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0022 GENTIAN CIRCLE - Health
22 Gention Circle nsterville A= I2q-080 P ,1 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40,00 for 4 years). A business certificate ONLY REGISTERS YOUR 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, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. - - . - DATE: y� Fill in please: APPLICANT'S YOUR NAME/S: STt-o{►en f'A nm oS BUSINESS YOUR HOME ADDRESS:_ ZZ Gen.t i A., Cr iLa e ' TELEPHONE # Home Telephone Number .Zd I 4KSa T/4--// : NAME OF'CORPORATION: NAME OF NEW BUSINESS_,¢¢)ezn1-It. H'o ax:rc lai s•v*A 1r TYPE OF-BUSINESS CQo,1Jva c��,r IS THIS A HOME OCCUPATION? YES NO ADDRESS OF BUSINESS 22- G-r.,���s► G�^c/� G)rlr..��ilc 0 1 MAP/PARCEL NUMBER_ [Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 20D Main St. — (corner of Yarmouth Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COM 15 10 ER'S OF E This individu I he e info ed any er ire it ents tha ertain to this type of business. MUST COMPLY WITH HOME OCCUPATION RULES AND REGULATIONS. FAILURE TO .4 oriz i r * COMPLY MAY RESULT IN FINES. OM N _ Q -- -l 2. BOARD OF HEALTH This individual has nforme I of the�rmit re y.irements that pertain to this type of business. 'Authorized Signature* IOUs tOMPLY"WITH ALL; COMMENTS: S. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of.business. Authorized Signature** COMMENTS: TOWN OF BARNSTABLE Date: 2l g I TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF'-BUSINESS: z}llanif �, Hou re Z,/h,'ohsts BUSINESS LOCATION: 2Z Ceh.hi e? C,;cly 0x*yui/l INVENTORY MAILING ADDRESS: .ZZ G TOTAL AMOUNT: TELEPHONE NUMBER: o? VSa 8'>y/ 7� CONTACT PERSON: SStenAen -`Aa�,�s EMERGENCY CONTACT TELEPHONE NUMBER: 267 V2 R/9/ MSDS ON SITE? TYPE OF BUSINESS: C-,,VaA61 INFORMATION / RECOMMENDATIONS: Lc��c /,��'� o�c✓ Fire District: I., f"r to m 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 s 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 0 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) aul rout 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 Daintsvarnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) -� - - Any other products with "poison" labels ❑ NEW ❑ USED Y (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 WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials • p ,iYV.1f�l� • V"1 .. • .�+� . . . o r`- L co f` F I I S co Postage $ N Certified Fee O �O Postmark C3 Return Receipt Fee Q 0 `v! M ere (Endorsement Required) Restricted Delivery Fee f> O (Endorsement Required) r3 Total Postage&Fees r a©STqL GN Sent e JOY-Ph h W S- .Zlc� a S-reet ------- -- ------ 0 - L or PO Box No. as --------------- - - - City,State ZIP+4 �A. �a b S� Certified Mail Provides: e A mailing receipt n A unique identifier for your mailpiece e A record of delivery kept by the Postal Service for two years Important Reminders: n Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. o Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. o For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is required. a For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". e If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office'for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. IMPORTANT:Save this receipt and present it when making an inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 ■ Complete items 1,2,and 3. A. Signature ■ Print your name and address on the reverse ❑Agent so that we can return the card to you. Xdressee ® Attach this card to the back of the mailpiece, B. eceiv_ by(Printed Name) C.-Date of Delivery or on the front if space permits. J� (C, 1. Article Addressed to: D. Is delivery address different from item 1-? la Nap, �- If YES,enter delivery address below: , as Ge�1� Gircl e MA- D-(PSG II I�11181 I II IBI I III I II II I I 110111 I II I I II II III 3. Service Type Priority Mail aipssCry ❑Adult Signature p Registered M3iITM ❑Adult Signature Restricted Delivery ❑Registered Mai Restricted Restricted Certified Mail@ Delivery 9590 9402 2480 6306 7768 03 ❑Certified Mail Restricted,Delivery" )Return Receipt for ❑Collect on Delivery" Merchandise _ .; , ,,,,, ,_ rr __�_:r._�_�: �._�_. --- — -����•-- Delivery Restricted Delivery ElSignature CohfirmatloriT O ❑Signature Confirmation _ 7 012 1010 0000 2847 8575 ��1 Restricted'DeliVery ,Restricted Delivery over 4'"• PS Form 3811,July 2015 PSN 7530-02-b01)-9053 Domestic Return Receipt j USP.S; ACINkC .i First-Class Mail .Postage&Fees Paid '` Permit No.G-10 9590 9402 2480 6306 7768 03 I United States •Sender:Please print your name,address,and ZIP+4®in this box* Postal service Town of Barnstable Health Division 200 Main Street 44 Hyannis, MA.02601 � I id •iii i•tl?-�. ii31i'i£1•:i;l:•J eli:•Itg ' ?