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Home My WebLink About0044 JASON'S LANE - Health 44 JASON'S LANE, OSTERVILLE A= 121 113 e i F a e �I TOWN OF BARNSTABLE L'N':ATION LA SEWAGE # �i:,LAGE C)5Jer V'%,Ve- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY I LEACHING FACILITY: (type) (size) 16®� s NO.OF BEDROOMS BUILDER OR OWNER (��e�ry PreSen+ PERMPTDATE: COMPLIANCE DATE Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 ac 'ng facility) Feet Furnished by L a t¢ AA 75 A lot AO 1 B® 311 4 TOWN �F BARNSTABLE LOCATION L �( 5LQ SEWAGE VILLAGE_ ASSESSOR'S MAP LOT INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY �. ,kou5 LEACHING FACILITY:(type) [to® GAWc,T (size) NO. OF BEDROOMS- PRIVATE WELL OR PUBLIC WATER it,a,� BUILDER OR OWNER, \14 4,�� J DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED- VARIANCE GRANTED: Yes No _ -24 ! _ 2-f fUtA ROW John Grad D.E.P. Title V Septic Inspector 564=6813 11,3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM _ A6dress of property �a5?,°�'5 l.�l, DS-�RV11e -Owner's name 0, <^t-A Date of Inspection PART A CHECKLIST Check if the following. have been done: _ Pumping information was requested of the owner, occupant, and Board of /Health. _ - ✓ 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. V As built plans have been obtained and examined. Note if they are not available with N/A. --.J,-/— The facility or dwelling was inspected for signs of sewage back-up. ✓ The site was inspected for signs of breakout. ✓ All system components, excluding the SAS, have been located on the site. V The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site has been determined based / on existing information or approximated by non-intrusive methods. V The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. 4 lU r� 1.719 ti s � �, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' _ PART B - SYSTEM INFORMATION FLAW CONDITIONS- ,If residential number of bedrooms - - number of current residents - Q garbage grinder, yes or no - - `c> laundry connected to system,--yes or no _TE seasonal use, yes or no -If .nonresidential, calculated flow: - Water meter readings, if available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: OMpei /�ciibtlC Mbtit _ System pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Ty 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. Source of information: 13 AD_ Sewage odors detected when .arriving at the site, yes or no r. 9 4, - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B - 'A SYSTEM -INFORMATION continued - , S EPTIC TANK':; (locate--on site plan) 114 depth, below .grade: material of construction: /concrete metal- -FRP other(explain) ! Lit dimensions: �- sludge depth - distance -from top of sludge to bottom of outlet tee or baffle 0 scum thickness distance from top of scum to top of outlet tee or baffle 4 distance from bottom of scum to bottom of outlet tee or baffle Comments: (.recommendation for pumping, condition outlet inlet inverta structural tees integrit or ybaffles, depth of liquid level in:=relation t evidence of leakage, recommendations for repairs, etc. ) GvL'R DISTRIBUTION BOX: (locate on site plan) &44o^oFC'r,f depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc. ) PUMP CHAMBER: n�'=— (locate on site plan) pumps in working order, yes or no - Comments: (note condition of pump chamber, condition of pumps and appurtenances;;: recommendations for maintenance or repairs.,etc. ) 1C . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART B SYSTEM INFORMATION continued _ SOIL ABSORPTION SYSTEM_ (SAS) (locate on site plan, if possible; excavation not required, -but maybe approximated ,,by non-intrusive methods) If-..not determined to be present, explain: - Type leaching pits and number - O p'`► Teaching chambers- and number leaching galleries and number leaching trenches, number, length leaching - fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condi ton,of veggetation, recom endations for maintenance or repairs, etc. )Dvez CESSPOOLS (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY: (locate on site plan) materials of construction dimensions depth of solids Comments: (note condition of soil, signs of hydraulic failure; level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) i 11 . -SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B . . SYSTEM INFORMATION continued SKETCH OF SEWAGE_ DISPOSAL SYSTEM: include -ties -to at least two permanent references landmarks or benchmarks locate all wells within 100' - MA ' AA A 9 4 C ADS DEPTH TO GROUNDWATER 1 , (16 depth to groundwater method of determination or approximation: a 0 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM- PART C - FAILURE" CRITERIA .. Indicate yes, no, or not determined .(Y, .N, or- ND) . Describe basis of _ .