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0088 GUNSTOCK ROAD - Health
88 Gunstock Road, Osterville A W 121 - 101 is r t t 4 TOWN OF BARNSTABLE L(Y-1ATION �8 clums 6C1 SEWAGE # VILLAGE 00��`AV l ASSESSOR'S MAP & LOT, INSTALLER'S NAME&PHONE NO. Ckv ,SEPTIC TANK CAPACITY tNnC) id LEACHING FACILITY: (type) 1A0 CAI 12 t I (size) r-4 140,OF BEDROOMS BUILDER OR OWNER �37 � TA -PlrrrATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility t O C Feet Private Water Supply Well and Leaching Facility (If any wells exist N� 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 x A3i -0 A V1'0`21 D� s6 L AT ION SEWAGE PERM T NO. G o g' V? LLAGE- ST LLEK NAME ADDRESS aalz e UILD R OR OWNER 0 ��/�� DATE PERMIT ISSUED DATE COMPLIANCE ISSUED b � � CA(L- . t N ........... ....."L THE COMMONWEALTH OF MASSACHUSETTS _-,--- B®AR® OF HE, s...OF........ . <� i. -�a ✓� Appliration for Uiiipniial Workii Tomitrurtinn ranfit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal Systeig ...•-- at: 0�� •------ --- ---- --- �. cation- dress �rfLot No. • . ........ ••. -• ....... ... ........ ....••----•---•--•-••-•----••......----------••--••-•......----------------•-•-•---•...-----••---- net Address W •.. ............ .................. - s - .... ...... �'��i. ........_..........__._ ................__..__.._.... Install r Address Q Type of Building Size Lot__ �aq. feet U Dwelling—No. of Bedrooms...................... -------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons__ _______________ _ _ rs — Cafeteria a' Other fixtures... ------------------ - ----- W Design Flow.................._._._ ______ . gallons per person�prr d��. Total dail o _______________ ._ ...............gallons.�r WSeptic Tank—Liquid capacit;��t�-�.gallons Length__ __ __.... Width__ 6iameter---------------- Depth_�_.� x Disposal Trench—No..................... Width......f-------_---. Total Length...___.________r.................... Total leaching area..___._.___........sq. ft. Seepage Pit No___________ _________ Diameter...../0....... Depth below inlet.•_....._...... Total leaching area.....sq. ft. Z Other Distribution box ( ) Dosing 1 ) - W Percolation Test Results Performed by....��--............................... Date �''--=--• - - - -. Date-- //S-/ ,a Test Pit No. L."- � minutes per inch Depth of Test Pit____________________ Depth to ground water........................ (i Test Pit No. 2_.G....._- iinutes per inch Depth of Test Pit.................... Depth to ground water........................ T --- ------•- fi ! --------- - Description of Soil-O.-Z.. _... O ..._...._ _...... � '.---,�.�CCiJS x U -•-•••••-----••••••---•----•--••--•-•-••-•-•--•••••......-•--•••--•--•--•----••-•••----•--•-•-••-••-------•-----•--------•---••-•----------•-•-••••-,............................................. W ................................................... UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ------------------------------------•----------- •--------•------------------------•---............-----•--•-••--------•-------••------••----•--•-•---•-•-----•----•-•--•-•---•-•......•------•...--••• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T`:L y g p y 5 of the State Sanitary Code— The undersi ned r her a r snot to place the system in operation until a Certificate of 'Compliance has een is ed by the th. Signed.. o --- ------... . .....3 at 111-. Date Application Approved BY............---621.-. --------- Date Application.Disapproved for the following reasons:---------------------•-----•---------------------------------------------------------------••-••••......----••-- ..--------••-•••--•••-••------•-•--••••--••-•---------•••-••-----------------•••-•--......_....••------•----••-•----•--••--•-••-••-•-----•••----•-...---•-•-•-•-••---•--•--•--•-•--••-----•----••••--••- Date PermitNo......................................................... Issued....................................................... Date N ................ ....... Fns.............................. THE COMMONWEALTH OF MASSACHUSETTS 1--_ _ " BO A R D,-O F H EA. .T M �r�... ...0 F.... i r'w 4 - .. Applirtation for Bh4paii al Worko Cann.5trurtion JIrrutit Application is hereby made for a Permit to Construct ( ), or Repair ( ) an Individual Sewage Disposal S stein at *,.......... ... ........•--=. u -r t................. . .................................. cation-Address t �or/Lot No. `- .......... t:�.: .�Q __ 1 /p ------------------•.................