•°s!tFt:��i•fel`' if a s J, 1i I �tME r Town of Barnstable Barnstable o. . : Regulatory Services Department* A6-AntedcaCay i BARNSTABLE I `"39. ,�� Public Health Division '�foraa�°i 200 Main Street, Hyannis MA 02601 2007 Office: 508-8624644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2847 8575 March 27, 2017 GEARY, JOSEPH W &DEIDRE L 22 GENTIAN CIRCLE OSTERVILLE, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 22 Gentian Circle, Osterville,MA was inspected on 03/16/2017 by Sean M. Jones, certified Title V Septic Inspector for the State of Massachusetts. , The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching pit or cesspool with high liquid level,<12" below inlet(per Town Code 360-9.1). You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH loe ZweKean, R. ., Agent of the Board of Health - QASEPTICU.etters Septic Inspection Failures or Future Evl\22 Gentian Circle Osterville.doc' of IKE rqy, Town of Barnstable • 1ARNSTABLF, • ' Regulatory Services Department '�fa ram' Public Health Division 200 Main Street, Hyannis MA'02601 Office:.508-862-4644. Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5/11/16 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44'and Title V: 310 CMR 15,000) _ An"x"marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge.or ponding of effluent to the surface of the ground x .. ❑Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA ❑ Static liquid level.in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA o Single Cesspool ❑ Any"conditionally passed,systems'.' (broken cover,relocation of a pipe, relocation- , of a driveway due to H710 components, etc) Leaching pit or cesspool with high liquid level, <12"below inlet(per Town Code 360-9.1) - ❑ Leaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:ISEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Mammchuaetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments :> 22 Gentian Circle M Property Address _ rD Joseph&Deidre Geary ,v Owner Owner's Name —� information is Osterville ✓ Ma 02655 3/16/2017 required for every � page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any = way. Please see completeness checklist at the end of the form. Important:When A. General Information form filling out for S/ /�� c� on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection Company Name 74 Beldan Ln. Centerville Ma 02632 . Cityrrown State Zip Code 774-2484850 smjonestitie5@gmail.com S14522 Telephone Number Lioense Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my.training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Local Approving Authority 3/16/2017 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of Inspection and under the conditions of use at that time.This Inspection does not address how the system will perform In the future under the same or different conditions of use. thine•3/13 Title 5 Mad tnspeaian Fam:Stbwface Sevrage piaposal System•Page 1 of 17 f Commonwealdtl of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph&Deidre Geary Owner Owner's Name information is required for every Osterville Ma 02655 3/16/2017 page, Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: , ❑ one or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old"or the septic tank(whether.metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a_complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5hs-3113 Title 5 Of Wd h epedon Form:Subsutaoe Sewege D(sposel System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property_Address Joseph & Deidre Geary Owner Owners Name information is Osterville Ma 02655 3/16/2017 requires for every Osterwn state Zip Code Date of inspection page. B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑.N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y , ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 in 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 wetiand or a salt marsh Mini•3113 Title 5 Offfdel Inspection Form:subwrtece sewage OieWal System•Page 3 of 17 f Commonwealth of Massachusetts Titre 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph & Deidre Geary Owner owner's Name informations required for every Osterville Ma 02655 3/16/2017 _ page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,If any) determines that the system is functioning in a.manner that protects the public health, safety and environment: ❑ The system has a septic tank and sail absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "This system passes if the well water analysis, performed at,a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and.nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all Inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or.cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow dins-3q 3 Tltla 5 Offklal Inspeolfon Form:Su nWaoe Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph& Deidre Geary Owner Owner's Name informationairedfor Is Osterville Ma 02655 3/16/2017 required for every City/Town state Zip Code Date of Inspection page. p 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5ins•3H3 Us 5 Otri W lnspecUon Form:Submtece Sewage Ofsposai System•Page 5 or 17 r - Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph& Deidre Geary Owner Owner's Name information is Osterville Ma 02655 3/16/2017 required for every page. Cityrrown 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? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as NIA) ® ❑ 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? M Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd 15ins•3M3 Title 5 OMW krspection Force SdM$fwe Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusefla Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph&Deidre Geary Owner Owner's Name Information is Osterville Ma 02655 3/16/2017 required for every page City/Town Site Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No current Last date of occupancy: Date CommerciaUlndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/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: 15ins•3/13 'nW 5 Official tnspedw Form:StAmrtece sewage Disposal System•Page 7 or V Commonwealth of Massachusetts Title 5 Official Inspection Form ra Subsurface Sewage Disposal System Form Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph& Deidre Geary Owner Owner's Name information is Osterville Ma 42655 3/1612047 required for every page. CiRTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? [] Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/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): t5irro-W 3 Title 5Offraal h8pedim Form:&bsrrb w Sewage Disposal system•Page 8 or V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph &Deidre Geary -- Owner Owner's Name Information is 4aterville Ma_._ 02655 3/16/2017 required for every Cityrrom state Zip Code Date of Inspection page. D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: original system 1979 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): _ Depth below grade: 1.5feet Material of construction: ❑cast iron [0 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting,evidence of leakage, etc,): Joint were ok, no leaks, vented through the roof Septic Tank(locate on site plan): 1 Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass. ❑polyethylene ❑other(explain) If tank is metal, list age: year Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons 601 Sludge depth: t53na•3113 Me 6 Offidef InsPeafm Foms Subswiaw Sguaga D'wpose4 System-Pape 9 of V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph &Deidre Geary _ Owner Owners Name Information is Osterville Ma 02655 3/16/2017 required for every page Cityrrown State Zip Code Date of inspection D. System Information (cont.) Septic Tank(cont.) 311 Distance from top of sludge to bottom of outlet tee or baffle 3,1 Scum thickness 6n Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers, took measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance.water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap(locate on site plan): Depth below grade; feet Material of construction: ❑concrete E] 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 t5ms.3113 TWe 5 Ofifclal Inspection Form!Sdmdece Sewage Oisposel System•Pace 10 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph &Deidre Geary Owner Owner's Name required for every is Osterville Ma 02655 3/16/2017 r page. Cityrrown state Zip Code Date of Inspection D. System Information (coot.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: --- Material of construction: - ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5na-3113 Tide 5 Oftal twoocdon Fom..Subau fmo Smw Disposal System-Pape 11 of 17 Commonwealth of Massachusetts y lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph&Deidre Geary Owner owner's Name information is r¢guired for every Osterville Ma 02655 3/16/2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Ut 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.): Distribution box was in good condition, no rot, water level was even with outlet invert. 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: t5irm•3113 Me 5 Official hapecUan Form Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph& Deidre Geary _ Owner Owner's Name information Is required for every Osterville Ma 02655 3/1612017 page, Citylrown state Zip Code Date of inspection D. System Information (cont.) ' Type: ® leaching pits number. 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching Melds 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.): Leach pit was found to have standing water 3"below inlet invert resulting in a failing inspection. 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 15ins•3H3 TWO 5 OfB W Nspecbon Form:StmsWace Sewage Ulsposel System•Page 13 d 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph & Deidre Geary Owner owner's Name information Is Osterville Ma 02655 3/16/2017 required for every page. Cityffown State Zip Coda 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 F Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): LAft-3113 Tltle 5 OBdal Inspection Fam Subaudaee Sewage Dlepo3l Syatem•Pepe M of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle a Property Address Joseph&Deidre Geary Owner owner's Name information is Osterville Ma 02655 3/16/2017 required tar every State Zip Code Date of Inspection page. C�ylTown D. System Information (cont.) r 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 11010 � At �$ C3Z ZS A3 3y t33 39 3 4 50' t5ins•3113 Mile 5 OMda1 k%pamon Fam:.Subsurface Sewage Disposed System Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph &Deidre Geary Owner Owner's Name information is Osterville Ma 02655 3/16/2017 required for every Pap. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 12'+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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 tlSGS database-explain: You must describe how you established the high ground water elevation. Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5tns•3113 Me 5 official Mopecllm Form;Subsurface Sewage Disposal System-Page 18 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Gentian Circle Property Address Joseph& Deidre Geary _ Owner owners Name information is Osterville Ma 02655 3/16/2017 required for every page, CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, G. D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed. ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 ofAdai inspealon Form:Subsurface Sewage Disposal System-Page 17 of V TOWN OF BARNSTABLE +JLOCATION C�-c) 4:e- f�� CIS SEWAGE#C VILLAGE ®,�P�- ASSESSOR'S MAP&PARCELAP/—®0"® INSTALLER'S NAME&PHONE NO. � ��®��✓�a�S'��l�, SEPTIC TANK CAPACITY LEACHING FACILITY: (type) eY W (size) NO. OF BEDROOMS �$ OWNER 6C<'WOF PERMIT DATE: S"— L"—,/;r COMPLIANCE DATE: Separation Distance Between the: --fte ® Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY l IB 7. 9 C0AeCA&r TOWN OF BARNSTABLE L0C. 'ION 9P- Ga 4t) Ciro- SEWAGE# I"VILLAGE D Mrt rVOL. ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY 10W LEACHING FACILITY:(type) T (size) NO.OF BEDROOMS 3 OWNER VA7'kevl c.� PERMIT DATE: 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 leaching facility) / Feet FURNISHED BY �It,OtLTien FO/ 1 � Dtc.k l � as ar 3 3y 3y� y 3� soy i 1.. No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 4pfication for his osaY pstetn Construrtlon permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No �,��' /�/}� /�� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel /o7J 0 G e-.41�J Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tt,No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 4914pill. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided � gpd Plan Date � Number of sheets Revision Date Title Size of Septic Tank-d��W- I- TJJVd' JO®O �r�4of S.A.S. G o'-'eoe"?4' C",00 l�c�?f Description of Soil �.rGrz_ eO Nature of Repairs or Alterations(Answer when applicable) tPe4& Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in r accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of lth. Signed Date Application Approved by Date '' (777 Application Disapproved by Date for the following reasons Permit No. G — Date Issued Fj - �- 13 2- No. �� Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ltlrltatlon for MIs l0sat �pstrm Construction J)Prmit Application for a Permit to Construct( ) Repair( ) Upgradee( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No.'.1 Owner's Name,Address;and Tel.No. - Assessor's Map/Parcel/a7/'" C O , G Fib XIA0, Installer's Name,Address,and Tel.No. 'A' Designer's Name,Address,and TeeL.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building XE.f'y No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date '��"/� Number of sheets J Revision Date ' Title Size of Septic Tank-d N'-1'7-W.6: /p O O 6;T1400f S.A.S. Description of Soil f�.Gr 1©erg Nature of Repairs or Alterations(Answer when applicable) t_pe f 400d-4olo' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of lth..� —I--- /,> Signeded Date Application Approved by Date f Application Disapproved by Date ` for the following reasons Permit No. G _ Date Issued S- 2 — i 7 THE COMMONWEALTH OF MASSACHUSETTS �. BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired . Upgraded( ) Abandoned( )by l.P/r! at C Ct/�'.r�i' /� G��� Of' has been constructed in accordance with the'provisions of Title 5 and the for Disposal System Construction Permit No.dO+ 1 32—dated ^r Installerll�J� lGt�Oy Designer 4O #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system Al funct'X signed. Date �� �2 Inspector , : �� . ..... -------------- ----------------------------------------------------- -=-= -_=--=_------ _____------------------------------------- -- V ----- No. 13r Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. 0 D -S ? _ C2 g ate �j 7 Approved by r. Town of Barnstable Regulatory Services ° ti c� Thomas F. Geiler, Director BARNSrABLE° Public Health Division 'DrEc39�a Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 - Fax`. 