` determination in all instances. If "not-determined", e;:plain why not)- Backup of sewage into. facility? Discharge. .or ponding of -effluent to the surface of the ground or surface waters? Static liquid level -in the distribution box- above outlet invert? Liquid depth in cesspool <6" below invert or available volume< 1/2 da-y flow? Required pumping 4 times or more in the last year? number . of times pumped Al Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exf.iltration? tank failure imminent? , Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? I within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well water analy: for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 - SUBSURFACE -SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D CERTIFICATION, - Name of Inspector - - Company Name JOHN GRACi Title Inspector _ Company Address P.O. Box 2119 Teaticket, MA 02536. - - - Certification Statement _ I certify -that I have personally inspected the sewage disposal system at this address and -that the information reported is true, accurate and complete as of the- time of inspection. The inspection was . performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and ma nitenance of on-site sewage disposal systems. !!Z one: I have not found any information which indicates .that the system fails to adequately protect public health or the environment as defined in 310 CMRL15. 303 . Any failure criteria .not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature ° Date Original to system owner Copies to: Buyer (if applicable) Approving authority f ------------- - . - _.. -- - ---- -- --------- N - TOWN OF BOARD OF HEALTH SUBSURFACE SEWAGE. DISPOSAL-SYSTEM INSPECTION FORM - PART D - CERTIFICATION -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS "i 4 � A'7 bA 05f'Crv%lie ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME PART D _ CERTIFICATION NAME OF INSPECTOR JO N GRACI COMPANY NAME Tit�nspector P.O. Box 2119 - COMPANY ADDRESS Testicket MA 02536 Street Town or City State Lip COMPANY TELEPHONE ( 5O� ) �j(E,l' - c!S '3 FAX - CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of inspection . -The• inspection was performed and any recommendations regarding upgrade., maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: ZSystem PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public_ health or the environment as defined in 310 CMR 15 . 303 ." Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have' conducted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - , FAILURE CRITERIA of this inspection arm. . ti . Inspector Signature ' Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, thL owner orsoperator shall upgrade the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . k partd.doc 1: z 1 u;E I>t s.PoSAt_ P t'T V$r-- t ye2Q L*'v"A t-- 3 '1ST 50TTO&A AMeA�s 5U fir_ 4 l�KP ;i,- `� 450 og 40 P��'t't o>J �`Iz t 1 u 2 A$!,.! oQ�-F�,+S. • � - �,.._ �d"� t00- - - - ell L01�� 4"pve 1000 •:e luu• 9-1,o twv. �jx• ;t::.. 40p pt<iT tit l,�IiL. OL Ilit/ — Box. Qt.t. lcjCsFTIC TAu K ti bey. Q4,z, 4od �. IN T +SWAStJ'ED ' ! � 3:;I6Z0 Ft (fir l...c�A.TiO►.1< ��=•I�/� ;�-/,�, t Cuwzl IF:,( T"AT THE PL-a t`t 2EFESZGtJG� ! ►-�E2EON COAAPL-YS WtTH Tt�6 zilUF_t..►i.1� ii �- I � wt> sarsAGtC f�EL7v�>ZL� MEzt•1T� OF '1 we F-O+t log Tb rc/ti.t O F I WATT✓ `' �' �� ,�� 8 tsTM MEt> LAAJr> ;L vie; THIS PL&Q 14 UOT $A5ED Ou Au tt.KTWm&"T OSTE:.ZVt• • AAA.CPS. f �U2vG`( 4 TWC- OFi-SET; -9i4C>)t.D UOT rE USPj APPI-1GAuT (�,, To VETeCmi ` L tioT LIWS;. `t 1��i 1�7("11� ii j'jvi.}tR No...._ .f... .... .............. THE COMMONWEALTH OF MASSACHUSETTS BOARD qF HEA T i � Q.Z.,t tom..O F...... III Appliration for Disposal Works Tnmunr#iun Frrmit Applicati n is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Syst t: , L A /�,,_. or Lot 130. .. — • - •.... ,e G.N. -- -•------- -. .. ... .-•-•-------- Owne n ddress W •........ .... --•..-••.. .......... •. -•. ..... ............... e- ►-a er / Address pe of Building Size Lot.... ~® •�f-_Sq. feet U Dwelling—No. of Bedrooms---------- .Expansion Attic ( ) Garbage Grinder P4 Other—T e of Building No. of persons............................ Showers Cafeteria Otherfixture,-, -----------------------------------•------•-------•----------------------•••-•---•--- ... .............................. Design Flow........ . ___gallons per person per day. Total daily flow---- gal Gd Septic Tank—Liquid capacity/l ns Length................ Width---___.____-__-_ Diameter---------------- Depth................ W Disposal Trench—No. ___ __.__-..•.... tidth__. Tot Len _ ._ Total leaching area....................sq. ft. Seepage Pit N _ ........... ... inlet.......... ...At leaching area.r?d./...sq. ft. Z Other Distribution box ( ) Dosing to ( ) ®yyyy�l ...Percolation Test Results Performed b �:.. .................................. Date__..._".z�:� .............. Y.- aTest Pit No. 1......Z minutes per inch Depth of est Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....................... x •----- Description of Soil..............G�` - '�- ,�------/ ' !r'� U -•-••----•-------•••------•-----------••-•-----.._.