--••---••--•.•. -fit . . a-L--••�-.... ..... ... ............................................... ner Address W � Installl.r Address "'�"� �- - Type of Building Size Lot------ ... ..Sq. feet U Dwelling—No. of Bedrooms................- ------_---..__.___Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building _____________••--__-____._-- No. of persons....................%4 Ihowers (--).,_—_ Cafeteria ( ) Q' Other fixtures - ----------- W Design Flow......................±�.__.......r......gallons per person,ve day. Total it . o .---.------.---- ------•------gallons..�r WSe tic Tank—Liquid capacity/ .�/. - allons Length-_ �_.. Width................I Diameter................ De th.- ' Disposal Trench-No. ................ Width.......I.._.._._ Total Length.__......._..._..... Total leaching area._..........q. ft. x --- � f � Seepage Pit No..................... Diameter..{__� __..... Depth below inlet__.....'=___. Total leaching area:.....__.c-......sq. ft. Z Other Distribution box ( ) Dosing to k r( ) 4��Percolation Test Results Performed b �....- .... -•'� _.. 4'` /�a **��,, Y , a �'.. Date = ...................... 0_- Test Pit No. 1..�.,"^:.minutes per inch Depth of Test Pit-________-- •..... Depth to ground water------------------------ G%, Test Pit No. 2...!'`.....minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ws.......--- 4.......................... Description of Soil ,••-••-. ••••....•... _... y_+_ _ .------. ..._. t-" =V -------------------------•-•---------------------------------•------ --•------------------------•----------------------- 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 T the provisions of T 5 of the State Sanitary Code—The undersigned furl=:er,agre& not to place the system in operation until a Certificate of Compliance has been is ed by the board-off health. ' . f ---------------- X- Signed �� •"�? . - P - _._....__:f _ Date Application Approved By.----------- ---------------------------------------- Date Application Disapproved for the following reasons----------------------------------------------------------------------- e =' ....•••.........--•--•................•-•--••-••••-•---------------•--•••••-------------.....-----------------------•----•--------------•---•-•-------------------------•----••--------•---•-....--•--- Date PermitNo..................................................•--•... Issue(L....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS `,, --- BOARD OF HEALTH _ j{jJ� <.......OF........'1...1 ..r.:.."."y.,^,^;.�'+:+;-.h........................................ T-5rdifiratr of ToutpliFanrr THIS IS TO CERTI�F , That the Individual Sewage Disposal System constructed (.,<,) or Repaired ( ) by..... _. _ . ---•....•---------------------------------------------------------------•---•-•---•.......-- o InBtaller has been installed in accordance with the provisions of T The State Sanitary de as d s ribed in the application for Disposal Works Construction Permit No.__ -:__.. ............... da.ted _: _y_ ..._.._.___._______. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE. SYSTEM WILL FUNCTION SATISFACTORY. E '5 � Insector____.__.__DATE...............:. .�_� �. . . �• THE COMMONWEALTH OF MASSACHUSETTS BOARD—OF HEALTF;V" r' ........... ............... No............... ....... FEE....................... Dtopoii al Works,' t,itr io' n Vamit . .� ......� � Permission is hereby granted_..- ...................................=••----------------- --------------------------------............................. to Construct (✓ ykor Repair ( _ n Individual Seuwage_Dljsposalt System at •� J Jrlf r /�� Street as shown on the application for Disposal Works Construction Permit :.__.__A._� ed......�:_;,3"� .......... Board of Health DATE......-- 1---------•----•-•--•---------•--------•• FORM 1255 HOBBS & WARREN. INC., PUBLISHERS IL _ iDt? O� . �a&,,C-s i W / ,y 4 / p A d 1� 3�- �. V) it- , . 1 60 _ /00• 00 ' (S akJS70C,r- Q©RL> . LEGEND ��,ti��� OFA+�ssAf - CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION OxO �� ROBER7 G EXISTING CONTOUR --- 0 -- - P. FINISHED SPOT ELEVATION o BUNIKIS FINISHED CONTOUR . 0 " " Rai �" �L Nu 22162 0 APPROVED : BOARD OF HEALTH n\sc�srE�b�`��` IN NAU�� NASS* DATE AGENT SCALE= 1" = 30' DATE = Feb " ow LDREDGE ENGINEERING CO. IN CLIENT_osk l,w �v Lysl, SSA I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. 