508-790-6304 Date: dtthci-4Sewage PermitplA A��� Assessor's Map/Parcel 0 Installer&Designer Certification Form Designer: c �� � Installer: J04 'f L. Address: I Address: r a✓Ir� �T6 � �( On `�" � — '� was issued a permit to install a (date) (installer) F septic system at • M based on a design drawn by. address dated 1411 2,6 Y (designer) ) 1 certify that the septic system referenced above was installed substantially according.to the design, which may include minor approved changes such as lateral.relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local R '-tions. Plan revision or, certified as-built by designer to follow. Stripout•(if rp acted and the soils were found satisfactory. • OF �P�tN MqsN I DAVID B. C ' g MASOy rc nstaller s Signature) ; a No.1066 a �; /gT esi er s Signature) q PLEASE RETURN TO BARNSTABLE PUBL._ fE OF COMPLIANCE WILL NOT BE ISSUED UN i iL asu i ri. i rin`r ORINI AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. q:\ofCice fonns\designercertitication forni.doc I`. Y� } ]tta Town of Barnstable r# Departitnent of Re ato ` r1'Services => Public Health D' � . nentlernHt� 1Y1S�OD.. , Date MA93 . }'e717� a, 200 Main Street,Hyannis MA 02601 Date schedules oD *. Time _V q Fee Pd. Soil Suitability'Asse meat for Sts a Disposal Performed•Bye. i - . Witnessed By: � LOCATION.&GENERAL INFORNATION Location Address /�%✓ a ear Owner's Name Address �!1✓�G� /' Assessor's Map/Parcel ~.,o�,2J 0000 -0� � - Engineer's Name NEW CONSTRUCTION J e REPAIR hone fi Telep ' �7 �6J j LT Land Use ' Slope;(%) / • Z4lol `6o& Surface Stones . Distances ftom: Open Water Body R '_Possible Wet Area ft Drinking Water Well . f[ Dralhago way___ft Property Line' Ot1teF ft S"TCH:(Street name,dimensions of lot,exact locations of test holes&pore tests,locate wetlands in proximity to holes) Parent material(geologic) A0 Depth to Bedroel( Depth to Orouadwator. Stan ng Water In Hole: Weeping fl-om Pit Fnae Estimated Seasonal High Oroundwnter -• DIF-ERUMATION FOR SEASONAL•HIGR WATL�R TABU k Method Used.- Depth Observed standing In obs.hole: In. Depol to sell mottled;Dellth to weeping from side of obs.hole: ln, Index Well fr' Reading Date.'-.Index Well lsval .. Ill.' Urotlndwater Adjustment {�t• Adj.gt nundwdter Level,, and Observation PERCOLATION TEST Hole fP _ .. r ^ Time at 9" a "^ .. Depth of Pero ' Time at V Start Pro-soak Time @ G") End Pre-soak Rate Miu./luch -22 Site Suitability Assessment: Site Passed 'i `Site Failed: 'Additlona[IT Needed(YIN)' Original: Public Health Division.4 ' Observ*dtIon Hole Data To Be Completed on Back Zf percolation test is to4be conducted witilin 1009 of wetland,you must first notify the 4 Barnstable Consei`vation Division at least one(1)week prior to beginning. Q:\SEPTIC\PERCPORM.DOC T DEEP-OBSERVATION HOLE LOG -Hole#� Depth•from Soil Horizon Soll Texture Sditolor Boll• Other ' Surface(in.) (USDA) (Mansell) Mottling (Slnucturo,Stoned;Boulders. r at tc c 96't3ravcll i ti y i r {T DEEP'0B5ERVATION HOLE LOG �Hole#_ Depth from Boll Horizon Soil Texture Soil Color Soil Other. Surface(in.) (USDA) (Mutsell) Mottling (Structure,Stones,Boulders. on i en DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Mumicll) Mottling (Structure,Stones,Boulders. Conalstancy,%G DEEP OBSERVATION HOLE LOG Hole# Depth from = Soil Horizon Soil Texture Solt Color Boll Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stopos;Boulders, Consistency. i . T Flood Insurance Rate Map: Above 500 year flood boundary No_ - es Within 500 year boundary No Jfes Within 100 year flood boundary No., Yes ,. Depth of Naturally Occurring Pervious Materlal Does at least four feet of naturally occurring pervlo torlal exist in all areas ohsorved thrpughout the area proposed for the soil absorptibn system? If not,what is the depth of h rally occurring per floucMatoriall r Certification I certify that on �• (data)I have passed the soil evaluator examination approved by the Department of Enviro ent Protection and that the above analysis was performed by me consistent with . there ui ,expar' a n perien a described in 10 CMR 15.017. ' Signature Date ( 216' • QAS.EPTICkPBRCPORM.DOC 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: 22 Gentian Circle Osterville,MA 02655 Owner's Name: Joe Vatkevich Owner's Address: Date of Inspection: April 6. 2007 - 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: � y ✓ Passes Conditionally Passes ds Further Evaluation by the Local Approving Autho ty ate' a is Inspector's Signature: Date: A ril8 MAX The system inspector shall sub i a copy of s inspection report to.the Approving Authority(Board 6 Health or =f )> DEP)within 30 days of complet g this inspection. If the system is a shared system or has a design 10 .of 10,( 0 +ai gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional o ice of tl9 DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and t,a approving authority. Notes and Comments ****This report only describes.conditions of 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. 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: 22 Gentian Circle Osterville. AM. " Owner: Joe Vatkevich Date of Inspection: April 6, 2007 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(§). 