooms(actual): 4 Q in house. 1 above garage) DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: I Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2004- 76,000 gals.:.2003- 122,000 gals.' Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIALANDUSTRIAL s Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: System pumped after the inspection for maintenance Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: ____gallons---How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM 10 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) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all'components,'date installed(if known)and source of information: ` Date of installation unknown Were sewage odors detected when arriving at the site(yes or no): No 6 ,x ' Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Emily Way Osterville, MA- Owner: David Hallett Date of Inspection: April 16, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: Y(main house) :S"(garage) Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) Dimensions: 1000 gal. (main house) : 1000 awl. (garage) Sludge depth: 2"(main house) :2"(garage) Distance from top of sludge to bottom of outlet tee or baffle: 30"(main house) : 30"(karate) Scum thickness: 4"hnain house) : I"(fie) Distance from top of scum to top of outlet tee or baffle: 6"(main house) : 6"(garage) Distance from bottom of scum to bottom of outlet tee or baffle: 10"(main house) : 10"(garage,) How were dimensions determined: Measurin stick(both) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Main system: Tees were present. There did not appear to be any signs of leakage. Garage system: The liquid level was W to the outlet tee. `There did not appear to be any signs of leakage. Both of the tanks were pumped for maintenance. GREASE TRAP: None (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM'-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Emily Way Osterville, MA Owner: David Hallett Date of Inspection: April 16, 2005 TIGHT or HOLDING TANK: None (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/day ., Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Continents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was level. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Continents(note condition of pump chamber,condition of pumps'and appurtenances,etc.): f Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Emily Way Osterville, MA Owner: David Hallett Date of Inspection: April 16, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 2-6'x 6'(1000 gal)w/stone leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number:' Innovative/alternative system Type/name of technology`. Continents(note condition of soil,signs of hydraulic failure, lever of ponding,damp soil,condition of vegetation, etc.): In the original pit liquid was up to the outlet pipe A steel cover was to grade The original pit overflows to the newer nit In the newer there was 6"ofliguid. The scups line was at the scone level The bottom to grade was 10' There did not appear to be any signs offailure. The cover was ]'below grade. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of pondirig,condition of vegetation,etc.): PRIVY: None (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.): 9 - i Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 33 Emily Way Osterville,MA Owner: David Hallett Date of Inspection: Al2ri116, 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. GArAIL Post. h , 3•f� - 0 0 0 a Ya S3 3, yq 30 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION(continued) Property Address: 33 EnzilyWay , Osterville. MA Owner: David Hallett Date of Inspection: April 16, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain: topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours neaps, the ntaps were showing approximately 30'+1-to ground water at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report. 11 TOWN OF BARNSTABLE A -i.00ATI0N 33 C,'^n�I�I WADI SEWAGE # "Y,LAGE �S ftrv., ASSESSOR'S MAP & LOT r✓ INSTALLER'S NAME&PHONE NO. LOT a- SEPTIC TANK CAPACITY a 01/0 LEACHING FACM • (type) a. p rS (- (G' (size) /OW I NO.OF BEDROOMS BUILDER OR OW<R PERMITDATE: COMPLIANCE DATE: 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 leacilinq facility) 1 Feet Furnished by T tvOn �D/G GArAlL I�ousc. 3 y 3-� O 0 O ,A 4 3 yq 30 17 LOCATION SEWAGE PERMIT NO. �'C"',k % , 1, & 33 Lo� 3 V1.L L AG E INSTA LL'ER'S NAME & ADDRESS ------------- R U I*L D E R OR bWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED � �, .. �� `� �� -)3` -. ,..., AV THE COMMONWEALTH OF MASSACHUSETTS BOARD PF HEALTH .--------- .......OF...... ..�!L/I/s. .... ...... Appliration for Disposal Works Tonstrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal - System at: Location_Address or Lot Now ----•.................. ..........Cl��`...1 .. .....0>C f l'`/i. ...- _ Owner Address .........•••--G�.Vv..... ........... 1 �!1/... .. �� %-� vrG---�=---•--.. J..... Cq Installer Address Type of Buildin j ` .T Expansion Attic Garbage..-r q. feet �,. Size Lot.....__.0 ___ 7.S f -� Dwelling—No. of Bedrooms.. .............................. .. p ( ) G age Grinder (ye)) �_l Other—Type T e of Building No. of persons............................ Showers dQ, YP g --------------------------•• ---•P--- (----)--- Cafeteria ( ) Other fixtures ..---•----------------------•--•-------•-- --------------------------------------------------•••• ------ W Design Flow................ .,5._.................gallons per person per day. Total daily flow....... ........ . . ..............gallons. W Septic Tank Liquid capacity............gallons Length----- Width.._._.......__. Diameter................ Depth................ x Disposal Trench—No..................... Width____.. ... A- ) Tot Total leaching area...............--___sq. ft. Seepage Pit No....__../.._........ Diameter..............� h g q. l� -_- i l�........ ........ Total leaching area-----------.-....s ft. z Other Distribution box ( �/) Dosing tank (, Percolation Test Results Performed by.............. __..C!"�',... ._ �:E? .