822*9_ BUILDING SHOWN ON THIS PLAN CIVIL LAND CONFORMS. TO THE ZONING LAWS ENGINEER SURVEYOR DR.BY J P OF BARNTAB E, MASS. 712 MAIN ST. CH. BY; 2 S I HYANNIS, MASS. SHEETS OF TZ— DATE REG. LAND SURVEYOR ?O OR PT M/N. N®TE` /i' drl7,,Y'R T/+/E SEPT/G r A/N/�C LZACAVI"rr-P/r AME MORES TNA/V /2"SOLO PV M/N �R�►OF, A ?4'O/AMT.FER CONC.4-F7AF COS/E /O I' w°SHALL SF 0 POtISN7- TO GRADE.64N EXTRA -• coNCA4.r4r /`IEAVy CAST /RO/9� CD✓ER .S/SAL 1- BE USEO v r E�� /OG, coY w�s/N. P/TCN j�}'Od9pFT OR/VENVAY WON M/N. CO/VCRL�TE A ON C`O✓ER CLEAN SA/VO 6AL.eF/LL AFL _ =�� . .A - • • I... .• a� DER%" / o/cvPt O G G _ M/N.P/7Y.N GAL. • • • . • • • •• • e WASVPV 570E 3' �Ni►'P�►R n SePrIC TA/VX D/sT • • • • • • • • • • . .;/• Boy • s • • 0 • • o •• r .•• . ,:, • • r • • p�PTN • •• • WASM.F0 STONE INYBRT CL�YAT/dlNd o �. r • • • • • • • • �. o P/7 DR L9p[!/✓. • s /#VYArA7 AT ON/LO1/V6 I FT, G s�7 D/A/rl. /NL E7 TAC Ti?NK FT_ FT. O/AM. C(SE6 n4etiL.�r)oiv� ali ®N74FT ' "PT/C TANK �� /NLFr PIS.RZA&7 N BOX 4 F7. SFCT/O/V OF GROUND I44TER TitdiLE oo7z&rpi3Mi®vrioN eooX ` P7 .SEyVA6 O/sPO�SA J. SYST�/rt *M4JFr LLrAC///NG /M/T rsY�._FT. � . .,�. -rA4M11-AT/4oN LEACH//VCw P/T 41 JtALL• %4~ _ / : D' D/Af4fi is/ON A FT. DffSlgrN CR/TER/A /o/v a—e —Fr , N//AI�Fi� OF jwzw00MS 3 D/ME/1/S/ON C FT G4jq 4C.Z plSpo5AL t w/r SO/L LOG SOIJ- 71A'57' o: T,9TAL E!T//*KT6.O P'L,0N/3,3a 4;A1../A4,r soli- TEST o/ SO/L 7TST02 MUMBL•iP OW 4rACN/N4 P/7S lrtL'✓. 9?,G I!ffiFY. q s' G OV4 TE OF d 0/L. TEST N!H i r j S/OF LOCH/NO AeR P/ Or BOTTOM L�OCN/N�PAR P/T PT. G 1 ' A 44COAATYDN MATE/ C �•c��- Su t I�JKOA.A7 70N RATE I&2 /M/N. NCH TOTAL lE.4CN/N6 AMFA �- '�a �P'T. � C I R/��i►Ri�E LE4C/V/NB IORBA_ �SQ. Pr Of Xrj, SERT a is SUNIKIS LL 1 �Q, p �-'/. G 7/Z /aAIN ST.• i SSi� t i` N/J NA •/I►iD B/�D�//V�+ I�,TBR I7VC0[l/VTBJtAr MEAN , MAi78. y o uwo hetA771 R �T ELF/. .JnO ,No. va awamr Or.. s - F yam. r V i 7 r X e 'k 7 t r. 'tr r ! / 7 , C0%V1%40N«VE.�LTH OF KkSS?►CHUSETTS ^� EAECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ DEPARTMENT OF E'�VIRONMENTAL PROTECTION I= " ONE WINTER STREET. BOSTON. I1tA 02106 6I7-:9_-540(1 WILLIA% F.UILD r.. TRUDY C z. GOvCmC ARGEO PALL CELLL'CCl ::-,... 3 - DAVID B STRL'1-- URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Comrrissianr. Lt.Governor SUBS A*Q— PART A CERTIFICATION - pQ,U %sT� Property Address; C'7VNc'fi'ocaL 1 0Sr-<AL•v%I Vt , /Address of Owner: lY.Z Date of Inspection: 11 V�� :(If different) �� --AA r: Name of Inspecto : er o __--- am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name:A}/ Q M-k,'e Eir k—, ag 0" p AA 4E-�/ Mailing Address: 3?O /3o,c �339 . . H/9S p2tZ H I9-0 e 6'4-'7 Telephone Number: r 5-e CERTIFICATION STATEME\T I ce.^.,f1 that I have pe,sonally inspected the sewage disposal systern a: this address and tha: the information reported be!o%,% is true. accurate and comolete as o:the time of inspectoo•-. The inspection Nas penormed based on my training and experience in the proper function, and maintenance o;on-sae sewage d,sposa; systems. The s-stem: , Pwzel _ Concit,onaii% Passes _ %eecs Further Evaluation 9v the Local Approving Authority I- WInspector's SignatureDate: q T;ie S,.•ste-r Inst:eco• sha!' submit a coPe of this inspection reper, to the Approving Authorim- within them, (30) days of completing this inspection. It the s%-stem is a shared system o, has a design flow of 10.000 god or greater, the inspector and the systerr, owner shall submit the report tc the appropriate regional office of the Derarment of Environmenta' Protection.. The orig!na! should be sent to the system owner and copes L—nc to the buyer, if applicable. and the approving authorir%. INSPECTIO'si SUMMARY: Check A, B, C, or D: AI SYSTEM PASSES: 1 have not found any.information which indicates that the system violates any of the failure criteria as defined in 310 C.mR 15.303, Any failure criteria not evaluated are indicated below. . COMMENTS: BI SYSTEM CONDITIONALLY PASSES: y One or more system components as described in the 'Conditional Pass" section need to be replaced or repaired. The systern, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'not determined",explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attachedi indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltrat,on, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (rev.cSod 04/2:!97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A c• ':;. �s CERTIFICATION (continued) Property Addms: --:; Owner: , . . . ..._ _.. . . . ..:r Date of Inspection: ej SYSTEM CONDITIONALLY PASSES (conun,P'' _ Sewage