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: 22 Gentian Circle Osterville.MA- Owner: Joe Vatkevich Date of Inspection: April 6, 2007 6 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 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 22 Gentian Circle Osterville,MA Owner: Joe Vatkevich Date of Inspection: April 6, 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 cesspool ✓ 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 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 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: 22 Gentian Circle Osterville,1W Owner: Joe Vatkevich Date of Inspection: April 6, 2007 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 22 Gentian Circle Osterville,MA Owner: Joe Vatkevich Date of Inspection: April 6 2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): .330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [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)): 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): and 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: Pumped last year-per owner 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 ' ✓ 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: Installed on May 25 1979-per as built card 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: 22 Gentian Circle Osterville, AM Owner: Joe Vatkevich Date of Inspection: April 6, 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: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 16„ 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. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 2" Distance from top of scum to top of outlet-tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Cement tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of IeakaQe. 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 y Page 8 of l l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 22 Gentian Circle Osterville, AM Owner: Joe Vatkevich Date of Inspection: April 6, 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 _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: 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 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 There were no signs ofsolids The cover was 2'below made. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(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: 22 Gentian Circle Osterville,AM Owner: Joe Vatkevich Date of Inspection: April 6, 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6' 6000 alb_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): The pit had 2'of liquid on the bottom. The scum line was at the same level. There did not appear to be any signs of failure. The bottom to grade was 9'. The cover was Y 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 ponding,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 Z Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART C SYSTEM INFORMATION(continued) Property Address: 22 Gentian Circle Osterville,MA Owner: Joe Vatkevich Date of Inspection: April 6. 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. � as ear 10. r ` Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.INFORMATION(continued) Property Address: 22 Gentian Circle Osterville MA Owner: Joe Vatkevich Date of Inspection: April 6 2007 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water . 35+/- 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 maps the maps were showing approximately 35'+/Around 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 11 L;0 CAT ON EWAG E PERMIT NO. ,- a S r+' AA C 9' I L L A G E - ( 20&I 680 INSTA LLE 'S NA E i ADDRESS 2611 i 5 4�p/ B U-tt D E R R O N E R ✓✓�� D r '1^ DATE PERMIT ISSUED , � L/ -17` 7Z D=•ATE COMPLIANCE ISSUED S_25= 7 °J. � r `4 No.----..:`&.�.P� ............... THE COMMONWEALTH -OF MASSACHUSETTS BOAR® OF HEALTH /...P... �11.._:...........OF......... 1�1"A/ °./<a.61...e--------------------------?---- Appliration for Diipnoa1 Works Tonarnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ............ / �I.SI_!�..`.�i-r,l lc, [err/ `7.Glf.� ./...j _. ./�g•rG/t_ll..!s:x...._... Location-Address y t o Lot N ....... --- __..!!`�ICF.r ...sl. .._ ...�.�s.L` �x f..:.Cf.�F•-...... Owner dress ea................................................... , 1 �_ � ... �1.�... } L--------- Installer Address Type 9f Building Size Lot............................Sq. feet V ✓Dwelling—No. of Bedrooms._ ��u _______________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures ---------------••----=--------- -- . W Design Flow.............................. gallons per person per day. Total daily flow................. .3�.�.............gallons. WSeptic Tank—Liquid*capacity..�p gallons Length................ Width................ Diameter_______-___-_- Depth................ x Disposal Trench—No..................... Width.................... Total Length............ Total leaching area.._...........,--___sq. ft. Seepage Pit No...!l_�L2..... Diameter._........... Depth below inlet.__. ....... Total leach in area.�'��_....sq. ft. Z Other Distribution box (;� Dosing tank ( ) oh- �� ` Percolation Test Results Performed b ...... ............................. ..... aTest Pit No. 1............_---minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------- - .......................... ----------•-----.--•--•------ ------------------------------ ••.......... --------- ••--- O Description of Soil........../7?�s`/---------------5 -------------------••----- x U -------•-•-----------------------------•---•--------•---------•--•-•••-•-----------...