Loading...
HomeMy WebLinkAbout0116 HINCKLEY CIRCLE - Health =Hinckleyircle � I u o Commonwealth of Massachusetts /o? , 0 so ��pTitle 5 Official Inspection Form ! �1° Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ; '• � r 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for osterville• ✓ Ma 7-20-2020 every page. Citylrown State Zip Code Date of Inspection', ; C art Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. Inspector Information 45"(.#-/ lWa l forms on the computer, use Douglas A Brown only the tab key Name of Inspector to move your D.A.Brown Inc cursor-do not Company Name use the return key. P.o Box 145 Company Address Centerville Ma 02632 City/Town State Zip Code 508-420-4534 S14297 Telephone Number License Number Bo Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® 'Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7-20-2020 Inspe igna ure 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts �v I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osteryllle Ma 7-20-2020 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: System met all passing requirements at time of inspection. This report can not predict the future performance under the same or increased usage. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins .doc-rev.7/26/2018 p Title 5 Official Inspection Form:Subsurface Sewage Disposal p g p System Page 2 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts it? Title 5 Official Inspection Form Subsurface SewageDi -Disposal System Form Not for Voluntary Assessments 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osteryllle Ma 7-20-2020 every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �v l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 1h 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 II f Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Hinckley Circle Property Address owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: l 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: ® ❑ 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts G Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. CitylTown State Zip Code Date of Inspection Do System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: according to as-built card this system consists of a 1500 gallon tank d-box and 5 infiltrators in a 35x8 ft area. Number of current residents: Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ❑ No If yes, discharges to: 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 Last date of occupancy: seasonal Date _f / t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �m l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 P Y rY 116 Hinckley Circle u- Property Address Owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts I-F Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 12-3-03 per as-built Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form I° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 2.25 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 per as-built Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): always recommend pumping at time of transfer and every 2-3 yrs there after for maintenance.] recommend installing risers at some point. t5msp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts lF Title 5 Official Inspection Form In' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osteryllle Ma 7-20-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts IF Title 5 Official Inspection Form 1° Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osteryllle Ma 7-20-2020 every page. City/Town State .Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm resent: ❑ Yes No P ❑ 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): box was functioning properly recommend riser at some point. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osteryllle Ma 7-20-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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 1 working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If.SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 5 infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts 1p Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 Hinckley Circle V Property Address Owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): We tried to find the shown observation port but were unable to locate it. 12. 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): J t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments � 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 f - Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Pr ovide 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I Commonwealth of Massachusetts ►p Title 5 Official Inspection Form 1 1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: none encountered feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts r l9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 Hinckley Circle Property Address Owner Mullin information is Owner's Name required for Osterville Ma 7-20-2020 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist- Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15:..Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 . Assessing As-Built Cards Page 1 of 2 �u1� ti�J TOWN OF BARNSTABLE LOCATION inG�eov iil c�P_ SEWAGE# JO J9I VILLAGE Q,'fet 4, (I i✓ ASSESSOR'S MAP&LOT I Z-05 4 INSTALLER'S NAME&PHONE NO. MA,u iz i a rt-,;aS 50T-5�i y;31 S SEPTIC TANK CAPACITY Sao &-a I LEACHING FACILrIY:(type) (size) 3 K X ' NO.OF BEDROOMS BUILDER OR OWNER Met,h e tt PERMrrDATE: 12.-a—�3_ COMPLIANCE DATE: I Z J C Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Ne lrh�° k�fe�Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) top-e. Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin Tty) ! d 67 Feet Furnished bytkaa.a r,l� e \� e-v— 2� Nils Bz= yy � 3s13 A. ;33 t o IGN https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?ma... 7/20/2020 Assessing As-Built Cards Page 2 of 2 https://town.bamstable.ma.us/Departments/Assessing/Property_Values/HMdisplay.asp?ma... 7/20/2020 TOWN OF BARNSTABLE LOCATION —�-1- � l e SEWAGE #)&3 - S q I VILLAGE f ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO.'LLiff vim: SEPTIC.TANK CAPACITY 566 Cda I LEACHING FACILITY: (type) h t�+ �f y 2 �siS (size) NO.'OF BEDROOMS- -BUILDER OR OWNER PERMIT DATE: I s " (Z3 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. No 6u rAeFeet Private. ate Supply well and Leaching Facility (If any wells exist on site`or within 200 feet of leaching facility) NarN a Feet Edge of Wetland and Leaching Facility(If any wetlands exist A Vt Feet within 300 feet of leachin facility) Furnished by I afie�'. ���_ 13 '' y 9 .A. s No. 2003- ( r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for ;h5poot *pgtem Construction Permit �jl r Application for a Permit to Construct( . )Repair( .Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. 1 l to t+n C K1e r Gk$ Owner's Name,Address and el.No. LDt-* 5,D G S ir),V II 1r �F:rYa T Assessor's Map/Parcel � 1 t to ✓�GK 1�� Cae 1 2- - 95o 3 VQ* Installer's Name,Address,and Tel.No. J�(?S_ Designer's Name,Address and Tel.No. yt.ti�t�nin y r�+e�2 of 5q e- �ev�r�t rQ P6s 0 CA C&,P_s �b fox 1 1 pa-5'1 q PSI t kol fl. W Oro1TGl=S.Te_Y_ ' dos 54D- LJ T- ��� 4 woo�-c�4 5(19q Type of Building: Dwelling No.of Bedrooms -3 Lot Size lO 1491 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) .Other Fixtures Design Flow c5 o gallons per day. Calculated daily flow 33 4 gallons. Plan Date 6 a4l abD3 Number of sheets ! Revision Date Title Size of Septic Tank 1 ry oo ajcL C Type of S.A.S. t) 1 5 Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been' ued by this oar f Health. Signed Dat o 3 Application Approved by_ Date v2zo Applicatign Disapproved for the following reasons Permit No. 2 a o 7-S y/ Date Issued 2- Z • No. -2bo3— �i 'a,_ �� " � �.:.. ,,.