backup or breakout or high static water level observed in the distribution box s due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass nspeciion if(with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed ; _'.......:..., _ distribution box is levelled or replaced _ The system required pumping more than four times a year due to broken or obstructed pipets).,The system will pass inspection if twith approval of the Board of Health): - broken pipets; are replaces -- obstruction is removed C) FURTHER EVALUATION 15 REQUIRED BY THE BOARD OF HEALTH: - Conditions exist which require furthe,evaluation by the Board of Hea h in order to determine if the s)•stem is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINE THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY D THE ENVIRONMENT: Cesspool or priv-, is within 50 feet of a surface wat . Cesspool or priv- is'within 50 feet of a bordering egetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH ND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THA PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The systern has a septic tank and soil ab rption system (SAS) and the SAS is within 100 fee, to a surface water supply ar tributary to a surface water supply. The system has a septic tank and soil sorption system and the SAS is within a Zone I of a public water supaiy we!l. The system has a septic tank and so' absorption•system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and s it absorption system and the SAS is less char. 100 feet but 50 feet or more from a private water supply well, unless we![ water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution f om that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method u to determine distance (approximation not valid). 3) _ OTHER - (revised 04!25/77) Page 2 of 10 • 1 1 .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D) SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following - I have determined that the system violates one or more of the following failure criteria as efined in 310 CMR 15.303. The basis for this determination is identified below. The Board.of Health should be contacted to termine what will be necessary to correct the failure. Yes No Backup of sewage into facility or systemcomponent due to an overload 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 boa above outlet invert due to n overloaded or clogged SA5 or cesspool. Liquid depth in cesspool is less than 6" below invert or available olume is less than 1/2 day ilov. Required pumping more than 4 times in the last year NOT du to clogged or obstruaea pipes:. Number of times pumped _. Any portion of the Soil Absorption System, cesspool or priv is below the high groundwater elevation Am' por:.on o:a cesspool or privy is within 100 feet of a urface water suppiv or tributary to a suriace water supply. Any porion of a cesspoo' or prr�• is within a Zone I o'a public well. Am portion o;a cesspool or pri,.tiv is within So feet 9f a private water supple well Am por,-or, o,a cesspool or pricy is less than 104 feet but greater than 50 feet from a private water supply well with no acceptable water qualiN analvsis. .li the well has n analyzed to be acceptable, anach cope of well water analysis for coliform bacteria. volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E7 LARGE SYSTEM FAILS: / You must indicate either "Yes' or "No" as to each of the following: The follow:ng criteria apply to large systems in 710,000 ttion to the criteria above: The system serves a facilm with a design flow gpd or greater (large System; and the system is a significant threat to public hea!th and safety and the environment because one or more of the following conditions exist: Yes No . the system is within 400 feet of surface drinking water supply the system is within 200 feet f a tributary to a surface drinking water supply the system is located in a ttrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00 Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: �7UNSrOG'� Owner. 