--••-•-•------.....--•---••••••--••--•------••-------•-----•-•----•----•----------------------•-••------------•-•- W -------------------------------------------------------------------------------------- ------------------------._......----------------------------------------------------------------------•--- U Nature of Repairs or Alterations—Answer when applicable__________________________________________________________________________________•-_-_--_--_-- ----------------••-•••------........----------------•••-•-•--•---------------------........._.....•-•---------------------------•-•---•-------••----••--•---•-•-----------•-•--••....--•••-............ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITL� p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has br is ed_ by the Soard of health— Date n v Application Approved By...... • --•1:�.. ..._ .. . - --...Y=1 T Date Application Disapproved for the following reasons------------------------------'--------- ----------------------------------------------._...----•••......_...-- -------------------------------•-------------------------•----•-••-••---••-••--•---••---......---......--•--•-••••---•---•---•--•--...••-•.......--------------------------------------------------- I Date PermitNo......................................................... Issued....................................................... Date �g7q, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / �av ..... OF.....-... 1.. !. ............................... k Appliration for Disposal Workii Tonstrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal. System fat: "s «. •--» f f�'j / f Location-Address ♦ ! o Lot Ng. ",� �I Owner 44dress W _..., � r'A. f.. �,h<t--..............._-----------------.................. �t�.� -,� . ✓,!11g...X.-_f? -- l Installer Address dType of Building � Size Lot.....................:......Sq. feet ✓Dwelling—No. of Bedrooms-_--•---f-%,-.�........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers — Cafeteria Q+ Other fixtures..-.................................................................................................................................................... Design Flow--------•-----•-•-••----------6$.::?. �-•.-•�••--=----•--gallons. W 'g "`-��gallons per person per day. Total daily flow................s WSeptic Tank—Liquid*capacity..'. ?__gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. --__--_--•--_----- Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No...1EG'F'M----- Diameter------ ....... Depth below inlet........ Total.leaching area.. d ...sq. ft. Z Other Distribution box Dosing tank ( ) 19c 1h, L1 -• -/y ~' Percolation Test Results Performed by-_..,a�,r .*_/_c........!±'Wit............................. Date._.F,..- CLT-3_ ...... aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --•--•-----•••-•---------------•-------•--•-•-•---•---•---------------:-._.---•••-•-•-•-•-•--.--•••-......................................................... ODescription of Soil..........IV`--d....-----•---•. --•------------------•-------------------------------- U ----------- •----------- •------------- •--------- ---------------------------------- .-----------..... ---------------------------------------------------------••--- ------ ----. ---------- �141 U Nature of Repairs or Alterations—Answer when a---licable__________________-_____----___-___-___._-.____--------__---------------------------------- -----•----•-•••-----•-••----•--•-••...-••-----------•-•-•---•----••---••------••-•---••------•-•--•••..........-•-------•••.....-•----------•-•-------------------••••••-•---•-••----••.............•--• 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 the system in operation until a Certificate of Compliance has beon is vvg,�by the board of healt12— Signe ..A...... "1 Date 1 y • Application Approved BY••---• �?e , Application Disapproved for the following reasons:_........................... ......................................................................... ..............................................-••-...-•-•-._......---•--•-------•------•-•-•-••---•---................................................................................................. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF � EALTH ........... .qr�ifiratr ..OF............... 1 ............................................ of Tlaimpfianrr THIS IS 7,P CE TIF ; T 'the Individual Sewage Disposal System constructed ( or Repaired ( ) f ' by... ...... •.---- .........................-•-•- ..-----....-------------------------•---- --••--........... at ...... 4nct - f s e .. { ----- �tall he State Sanitar ohas bee installed in accorda the prop lslons of T o y de as described in the application for Disposal Works Construction Permit No._ _ dated_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED ASA GUARANTEE THAT THE SYSTEM WI A UNQTION SATISFACTORY. DATE............. ........................�•----7 ._ ------------------ Inspector..... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF................ ,�........._..................._................. r �7d. !.... �y�t� FEE..._a .......... No................ ••... o ur#ion "antic Permission is reby granted....-- . - �----'-------------•-=......---•---•-••--•-------•---•-•••......--•--................. r an to Construct ( epair ( ) Ili lvi.ual Sewage Dispo j S st � at No..... 'A �L' l.. . ' treet as shown on the application for Disposal Works Construction Per, it o. _:__1--------_ Dated.._........ �......... .......... �.. c¢,01 -1/ ff� g ��......-•-•-•-•...............— r Board o�FIealth DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS f �',�t t.1GL'E trn�J1/lIl_�( - 3 �t?AQNC C�.J i •' �� :APT-lG TAR-.1K = 3-&O 4-95 6.P.D. USA- k >OCG 6AL-. t 4r L �SPOSAL PIT - uSE f oyo G&L SUMWA L AMSA. = tSo S.F. v F3c�t'�'tSa/l AA A* SO Sir`-. )Fir ! TO-t"A t_ 'C�ESIGIJ = 425 La.A.D. r a rati�e i -�To t_ 't>,d.1 L-Y Ft..Dw - 3'3D E•.P.D- �,� � _ VU12C-OL Tloat Owre : t"Iw 2Miw orz LL-9;. 3G '29JA Po t T� ;740 ba.d 91. 1OtsU 1{1V y t 7z '80U Srlc i o. ENV. f TA 04W- Ivao �5 �` iuv. tub ':• L 4 L�bcN ��r�� WAS►1ED , 0 Y ta GGtZTtG,( TWAT TNt� t' � C�1C S"OwbJ �Z���2c�IC. 4-i r ti r�i-.� GcxvlPL�(S W I TP TW- PATE -..-Akll— ::T l S $JOT ',A��CL7 U4•� /1 Ay5, ttJ�elavr�.t.tT ;U�.uc�{ � "t'Nt;- t3Ft~S�T�, St-1o�l.n A.F�t��t t�A.t•�t"T' 4F ,br ec IVSC TC> i7G�'CQMI t= t_t� C' l_I we-: -- - 17— Va'T�AV,IC b: ___. O��tG►.t TA. S+iu ;'AMID-e - 3 -S�eooM h ! ►,lo GArz M6-GS- 6 C +.Jar:47— t--A+L4 FLAW s Ilb 3 = 'fib 4,P•V. usue- t C7C7p 6 AL. +' 'I r r `1 p� -Pt75A,L t-iT - use- t000 l cjv 5vr ,c 2.S = S7795, 4;.P.V' (>j 4•y �- 1 v TCFr,&L srk y 3`d T'2>TQ L. t�/s•1 t,.�f FL.t�W s 3'3U 6.F?D. � ,•, �� �o r,ar�+C GC-iZGGt,.4T1t�tJ CZI�TE . � +�.1 2.1�ri��.l• Ot'L �F,. �,t '�' ; 1, _ t �,h.��•' �s1 �j l..o441 „ sots» 4'P"vr. VKT. iw. G,a�. 4�•7 -Boy4U Sc-uric o I V- T-A BUG GAL. lfi.Gs �G'Z f4 4 LsAas4 a PIT lwgrw ! WAWF-D <� STONE. 5'i.� L c>CAT t o" Ow>TSU,,I u 9 i2 'O A.-T t--- A /shcj �-t o v/kTa*., ; c G T �rti-t A-r- N ovUoA�"►a�,.l 5uow+.� t�,r..t R �a�,4CC_ { ic:OAAVL l-(S W I TtA `W �j 1 U .t�i►=� , ij A,1J t� �E'x't?�G tC �'E-Q U i�Z E.ltit c i.l�'�s O F T►-1� -t � .� "(`1-11.5 VL.AW lS LloT Ate' 0.5f�2�/1L.LC ei rS.S�i, tW�,rQU,V1�t.1Z' ;u�+ie�{ � T+at✓ UFt✓,�T�, 5�-1a�l.D A;�P�:l G�S;ti,s•T-- f TOWN OF 13ARNSTABLE LOCATION -SO �t S 17(. SEWAGE# VILLAGE CE/tef,►4- ASSESSOR'S MAP&PARCEL I7/ 6 j INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) G"i x size on NO.OF BEDROOMS 3 OWNER (�� w�; V PERMIT DATE: 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 leaching facility) Feet FURNISHED BY T,1Uc.&l— T FOr2 i GArA L rr�on► -p0°< �1 11 � � 6 c�- III a5 i � S AssEssoRs MAP : TEST HOLE LOGS PARCEL : p SOIL EVALUATOR : 1 ►/ 1) The installation shall comply with Title V aj;-J Town 401�*board olr � Z� FLOOD ZONE: /�QJ' ��G��� WITNESS : ( � � lfealth Regulations. 2) The installer shall verify the location of utilities, sewer inverts and septic REFERENCE: DATE: m components prior to installation and setting base elevations. V� h.� ,� �! PERCOLATION RATE: .— 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first Y two leet out of the d-box to the iraching shall be level. i l TH- I TN-2 4) This plan is not to be utilized for property line determination nor any other 74purpose other than the proposed system installation. I 5) All septic components must meet Title V specifications. b 6) Parking shall not be constructed over H10 septic components. ?74 LID yp 19 O, 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total LOCATION MAP ! f 4)0 design flow and number of bedrooms to be considered for design. Receipt W of payment for the plan and installation based on the plan shall be deemed `V+�-I approval of the design flow by the owner. C '�`� 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall .t be removed along with contaminated soil and replaced with clean sand per Z U Title V specs. I + 1 b 10)System components to be 10 feet from water line. Sewer Iines crossing the water line shall be sleeved with 4 inc h SCfl40 PVC with ends grouted it applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. l SEPTIC SYSTEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. 'o FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such exists. ) D 00 - GAL/DAY 13)Tae installer shall veri the location quantity and elevation of the sewer BEDROOMS AT IO GAL/DAY/BE R M ? fY , q Y r' lines exiting the dwelling prior to the installation. Nl14)This plan is representative only that a system can fit on a property meeting / J SEPTIC TANK �a I 0, Title V requirements. MGAL/DAY x 2 DAYS - W GAL 1 � USE �� GALLON SEPTIC TANK IMt j1r� r' Q� _ o-1 1 R P�i ON -'--CSYSTE - — y, - .r31 SIDE AREA: Z� -�- vZ�0072 )(z X �1 I I �, q d�� DAVID _ s BO'�TOM AREA: zS l2,'��a X 0,�� Z�J, ( F t MASON r v & NO.1oss o �y Q/STEPS S'tNl AR\P��/' ELC SYSTEM SECTION 6� II X IGAL �_ L n j D�_�.,. �'� � f�1 �1 1 n ! SEPTIC T NK b� I 4 \ SITE AND SEWAGE PLAN LOCATION : �ka / yl r PREPARED FOR : 0 o l SCALE:I 'ib) DAV I D B . MASON R5 D 0 11-7 ' J DBC ENV I RONMEN�TAL DESIGNS ATE J W EAST SANDWICH . MA DATE HEALTH AGENT ( 508 ) 833- 2 177 Z