�,� Fee THE COMMONWEALTH OF MASSACHUSETTS I Entered in computer: a,a PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS r Y•-p�' ' es ZIppYication for Miopoga bpotem Construction Permit Application for a Permit to Construct( . )Repair( 4 Upgrade( )Abandon( ) ❑Complete System O Individual Components Location Address or Lot No. 1 1p H n C-l'<\-e t1 r C\I-- Owner's Name,Address and Tel.No. ` Assessor's Map/Parcel �)U w VN G �L31�) K-1 U' .v CSC'.142- - eo A�v\sT 6� V�-1 i- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.. y�,ir�rlv�y � �i2o�.75 5y - Favyexra Ass 66Ck e _ fb 3ox Dd5l q 1�51 l ln� i\ warcz.STV r Ci540- L.J e. T- ��tv�cx�►ti, lu FW vuo 0-ni,U A 0`4640' 6(,9c�. Type of Building: Dwelling No.of Bedrooms -3 Lot Size 10 L1'?I sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow �rj gallons per day. Calculated daily flow 354 gallons. Plan Date 1 I I a 14 l a-00 3 Number of sheets I Revision Date Title LLQ a ' „ �` o \ Size of Septic Tank 1 5C>0 :4. l . Type of S.A.S. In f l 1+ra br 5 Description of Soil, See.- pl CAr ! �f �.11, o 1 x Nature.of Repairs or Alterations(Answer when applicable) 1 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 off the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has,beii_issued by this Btoar of Health. /A Signed! X ' 1 r Datefl�.�f 2,-63 Application Approved by �7, e. - �_ Date I'? y Applicati nwD, isapproved for&,following reasons x a Permit No. ?tj o-7-S y�— Date Issued 12 2 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE' MASSACHUSETTS Cert.ificate-of Compliance THIS IS TO CERTIFY,that the-On-site Sewage Disposal System Constructed( )Repaired�)Upgraded( ) Abandoned( )by / /� at %_ �[ Ur ( .rY �n or Al has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �Ud 3 - S71/ dated Installer Designer —T f not be constr ill ued as a guarantee that the system £nc o, esigned. The issuance of this permit sh Date /� ©3 '` Inspector ..�� No. F7 0 a-3 Fee THE COMMONWEALTH OF`MASSACHUSETTS ,PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS i� ogarpgtem Con!5tructioi ermcit Permission is hereby granted to Construct( )Repair( �)Upgrade( )_Abandon( ) System located at / 'n f ,r .1 ./11 , and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Con truction must be completed within three years of the date of this a t. Date: J r y a / Approved by - / _ i TOWN OF BARNSTABLE LOCATION f I SEWAGE #q03 9'I VELLAGE— f k o2 6 41 ASSESSOR'S MAP & LOT � " INSTALLER'S NAME&PHONE NO. HA uw_ ) i, bus .Sag"SyX--3`h�rs ) SEPTIC TANK CAPACITY LEACHING FACILITY: (type)) h + v a &S (size) NO. OF BEDROOMS a .BUILDER OR OWNER e J.b a afi r 0 u° 4e- i o PERMIT DATE: B - a " 6-3 COMPLIANCE DATE: , Separation Distance Between the: ) Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �� (,rhgu��!14 26'Feet Private.Water Supply Well and Leaching Facility (If any wells exist N on site"or within 200 feet of leaching facility) r N e Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leachin fa93rA ty) /y d d"1 Feet Furnished-, T U "'A l C 1� G 14 ) 1 ' y25 116 ' A 00 r 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I, A.ae ew /�,8e47g/,7 ,hereby certify that the engineered plan signed by me dated WOO, Z4 Zoos, concerning the property located.at U i 3o r1Ae i4Z. PCL 6c) 1l meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 48.