61 Its Trr Dave of Inspection: Check if the following have been done: You must indicate either "Yes" or "No"as to each of the following: Yes No_ Pumping information was provided by the owner, occupant, or Board of Health. *uC _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As bull: plans have been obtained and examined. Note if they are not available with N/A. The facilin, or d,%elling %%as inspected for signs o`sewage back-up. _ The system does not receive non-sanitan. or industrial waste flow. The site %%as inspected for signs of breakout. All system components, excluding the Soy! Aosorpuon System, have been located on the site. -- The septic tank manholes Nere uncovered, opened. and the interior of the septic tank was inspected for condition of t� bafiies or tees, materia' o' construction. dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on The iacilit� o%%ne• tano occupants. ifdifteren: from owneri were provided with information on the proper maintenance of Sub-Suriace Disposal Svsterr.. (A- Existing information. Ex. Plan at B.O.H. _ Determined in the field :r an,, of the failure criteria related to Part C is at issue, approximation of distance is unacceptable (15.302.31til (rovimad 04/25/97) Pag• 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORtit PART C ` SYSTEM INFORMATION Property Address: e� C- AJ5Tr OTC- Owner:($(I ST'& Date of Ihspection: 1 l FLOW CONDITIONS RESIDENTIAL: Design flow 3-21Q p.d./bedroom for S.A.S Number of bedrooms. Z Number o current residents--o- Garbage g,.:der (yes or not:, i z Laundry co-•-ected to system (yes or no). - Seasonal use (yes or no::L1 r Water meter readings, if available (last two Q1 year usage tgpd): 1�) Sump Pump (ves or no) 1J Lac- date o!occupanL%-6 �'R- COMMERC i AL'INDUSTRIAL: Type of establishment. Design fio%% _galionsida% Crease trap present. (ves or no-_ Industrial V%aste Holding Tani: present. (ves or no ':on-sanitan waste discnarged to the Tine 5 system, ;ves or no %%ater meter readings. if availabie Las:pa;e o; o cL;;anc-% OTHER: .Dekcribe Last care of occuoanc• GENERAL INFORMATION PUMPING RECORDS and source of information. r� - �oT wt 11•., t.�cw �vJ r.-+•e-�/L ra tire.-cry 4�� ev�,p System pumped as ar, of inspection: (ves or no.,Za If yes, volume pumped gallons t Reason for pumping TYPE OF SYSTEM _ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: U Sewage odors detected when arriving at the site. (yes or no) /z (revised 04/25/9*7) Page 5 of 10 r r 1 SUBSURFACE SBVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTE.41 INFORMATION (continued) Property Address: Owner: &?�15ft+ Date of Inspection: I I BUILDING SEWER: (locate on site plan) N Depth below grade. Material of construction. _cast iron _ 40 PVC _other (explain) Distance from private water supply well or suction Ii Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site an 11 Depth below grade Material of construction: ,&concrete _meta _Fiberglass _Polyethylene _othertexplain 1f tank is metal. Its: age _ Is age confirmec b\ Cen:fica:e of Compliance _(Yes-No Dimensions U60 I Sludge depth Distance from top o: s!udee to bottom of outie-. tee o• ba^';e Scum thickness: let Distance from top of scum to top of outlet tee or ba^ie�1 Distance from bottom of scum to bo-o-r+ oi outlet tee e• ban-e Itl�l Now dimensions were determined t1�A�no�� Comments. (recommendation for pumping, :condition o� inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.t GREASE TRAP:A (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 04/25:97) Page 6 of 10 i ' n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertm Address: S O (f,jW STkIc, Owner.�1<<,jTA- Date of Inspection: TIGHT OR HOLDING TANK: 7ank must be pumped prior to, or at time,of inspections (locate on site plan, Depth below grade: Material of construction. _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacm gallons Design flow galions•da. Alarm level Alarm in working order_ Yes. No Date of previous pu`nping Comments (condition of inlet tee. condition oa alarm and,fidat switches. etc.( DISTRIBUTION BOX: + (locate on site pa- Depth of liquid level aoove oune: m�er� Comments tnote rf leve! and distribut,on 1� ea. a' evidence or solids carryover evidence of leakage in o or out of box, etc.