__...._..._ Date........................................ Test Pit No. 1................minutes per inch Depth of Test it.................... Depth to ground water........................ ft, Test Pit No. 2................minutes per inch Depth of Test Pit............ Depth to ground water.......- Description of Soil..------. =� ��'%''` '' x r -• ° ------f. -•-•-- ---•••---•------••. U •---•--------- -----1•2--------_�1 .t��. f '' z......................................................................................................................... ----------------------------------------------------- ------------...............................................--------------------•-----------------------------------••--------------------------- V 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 iITLi,:. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss ed by the board of hea • Signe In � �� /� Date Application Approved B —1''3 (✓ .,' t �i. --------------•---- ---- ---K....---- PP PP y Date Application Disapproved for the following reasons: =--------------------------------••--------------............................... --------------------••-••••••--•---•••-•...-•--------•-•--•-•---•.......--------••-----•••••••-----••••.........•-•---•--•-•--•---•--- ----•-•••-•••-•--•-••----•---•---•-•---•-•-----••-•-••---•-••-•--- Date PermitNo......................................................... Issued....................................................... Date ' E�Y� t*r n ?W yti�� q�gt tiq: E K •- •- -....... --•- 5 Fns......... ............... " THE COMMONWEALTH OF MASSACHUSETTS r BaARD OF HEALTH .......OF....... _ .- ---................................................................ Apli iration for i a1Works Tanstrur#ion Frimit Application is hereby made,-for a Permit to Construct,!'( ) or Repair"( an Individual Sewage Disposal System atjjff,� ,� i y ..... - ..�P.1!'':�y ...Lo t r dre l ! ........ . ....+ e . �»�f >:�t N'„ ------- ---- - O ner r' Address ...................... Installer Address Type of Buildin `/ K + Size Lot-- {� - -Sq. f et a Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (jfo p, Other—Type of Building ............................ No- ..of persons............................ Showers ( ) — Cafeteria ( ) Other fix urea. = ..... ... ••-•--------•• -1 Design Flow_______________ :__._ allons per erson per day. Total daily flow----------- ... gallons. W g g P P: P Y Y WSeptic Tank L Liquid capacity............gallons Len h___.._. ,:.____ W•rlth. ............. Diameter________-____-_ Depth.... µ: x Disposal Trench N Wid _ Tot en Total leaching area....................sq: ft. Seepage Pit No ____. _ Diameter ............. e tl ------ T tal leaching area..................sq. ft. Z Other Distribution,box ( ;) Dosing tank Percolation Test Results ''Performed by. .. -•-••-••_._. Date_:_ .........................-... Test Pit No. 1................minutes.per inch Depth'.`o°f Test it...._......__....... Depth to ground water........................ Test Pit No. 2........ ..minutes per inch- Depth-of Test;Pit______________ _ Depth to ground water .... M1 { O Description of.Soil ,'. - --�._ .. �` o �w......... .................../ •. ---------•• ---------------------------........................................................... W --------------------------------------- ..... ......................... t d r UNature of Repairs or.Alterations .Answer when'.applicable ;. ----------- --•-••. •-•- ... ---- Y_ == = 7.1 Agreement M1. The undersigned agrees,to install the aforedescribed Individual Sewage Disposal System in accordance'with the provisions of TITL is 5 of the State:.Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is d.by,tle•board of hea ...-- - .._..... s .� a Application Approved BY " " --•-----. ..¢.."....I - Date Application Disapproved for the following reasons:............................•-•-----•-.......................................................................... ..............•-=---•-----•--•----•---------•----------------•---•---....--•----•-------•--•----.._...----•----••---•-•=----••--•-------•-•••-•-...-•---••-•••-------•---------------------•-------•=--- Date PermitNo....................:................................... Issued..................... ............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH .........OF......... . Tatifiratr of Tnntplianrr TO- V S TO C Y�' That the Ind vi al wa e s o S stem constructed ( ) or Repaired by..--•- ...... : ••. •- • xr dns 1 r has been installed'in accordance with the provisions j o he State Sanitary C d: as described in the ap W Permitv dated : _ ________________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS'A GUARANTEE..THAT THE SYSTEM WILL FUNCTION SATISFACTORY.` DATE......................................................................:......_.... Inspector . .......................................... THE COMMONWEALTH OF MASSACHUSETTS BOAR L � : . ... W4w1. :... . ; .. .OF........ N --• .. FEE... ................ Disposal orku go lion uti �"7✓ Permission ' ereby granted •--... . ---- `. to Const yt' (° pai ( n ividu Sk,r geyDis Osal System . at No...�' '._, _:_ * a « �?'- •-} .- •..............•••--- #� treet as shown on the application for Disposal '"Torks Construction': P t No. _, _ :`.". Dated 't"" /�_ : _ DATE.. 7 7 °f Board Health' FORM 1255 HOBBS .& WARREN, INC., PUBLISHERS 'tom;. . ... .. �/��,�,,,,,,�•- _1. _.,..,..K.� ►.►o Gi��:�t�. Gee l�taEC.. "�.,c,,.`t F ti..vuJ - i t 0 �3 � 33 c� cs'►'.i~'�, �i1�G'� �� SE-�r"tG TAti11G.. � 33CI �.,t�7D",�c' dgSGPb � d-,ljv 4� `D I S Pty AL— PIT - I O C%:) ew A.L,. (50 'Z. 3"15 &PD _• " c' Fvv. Bol-rom AfLeA - 5C) SC , 5o S f < t 5O G PCB ' -TOTA%— -O ESt&W 41S 4,PT3 , rod C- Pt IG TE5$T 1`► 11-4 2 M1�4 OE- t.+*5 � 4 � 113177 rbP Fnru =inrs C�I y�jyy/ (r�� r {del f f / '�- ��_ r-- .-..��.�r�^�. �y✓}�Py WOOD ��l AVtZ Ala �"4 /a �..f�.1 iov v SRAW'L> t sa.v� k C..E17TtPtaID Pt.-.A.t...i T"A T T O G— t'"Ot3 rJ o!a"t'i n~r.t S UOtic/u �--A�,1 1Z�>^'�GZ E►•1 C C. 1. r-lZUo1-.11 GC>AAf71. 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