() ' B) G.W.Elevation 1 _O +adjustment for high G.W. DIFFERENCE BETWEEN A and B Z. SIGNED �6�4� DATE: -Z G-U3 NOTICE Based upon the above information, a repair permit will be issued for 3 bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:percexmp i t SYSTEM? PROFILE O SCALE NO TES. NOT T FINISH GRADE N/LY.S.L, ELEt/ATIONSBASEQ O _. F/NSH/ BADE ' G .<a , IH OR - •f9.3 FINS G ONHAZARD �-.- "ot�R rANrr 2. FLOOD�ONE C/N I ,: 4aa t ,� OVER JRENCh`ES 9 TOWNWAMRONS/TErop IVA -. �r« rt;.ri .#,-+bv _. ,,. _ _ _ -t tea►.y., 90 LOT COVERAGE' ;s� 4 . 4 � >500 GAL ,. `.EQUAL%2ERS (LOT30-10,491 S.F.) BSIGITFtR ., - ANNFORCED _:..c; CONCRETE AS D>'ST• BC)X ,3 I " H->0 BAFFLE TORE/NSiALIEDONA r +,ry EXISTING HOUSE-1137 S.F. -70.8% •," i fps 2 w:,r r-. _ ,.,; . r. LEt/El STABLEBASE EXISTING PORCH 167 S.F. .6/v L.NGTH. d 7RENGH EXISTING DECK-67 S.F.-0.6/ , . � ,•�. - .5FPT/C TANK NA 5WIN.HEIGHT r0 BE/NSTALLED O 4�.70' ABOWAD✓USTED ' .,. . LEVEL SMBLEMSF GROUNDWATER SOIL AND AERCOLATJONDATA NO; 00 NOTR4MgE4 VYEOL110l9ENT OILER SYSTEM PERC. RATE <5 M/�//N TAKENSY RICHARDFERREIRA DATE NOI/EAMER2t 2003 5 LEACHING TRENCH SECTION TESTPITELEi/ LOT 31 NOT TO SCALE SO ` ✓ j o FORF/N/SHGRAOE TESTHOLE f ELEI!Pd.r 7 •'.N. 2 Etfv. 1 N69 56 20 E sEEsrsn=x4�ROF,z� 0" 5�4 101.17 A A �s/n!2'-ZSM)f7 SAND YLOAM 10YR3V -SANDY LOAM 10YR 313 WASHEOSTONE 6" (1"INf B E B SANDY LOAM 1DYR 5/8 ttt 1e n --'- SANDYLDAM '>DYRS/d' W LOT 30 <i500 sAc: 4-a�,.PEE 3?' c> } EP7 TANK ':' :. 4_ MEDIUM SAND 1✓ITN 10,491 S.F. •... .. ::_ ISAND 25Ys�a (� IL-,S2 .. .. .. COBBLES 6 STONES cr_ R.5Y B/5 NATURAL SO/L :_ l ? EFFECT�uE "MED/UrLfSAND-COBBLES � - OEPrH STONES B' 35.5 .. .. ... B - cz WASHED STONE ti -FL'VE' SANA EDSUM M EFFECT/uEWrOTN SAND ?.5Y Z/4 L S ,,. ! NI TN COBBLES m . ", B,-0. MEDIUM-FINE w , ExcauArFO f 2.5Y 7/4 36.8 't ! MDEWALL " SAND N.�/THCOBBLEs LU wad_"_Tne- _ ut U., EXISTING (n ?-B 2-6zwl 1 Q t4 q SEPTIC l to be l G o D p2 removed o N DECKVi n 12O" 32 rn NO GROUNDWATER <r cV C x m EL EV 38.0 J w o NO 6ROMOP'ATER �. toot NUMNER OF TRENCHES 1 y ,Ao1♦ F NUIMER OF/NF/L TRATORS 5 L?ES/GNDATA - NO. OFBEDROOMS 3 V gravel drive rest m D/SPOSAL NO hole 35.r N EST..TOTAL DAIL Y6,1L9MENT 330 GALS. 172 S.F SIVEWALL AREA .74 G I—S/SF 127 GALS. SEPTIC TANX 9500 GAG 280 SF. ,607TONAREA 74 GALS/SF 207 GALS. -,, S.F. TOTAL AREA 334-. `GALS. 52 104.5¢ GENERAL NOTES S69°56201~w t - , PROPOSED 40 MIL 4L -re) "".iMFERVIOUs LINER >. ALL SYSTEM COMRONENTS SHALL REINSTALLED IN LOT 29 TO BE INS TA"LLED ACCORL)ANCE W22VT/TLE50F THESTATESAN/TARYCODE f,1AMOIIMARCH>995ANDANYL004L RULESAPPM/CABLE 2 ANYCHANGEINTNIS)OLANAfY STBEAPPROIiEQ BYTHE804RD OFt/EAL THANOAERRE/RAASSOC 3. WMENCONSTRIICTIONIS COMPLETED, PRIOR TO BACKFILLING NOTIFYFERRE/RA A.S SOCIA TES FOR INSPECTION FM &&FY A?USTBEOXECKFD M-NEN COY)OZ.ETED THESEELEV ,YSTNfJTBE CHANGED M7NO417 LEGEND THE80AR©OFHEAL THAPPROVAL _ 6- BOARD OFHEAL THINSPECTIONRE029 DYf�i'EIVEXCAC/ATED REVISEa 12 DI_03 ADDED -TEST,HOLE 2 6 IMPERVIOUS BARRIER 50=---ExIST, CROUNDELEY � - C�Q /� / �J J�F/NISHGRDUNDE1Ei� i YY/-1 LJ �I.:JI O TI L SY TEId'O' ""iN UPGRACAE SE 48.3?' P/PE/Nt�ERTELEti . � � PREPARED FOR rEsrP�rtocA"0 H1:..._►, l.�.Ji.� ...TPOWER d©Q RCLE S60770 MAX Act I- DIISE 7 6 HINCh'LEY Cl 13 DISMIRYTIONBOx , n. ' ,. BIRNSTA BLE MA SS. a . r. AREA PLAN RA A5SOCIA TES pE5/G E N D. _SAP DATE. NOV _24, 2003 `FERRE/ ._..._. . PROPERTYL/NES x t 7 E TER LOUR V/ A_ r _ .SCALE; . f 20 16'1A WQRC 5 . SCALE r 20 - . .3 ., DRAWN. AMtB _ � r ✓ >42 O 30 SETBACKD/STANC,E' . ..,� �' �.- ,�., > x 0240 • � ,.� . DWG ,NAME. CADD EALAMOUTH .:. ..,,AMASS. 5 .-_- .., .., CHECKED G5 MAP SEC PCL LOT