( I c r 5� �-s-T2tbUA-JQ� 2jt a �y�,c Sr,(�c� PUMP CHAMBER: (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.) rw { (revised 04/25/97) Page 7 of 10 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C SYSTEM INFORMATION (continued) Property Addr-ss: g$GVw,(cC,L Owner:0 t3TA- Date of Inspection: t I 149 9& SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible, exca. tion not required, but may be approximated by non-intrusive methodsi If not determined to be present, explain: Type: teaching pits. numberl�4J, leaching chambers, number:_ leaching galleries, number: leaching trenches, number,)ength: leaching fields, number, dimensioni. overflow cesspool, number Alternative system Name of Tecnnolog% Comments. in to ndition of soil, sign f hydraulic failure, level of po ing, c iti of vegetation, etc. c lI CESSPOOLS: (locate on site plar, Number and configura:.on Depth-top of liquid to inlet inner, Depth of solids layer Depth of scum layer. Dimensions of cesspoo: Materials of construction Indication of groundwate• inflow (cesspool must De pumper as par, of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:0 (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.) (revised 04/25/97) page I of 10 f r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: U�3� ' OwnerAIL51— , Date of Inspection: ' SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) ?- 30 P _ y PVZ- 37 I-3 t�3 �t 6 A xi ' 56 (revised 04!25/51) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property AddresF• Owner:C-7tiSTe.` Date of Inspeciion: Depth to Groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Cnec*" %%ith Iota! Board o• neaar Chec:. FE.MA Maps Check pumping records Check local eacavato,s. installers lase L SCS Da:z r• Describe it vour o%.-. %.oras ro,.% %ou established the High Groundwater Elevation. (Must be completed: vi s. Colo co-D �VIzm 40105f c '�J%�esT-I-CJ .�p-VMJS )Q-. l¢qZ- lzaviaad 04,25'9-. Page 10 of 10 (A Com monwealth of Massachusetts Executive of Environmental Affairs, p DEP <�- Department of ; Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A -CERTIFICATION Property Address: SS Address of Owner:--?,,,& cxrA (if different) VA. x5\8y Date of Inspection: Name of Inspector: V- 9-M, Q� Company Name, Address and Telephone number: 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 inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system Passes --- Conditionally Passes a --- Needs further evaluation by the local Approving Authority Fails Inspector ' s Signature: , ,�,c,, Date: �Ct\ The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 or the Department . of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. r. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: as Owners : i�aAa , Date of Inspection: AVA-IS INSPECTION SUMMARY: Check A,B,C,or D A)SYSTEM PASSES: -x I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,passes inspection. Indicate yes,no or not determinate CY,N,or ND). Describe basis of determination in all instances. If "not determinated", explain why not. ---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration , or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of H ealth). ----- broken pipe(s) are replaced ----- obstruction is removed ----- distribution box is levelled or replaced ---- The system required pumping more than four 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 88 ���►xT��'� Owner : Date of Inspection : C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE j SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC. HEALTH AND SAFETY AND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within_ 100 feet to a surface water supply or tributary to a surface water supply. --- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. --- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. -- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: --- I have determined that the system violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. ---- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3e C4uN97(-o,_IL Qd, O wner. 1 raAwoba. Date of Inspection 1119lgS D) SYSTEM FAILS (continued) --- -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 over- loaded or clogged SAS or cesspool --- Liquid depth in cesspool is less than S" below invert or available volume is less than 1/2 day flow. --- Required pumping more khan 4 times in the last year NOT due to clogged or obstructed pipe(s). number of times pumped --- Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy is within a Zone I 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 ana- lysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION.(continued) Property Address: Owner: k1o>joaA Date of Inspection: E) LARGE SYSTEM FAILS: r The following criteria apply to large systems in addition to the criteria above : The design flow of system is 10,000 gpd or greater Large System and the .system is a significant threat to public health and safety and (he environment because one or more of the following conditions exist : --- 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 Zane 11 of a public water supply well. The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: % ST-ce-►`.. Owner: NzeowcoA Date of Inspection: ttkcAdtS Check if the following have been done : Pumping,information was requested of the owner , occupant and Board of Health. X None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. - All system components,excluding the'Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. - The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. �n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: S'b Owner: AgxCX.k,cA. Date of Inspection: ktWc� 5 RESIDENTIAL: Design flow : 3 bo gallons Number of bedrooms o"b Number of current residents: v Garbage grinder (yes or no) : u� Laundry connected to system (yes or no): ye Seasonal use (yes or no): No Water meter readings,if available:v\A. Last date of occupancy : S%3vnm-p-q COMMERCIAL/INDUSTRIAL Type of establishment: Design flow : gallons/day 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 i Last date of occupancy Other: (Describe) ............................................................................................................ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information : .. ... ........ System pumped as part of inspection(yes or no) .....*?4?........... if yes, volume pomped : .................... gallons Reasonfor pumping :............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 8b Owner: "wou31, Date of inspection: i i q q S 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) --- Other (explain)............................................................. .............................. APPROXIMATE AGE of all components, date installed(if.known) and source of information �1QQAAK�wkt ...t t....0$..CRm.�Oe�F.►aTS..Qr, as..a1s'�.... r 4-. ... Q .:N`NVI ................................................................................................................................................. ................................ Sewage odors detected when arriving at the site : (yes.or no)...jx?..... SEPTIC TANK : ...k......... (locate on site plan) Depth below grade: ..4'�.... Material of construction: ...Y--. concrete ......... metal ........ FRP ........ other (explain) ................................................................................................................................................. Dimensions: . x.�� . Sludge depth:....%.......... Distance from top of sludge to bottom of outlet tee or baffle'...... ... ................. Scum thickness:...0............... Distance from top of scum to top of outlet tee or baffle: .... ...................... Distance from bottom of scum to bottom of outlet tee or baffle:....vs"................. Comments (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of.liquid level in relationQ to outlet invert, structural integrity, evidence of leakage, etc.)...................... N V..�Sd.?�aQ..T.�!r�►� .�..�...�oxa...?�.,J�!��t�:.�, vti+�9,�t..$:..��.o,.va?tp-�...,d�:1rn.4�:�,. ...EMA ...................................... . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: E3g,G,,,�S�—, , . Owner: Mkwccj, D ate of inspection: r i 5 qS GREASE TRAP: .................: (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FRP........other(explain).... ............................................................................................................................. Dimensions:............................... Scum thickness:........................` Distance from top of scum to top of outlet tee or baffle:.............................:,..:..... Distance from bottom scum to bottom of outlet tee or baffle:.................... ..:....... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................ . .................................................................................................................................................. ................................................................................................................................................ TIGHT OR HOLDING TANKS:.............. (locate on site plan) Depth below grade:............... Material of construction:........concrete........metal.........FRP..........other (explain).......... ................................................................................................................................... Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) .............................................:.................................................................................................. ................................................................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Wvv- 1, Date of inspection: r�Ic, DISTRIBUTION BOX:...X.... (locate on site Ian) - Depth of liquid level above outlet invert:....: Comment: (note if level and distribution equal evidence of solids carryover,evidence of leakage into or out of box, etc.). b ..�............ ....................................:............................................................................................................. PUMP CHAMBER:.............. (locate on the site) Pumps in working order: (yes or no)....... .. .... Comments: (note condition of pump chamber,'condition of pumps and appurtenances,etc.)....... ........... .........................................:...................................................................................................... SOIL ABSORPTION SYSTEM (SAS):...? .............. (locate on site plan, if possible; excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: ..........................................................................:.........................._............................................ Type: leaching pits, number: .......1......... leaching chambers, number:........ leaching galleries, number..........:. leaching trenches, number , length:..................... < leaching fields,number, dimensions:................... overflow cesspool,number:.......... Comments: (note condition of soil ,signs of hydraulic failure, level of ponding, condition of vegetation, tc.]... ......Nv..� n5... . . .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: Owner: NQMWooa . Date of inspection: . CESSPOOLS:.......... ESSPOOLS:.......... (locate on site plan) Number and configuration: .................................... D epth-top of liquid to inlet invert: Depth of solids layer: ............................................... Depth of scum layer: ............................................... Dimensions of cesspool: ...................... Materials of construction: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ........................................................:........................................................................................ PRIVY : . (locate on the site) Material of construction: ................. Dimensions: ........... imensions: ........... Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . .......:.......................................................................................................................................... ..................................... ........... .. . ........... .................... . ................ . . ......................... SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : ee QioN,:i; �� Owner: Kkowoo&k� Date of inspection: i SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. _ 0 O O �- 1 L \,%A- DEPTH TO GROUNDWATER: Depth to groundwater X.-N.feet ` Method of determination or approximative: l\c� .79 ..L�S�Ss Q1K1v.� L'!!?...� S.. tc�o �r.c G�...S.V.V.1f. !i`..�. 1 A`.C.AY .G....IR?�e`�.1 �'*�•'NS ATLANTIC ENVIROMENTAL P.O.Box 2384 � i Mashpee,Ma. 02649 a Attn: Commonwealth of Massachusetts Date: 11/13/95 Town of Barnstable Board of Health 367 Main StreeE Hyannis MA 02601 From : Mr Michael DeDecko Po Box 2384 Mashpee MA 02649 Dear,Board of Health Official; I certify that I have personnally inspected the sewage disposal system at the following adress : 88, Gun Stock -Osterville Mass. The information reported is true,Accurate and complete as of the time of the inspection. I have not found any information which indicates that the system fails to adequately protect the public health or the Environment. If you have any questions regarding this inspection,please contact me at this number: (508)477-14-20. Thank you. Sincerely, LLChael cko phone(508)477-1420 1 p Q ' ti9 I II II I.I II II II BATH II . + LOFT MASTER BEDROOM II II , I II REMOVE WALL II II p BALCONY Ii II I I, i WALK IN I I II �\ CEILING SLOPE I I CEILING' SLOPE OPEN BELOWTO 4' KNEE WALL 4' KNEE WALL II C II IIDORMER WALL UP i N 14'-0" 27'-0" 04m!`�� Ore- � 14'-6n r zzzzzz DECK 0 r STEEL BEAM ABOVE FLUSH 00 0 00 BATH FAMILY DINING KITCHEN REF. rl IN I PAN MY3 O I REMOVE WALL O I I ' BEDROOM #2 L I M N LA U.N DRY ;. I I I UP I � Uv4J 4'-411 q'-2" q'-2" 4'-411 r1 V @1 G� J 14'-0° UV d AAU1- 27'-O" 46'-:O"