•••-----••--••-••------------••-••-------------------•-----•---••••••--•-------------••-•---•---•---------------•--•••-......--•••....._----•-------. W ----•-•--------------------•-------•---•-------•---•----------------...-••--.....--•-•••-•-------••----••----------------------------------------•--••--•••-•-•--•••-....................-•-•--•----... VNature 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 iI'L U, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sig , d -----------------------------•---••---•--•-•-- D3 t,o �' Application Approved BY--- ✓---------------•-••--••--•. ........7-r a�= ............. Date Application Disapproved for the following reasons:................................................................................................................ Date Permit No.......................................................... ----•--------•----•--. Issued_...... ••---��-•---- .................. Date No........../_It ... Fns ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF !-IEAL.T .............. OF....... App irtt#ion for Disposal Works Tonotrnrtion rumit Application is hereby made for a Permit to Construct e or Repair ( ) an Individual Sewage Disposal System at: . .... __... ............... Location Add- S$_ �F'�� or Lot No .2 ..s-. .. !U`* 9✓✓ .Ma a.. awA..? M Owner/ - Address ' seer Address 4 � d Type ...of Building Size Lot.... .......................Sq. feet U Dwelling No. of Bedrooms._.._._... 4 .Ex Expansion Attic Garbage Grinder �-' g P ( ) g ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeterias. ) dOther fixtures •6 .�+�-- :---•---•------------------......------------....-------------------•------------- ---------....----------....--•--•----- W Design Flow.............6. .��_.................gallons per person per day. Total daily flow........ ..:_-.. ....................gallons. WSeptic Tank—I' wj y 'j]Ions Length .............. Width................ Diameter__-_--__.-_----. Depth.................... x Disposal Trench No ..................�idth TotaVLength ............... Total leaching area.._.. ._.... sq. ft. Seepage Pit No, �?. ?. Dia e . I eptlT b*61-cw nle ................. Total leaching are �......sq. ft. Z Other Distributio ) D in tank ( ) ~' Percolation T esults „ Performed by.............. ... ..... Q "_ ` ' Date--- Test Pit No: 1........_... a minutes per inch Pit................... Depth to grounds w r +gym..........._.. Test Pit No..2..... .npinutes per inch Depth of Test Pit.................... Depth to ground water......................... ----------------------------•---••--•-----------.........-----•----...........-----•----•---....................................................... O Description.of Soil U ............................................. 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 TIT1E 5 of,�tbe State Sanitary Code—,The undersigned further.agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. A, og..- ..................A lication Approved By.; .-"••'G` , .................----------- -•------------------o-�--- ............... Application Disapproved for the following reasons:- ......... "`...F7:........................ ..........:..................•-•-•-•--------•------------.....--••----•---------..........------....---...-•-.................---- i; - Date Permit No............"...........................................` - Issued. 1 `Q Date THE COMMONWEALTH OF WASSACHUSETTS BOARD O.F HEALTH .............�;»! 0 F... �r •< Trrtifiratr of wontplianrr THIS IS TO CERTIFY, That'tVe Individual Sewage Disposal System constructed .(1,o or Repaired ( ) ..-- --- .��.�I^�r�a� --•--•--.................................•--•-----•• • ---- -. 1+� Installer at ......................................" ff �� '`' a; .de -•--•--------------------------------•----------- ,. � - 6. - --- has been installed in accordance with the provisions of r 5.of The State Sanitary Code as Wed bedlp� in the application for Disposal Works Construction Permit N .. ......��..................... dated........"�_� 7.'" THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G RANTEE THAT THE SYSTEM WIL FUNCTION SATISFACTORY. DATE........ v ll.... 17....... Inspector--------- '. THE COMMONWEALTH OF MASSACHUSETTS f' BOARD OF HEALTH Q`•' , .......OF. ' ......................... No......... �.j441 ...... FEE..'�.'�............. Disposal. Nods Tonotr wan rrntit Permission is hereby granted•••. ,, - :.. :. ...... .................. to Construct E(` r Repair ( )6'Z? Individual Sewage. Disp�s System " ,P �t Street {. ............................. f as shown on the applicationAg D sal Works C��struction Pe r.• it - . .. ........................................... ......... `" ..............•... •..• Board of Health ---- DATE----------- ---- ------- ------ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS