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HomeMy WebLinkAbout0094 KING ARTHUR DRIVE - Health .. 1 94 King Arthur Drive Osterville J: A— 14.5 —043 c o > 0 y r a il, LOC T ; EWAGE PER IT NO. _o VILLAGE t INS TA L ER'S NAME 4k-DDItESS � B O L D E R OR OWN ER of DA T .E PERMIT ISSUED DAT E .C 'OMPLIANCE ISSUED e� y !b� (;fRJ },,,, �� `� �Q� ��M C �c ��- 3 �. � o . �J Hazardous Materials Inventory Sheet Checklist & ate Physical Street Address-Check_database to ensure it exists VIorking Phone Number - ,/ Actual Amounts -( ie. gas being used to fuel machines, thinner to / clean brushes all count as hazardous materials) Storage Information - location of storage, how long is storage for? f none, note that. Disposal Information -where and who? If none, note that. Applicant Signature-understand what is listed and noted taff Initial -any questions, know who to ask ehicle Washing/Rinsing? -provide a vehicle washing policy and explain it- note that itwas given Attach the Business Certificate with.your sign off and comments **The inventory form should explain what the business consists of and the procedures they are doing. Notes need to be left to explain what you discussed with them. Hazardous Materials Inventory Sheet Checklist YOU WISH TO OPEN A BUSINESS? For Your, Information: Business certificates (cost$4-0.00 for 4 years). A business cerrificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it,does not give you permission to operate.) You must first obtain the necessary Signatures cent this form at 200 Main St., Hyannis. Take. the completed form to the Town Clerk',, Office, 1 st. FI., 367 Main St.,'Hyannis, NIA 02601 (Town Hall) and get the husinc"', Certificate_rt.e that is equired by law. � DATE: 3 �2 Fill in please: k APPLICANT'S YOUR NAME/S: z BUSINESS YOUR HOME ADDRESS- h _ L ti.. TELEPHONE # Home Telephone Number v Z M NAME OF CORPORATION: a P S 5 NAME OF NEW BUSINESS ), TYPE OF BUSINESS CK. �vt ;r•, / ��G.�����, IS THIS A HOME OCCUPATION. YES , NO J ADDRESS OF BUSINESS : 1 A0 AP/PARCEL NUMBER ' -I (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your usiness in this town. 1. BUILDING COM ISSIO ER'S OF CE This individu I ha e imfor an pe mit requirement hat pertain to this type of business. NJ v\ tJ- ciz& Q�^ck * MUST COMPLY WITH HOME OCCUPATION Au size i tur _�� RULES AND REGULATIONS. MMENT � FAILURE TO o TIN FINES. 2. BOARD OF EALTH This individual ha beerpi 9 rme f the permit requirements that pertain to this type of business. MUST�;OMPLY WITH ALL KAZARDOUS MATERIALS REGtJL.ATIO;.'S Authorized Signature COMMENTS: 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: r r .r i . Date/, I / TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: A (,,- Ei 2 BUSINESS LOCATION: 6L625r INVENTORY MAILING ADDRESS: - ,r e - " TOTAL AMOUNT: TELEPHONE NUMBER:�� Z5 - CONTACT PERSON: V S EMERGENCY CONTACT TELEPHONE MBER: 502 47,0 tkQI�S MSDS ON SITE? TYPE OF BUSINESS: GO c INFORMATION / RECOMME DATI NS: IJ Fire District: Waste Transportation: Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product: Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month requires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum 0 Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) D Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals(Developer) c�,k ' Pal lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal C Printing ink Degreasers for driveways&garages Wood preservatives(creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda l Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers 5 Asphalt& roofing tar PCB's 9 Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, _ 2Lacquer thinners C) (including carbon tetrachloride) — // - Any other products with "poison"-labels NEW USED (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initia(_41 %oriimoniWL i=i of M—i— hiji6 Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Volunta ry Ass essments sessments 94 KING ARTHUR DR Nroperty Address CHANSKY Owner Owner's Name information is required for OSTERVILLE MA 9/10/11 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the and of the form. '"'p°' "` A. General Information When filling out forms to the ;I ^ computer,use 1. Inspector: only the tab key to move your cursor-do not DOUGLAS A BROWN c use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name r� P.O. BOX 145 Company Address CENTERVILLE MA 02632 City/Town State Zip Code SCi -41U-45 14267 Telephone Number License Number I B. Certification cM rat f I certify that I have personally inspected the sewage disposal system at this address and that the jE information reported below is true, accurate and complete as of the time of the inspection. The inspection c was performed based on my training and experience in the proper function and maintenance of on site . r sewage.disposal systems. lam a DEP approved system inspector pursuant to Section 15.340 of Title,5`(310 CMR 15.000). The system: .1 E�,Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Cat x y11611 Inspector' Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board ; of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the apprgpriata regional offi- of the DIjP Th1 original should be sen#t4 the system Awn r ,_., and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under I j the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface S 1ge Disposal System•Page 1 of 17 -0 onweaitn of nnassachuseits Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 94 KING ARTHUR DR Property Address CHANSKY Owner Owner's Name information is OSTERVILLE required for MA 9/10/11 every page. City mown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: t have nOt f�u-rj arty!nf^�l��wtlOn�A�hlrh [nd ca+G'S:thy+an the fa!!'[rc rrifcria rieSrrihcri _,._ _y of_. ., . ,p .. in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are vV indicated below. ' Comments: SYSTEM IS QUITE OLD^1978 BUT MEETS MINIIM�UM PA�S�SSI�NyG REQUIREMENTS AT THIS T IME, HOUSE IS NLY.00CU?IED BY 0- PERSON AND T H,E WA T ER USAGE IS LV V V, CAN NOT PREDICT FUTURE PERFORMANCE UNDER THE SAME OR INCREASED USE ❑ 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 Pi tai SCjit G ia[in:Vrvill a5S 11 iSPv, 1101 i if A is sty u lurally.sduhtJ,;of.lcak1:hg and if a CGS if i�,aiC Of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): Pns•as/Qs Title 5 off[c[al lnspectlgn Form:Suh--urfrse Sewege Dispq�t S 17 ommonweaith of Massachusetts Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 94 KING ARTHUR DR Property Address CHANSKY Owner Owner's Name information is OSTERVILLE required for MA 9/10/11 every page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) B) System Conditionally Passes(cunt.): ❑ 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 P3Sq lnsp iqr2 if()!rrth ap�rQbai of Rnard f FlPalth): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 'st r❑ dnNo e.ae rep!aori I❑ Y ❑ tJ ❑ Nfl l(F�rpain helncnrl; ❑ 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): C) Further Evaluation is Required by the Board of Health: Conditions exist which require further'evaluation by the Board of Health in order to determine if the system is failing to protect public Health, safety,or the environment. 1i System will pass unless Board of Health determines in accordance with 310 CMR_ 15.303(1)(b)that the systemis not functioning in a -protect-public manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water 0 Cesspool or privy is within'50 feet of a bordering vegetated wetland or a salt marsh tSlns•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 r \ Qommonweaiith of Massachusetts Title 5 Official Inspection dorm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 94 KING ARTHUR DR Property Address CHANSKY Owner Owners Name information is required for OSTERVILLE MA 9/10/11 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ - The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and'SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well* Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and'nitrate nitrogen is equal to or less than 5 pp,m, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) S st6ift'F-ail i d CirjtCi'ia MA `iidabld tb All�w Systalfis€ You must indicate"Yes"or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or'cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 M�Iommonweaifi! of Massacnuse s W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a'< 94 KING ARTHU'R DR Property Address CHANSKY Owner Owner's Name information is OSTERVILLE! required for MA every page. City/Town 9/10/11 State Zip Code Date of Inspection B. certification (cont.) Yes -No ® Required pumping.more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped:. n I Ary nnrtim of tha , rnrG&�, nacnn�lJ nlivy is -nd water alev .'nn)eI M hlh gr ,. Ei ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. n Any portion of a cesspool or privy is withinr 50 feet of a private water supply "y 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 am!iPonia nitrogen and nitrate nitkr�aegn rs P�ra�1�or lea thin 5 cac�m 9g provided that no other failure criteria are tr rr". ggered.A copy of the analysis and chain of custody must be attached to this form.] E] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. n The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd:to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ tha cyctam is ygiithin 4n0 feat of n su far-a�1rr?king eater Si irnrnly ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ C the system is located in a nitrogen sensitive area (Interim Wellhead Protection /� Area—IWnPA)'or amapped Zone-II of a public water..supply well �f y:3U:haYg nJ VrVd„y�yH to ylYy;uV�ti^n If l Section.6E,.llle ov, tVm 1J_VVl IJ,I4V1 V GQj JIgnl:fl Ant Mfk t 11 VGl or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5i„s-osros Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 \ Commoin"Aifh of Mii§6065i6 s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Ass essments GM 94 KING ARTHUR DR i°+roperty Address CHANSKY Owner Owner's Name information is OSTERVILLE required for MA 9/10/11 every page. Cdy/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No PL[?,pi!?g 1nf,L�ClTt2til n was pm%�ldby the owner, m CUpan#, ?fEnaf� �f �Qalth ❑ ® 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 CI IRI 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 inspPpte fer s gne pf t?re2k nut? ❑ ® 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, imensie►?s; death�f Its lcl; Qpth cif slU ?and de th of SFm? ❑ ® 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: IQI r l Existing info71 rmation. For exempla, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Fart C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 FSlrN f!ow based en �0�'MR 1 203,(fir ex�mnle: ? 0 �+ 330 t5ins-08108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Cohi i onweaiin or'massacnusei s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y� 94 KING ARTHUR DR Property Address CHANSKY Owner Owner's Name information is OSTERVILLE required for MA 9/10/11 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A SEPTIC TANK D BOX AND LEACH PIT C Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ElNo is laundry on a­11separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No us Seasonal e? .. ❑ Yes ❑ No Water meter readings, if available,(last 2 years usa e• d SEE BELOW Detail: 2009--------98.7 2010------101.3 Sump pump? 0 Yes ❑ No Last date of occupancy: CURRENT Date C®mmercial/IndUstrial Flom 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 ptos6ht? Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water:metdr r,eaditigs, if available: l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Gommonweaifn of iviassach se s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 KING ARTHUR DR Property Address _ CHANSKY Owner Owner's Name information is OSTERVILLE required for MA 9/10/11 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information 'Pumping ReCOrds: Source of information: Was system pumped as part of the inspection? ❑ Yes Z N© ff yes,; volume pumped, gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single Cesspool El Qyerflow cesspool ❑ Privy.... � ❑ Shared system (Yes or no) {if yes; attach previous Inspection records if any} ❑ Innovative/Alternative technolegy Attach a egpy pf the cgrrent 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 D€P appr©val; 0 Other,(describe): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonweaitn of nnassachuse frs Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 94 KING ARTHUR DR Property Address CHANSKY Owner Owner's Name information is OSTERVILLE required for " MA 9/10/11 every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Approximate age of all components, date installed (if known)and source of information: APPEARS TO BE ORIGINAL FROM 1978 �rllere,ce�frage odors detected lticl?en arriving at the bite? ❑ Yes. = No Building Sewer(locate on site plan): Depth below grade: feet Material of Gnngtn Coon: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet COn?!?t?nt$ On r•nnriitlQn^f ipints, Denting, e��irlcrlCe of leak?ge, etr. ).-_ (...: Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ ietal fibdtglas°s ❑ 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,. Sludge.depthi: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 %omoweatn ofnassahsettsc Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 94 KING ARTHUR DR Property Address CHANSKY Owner Owner's Name information is OSTERVILLE required for MA 9/10/11 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Cn,,�rp thir,t{necg Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle HQ\f/w re dimensions d2termined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK LOOK'S CLEAN AT THIS TIME WITH MOSTLY CLEAR WATER RECOMMEND PUMPING EVERY 2-3 YRS FOR MAINTENANCE Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): - Scum thickness Distance from top of scum to top of outlet tee or baffle DiStaiiC@.iuM.bljtivi .i Gf SCUM to bottoi7i of 0 tlCt tee.oi.baffic Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonweaith 0-f Mastaidhuset s I itle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 KING ARTHUR DR Property Address CHANSKY Owner Owner's Name information is required for CISTERVILLE MA 11 every page. Citylrown Dat e of - State Zip Code Date of Inspection D. System information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons.per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Mai ssachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 94 KING ARTHUR.DR Property Address CHANSKY Owner Owner's Name information is OSTERVILLE required for MA 9/10/11 every page. Clty/-rown State Zip Code Date of Inspection D. System information (coot) 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 LEVEL NO LEAKAGE SHOWS TYPICAL SIGNS OF AGE APPEARS TO HAVE NEW COVER 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.).- Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located,.explain why: t5ins•.09J08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonweaitn of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y( 94 KING ARTHUR DR Property Address CHANSKY Owner Owner's Name information is OSTERVILLE required for MA every page. City/Town State Zip Code D of Date te of 1 Inspection D. System Information (Cont.) Type: ® leaching pits number:El 1 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leeching.fields number,.dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system .Type/name.of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): PIT HAD @ 2 FT OF WATER AT TIME OF INSPECTION, STAIN LINE WAS AROUND 2 FT FROM INLET INVERT. PIT WAS PRECAST CONCRETE BUT NOT ROUND , IT WAS THE OLD STYLE FLAT SIDED. SOME ROOT INTRUSION WAS EVIDENT BUT THE TOP SECTION OF THE PIT HAD CLEAN STONE VISIBLE THROUGH THE HOLES.COVER SECTION OF THE PIT APPEARD TO HAVE A NEWER COVER WITH CONCRETE POURED AROUND IT . COVER SECTION APPEARED TO BE STRUCTURALLY SOUND AT TIME OF INSPECTION Cesspools(cesspool must be pumped as part of in (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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 94 KING ARTHUR DR Property Address CHANSKY Owner Owner's Name information is OSTERVILLE required for MA 9/10/11 every page. City/Town State Zip Code Date of Inspection D. System Information (cons.) Comments(mote condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, 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, etc.): !Sins•09!09 ?','.itle,S.01ficialInsgec!bn Form:Subsurface Sewage ei� I System f 7 S -ice -,-•-m•Pace 4 of t. �ommonweaith of Massacnuseif<s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 94 KING ARTHUR DR Property Address CHANSKY Owner Owner's Name information is required for OSTERVILLE MA 9/10/11 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below Z drawing attached separately t5ms•09108 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Ma's' sachuseft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 94 KING ARTHUR DR Property Address CHANSKY Owner Owner's Name information is OSTERVILLE required for MA 9/10/11 every page. Cdyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope 2 Surface,water ® Check cellar ® Shallow wells Estimated depth to:high ground water: GREATER THA 4 FT 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: AUGERED TO 4 FT BELOW BOTTOM OF PIT NO GM ENCOUNTERED Before filing this Inspection Report, please see Report Completeness Checklist on next page. t51ns•09108 Yltle 5 Official inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 commonwealth of Massachuseft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 94 KING ARTHUR DR Properly Address CHANSKY Owner Owner's Name information is required for OSTERVILLE MA 9/10/11 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed Z System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•04!08 Title 5 Official inspection Form;Subsurface Sewage Disposal System-Page 17 of!7 Assessing As-Built Cards Page 1 of 1 LO�C�T Obi WA G E PER IT N0. t � VILLAGE INSTA L EIII A & 4DDRESS -S U L DER OR OWNER 0A TyE PERMIT ISSUE © -Z Y ,� .., DATE COMPLIANCE ISSUED ,ewe .0•` ,l�ArsE \ fa t f o. F �J ttp://town.bamstable.ma.us/Assessing/HMdisplay.asp?mappar=145043&seq=1 9/10/2011 I No.----•-�-----•�-�-�-- Fps.......... o...........p THE COMMONWEALTH OF MASSACHUSETTS Bdp .Ap R® ®F HEE L .........OF......... .................... Appliration for Disposal Works Tnnitrnrtiun VrrAttt _w } Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal ' Syst t ...... ..-. J •• -l!1....-- % .._. --------------- .....«�:�......------•--...........-- Loca ess / or Lot No. n = ..__... - -- ..................... Ow ddress _ nstaller Address T e of Building Size Lot.��r_ ®__ ._..Sq. feet U Dwelling—No. of Bedrooms.... ...................... _Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures .. W Design Flow.................!5 0.................gallons per person per day. Total daily flow__._._...._..'3-a.0..__...__..._..gallons. WSeptic Tank—Liquid-capacity/".'.r atlons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Wi otal Length........... __..___ al leaching area....................sq. ft. 3 Seepage Pit No........ "Di to // ._... al leaching area_ �'_?..sq. ft. Z Other Distribution box ( ) Dosing tank O!�^ �� 3�- 7e- �• ~' Percolation Test Result Performed by....... . ...... ...... LP.A ..t!Q............. Date....��'El_-.7..�.-........... Test Pit No. 1... .__.minutes per inch Depth of Test Pit.................... Depth to ground water........................ (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ...............................................•• f ------------•---- -_ -------- �.� ..`...iZ ---CV. ... �G..r.. -= •+�"' O Description of Soil ........................ W V ------------------------------ ........ •------------------------- ..._........----------•----------------------------------•------------------------------------------•--•------------- 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 i ITL1 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 bo d of health. Sig d � Dat Application Approved By.....--- ......... ....... - ------------------------- .... - _.__ _-_7 • Date Application Disapproved for the following reasons----------------------------•------------------------------------------------------•-----•......---._.........._ Date /v Permit No.... Issued... .--------•....................................... Date NMI No......................._ ? F�$.' ."�_....~.....r. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE L X I . :. .....OF........ n...---------.................... Y. Appliration for Disposal Works Tonstrnrtion Prrmit v Application is hereby made for a Permit to Construct (1 or Repair ( ) an Individual Sewage Disposal syst t• .'�G � � /A � �� Loca IC7io �idRress ,-�;:- or Lit-No. 1, ............ .!'6:............ ... i. �/"�,:----•-----•---------'------- .............................. Z `""�.._......................----^ ........................ d Owf ddress -- a •.-' - •----......,.A/4*'/{. -- ........ --•----------------------•- -- ----h---------• ----_- Installer Address vType of Building Size Lot. __�®_ ----Sq. feet Dwelling—No. of Bedrooms...__ _________________________________Expansion Attic ( ) Garbage Grinder ( ) '4 Other—Type T e of Building No. of persons............................ Showers — P.I YP g ---------------------------• P (. ) Cafeteria W Other fixtures .. c "'------------------------------- .............................................................-------------- . W Design Flow...............-IT-JV..................gallons per person per day. Total daily flow............. _O_.a...............gallons. WSeptic Tank—Liquid capacity/1 ca ons Length................ Width................ Diameter-----------_- Depth................ x Disposal Trench—No..................... W' h.................. otal Length.._.____. tal leaching area....................sq. ft. Seepage Pit No... � `` Di ..............--- t"*60 otal leaching area _o_�r'..sq. ft. Z Other-Distribution box ( ) � Dosing tank ( ) A �� '� Percolation Test Results Performed by....................................................•••-••-•-- ••----. Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..................... Tesi Pit No. 2................minutes per inch Depth of,Test Pit.................... Depth to ground water........................ ----- ---- - D Description of Soil................ff-. �.`....-• • •. = x - �.. .Aed.' .. S� U ---- ----------•----••-•-•-----•---------- sue. ,�. W -------------------;----------------------------•--...------.._..------------------•---••-----......----•------------------------.......-------------•------------------------------------...••-•--••••- U Nature of Repairs or Alterations—Answer when'applicable............................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 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 bo rd of health. Signed. , f Y': •. Application Approved BY----•------------------------------ _...... ... Date Date Application Disapproved for the following reasons________________________________________________________________________________________________________________ ................•----......---------......._........-•----••----•---•------------......-----------••---r c•----------------•-•-------•-----•-•--------_____..--•--------............................... Date PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHU TES ' BOARD OF HEAL H %L ......O F........ Tntifiratr of Toutplianrr THIS IS TO CERTIFY,�Tgthe :vidual Sewage Disposal System constructed or RepairedbY•---.� �"'" ............ ....•----- .yl - �'""''"--..... ....._._.__.... taller at......... -�........G............... •------- - '"a`'!"''�......................' . ............................ has been installed in accordancehe provisions of TIT `df: he State Sanitary Cod U essr fe the '� application for Disposal Works Permit No------ ------------�._..-----..... dated................................................ i THE ISSUANCE`;OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE 4 SYSTEM WILL FUNCTION SATISFACTORY. DATE........... Inspector .. t ;4g, THE COMMONWEALTH OF MASSACHUSETTS BOARD O�H EALTH 7 I e -- � � .....0 F.....: .... ................................... .................... No................. . . FEia- .............. ipax a Works T�atil ' ua rrnti# Permission grTair granted....... -•--•• r _...._...-• .. ........- ............ -• - --• - to Construct ( ) Individual Sewag posal Sy em, �'as sho n on the or Dispos orks Construction Per o_____ ____ ___ _ ed__.___..____.._............_._...___._.... Board of Health DATE................................ ................................................ FORM 1255 HOBBS & WARREN. INC., PUBLISHERS THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) mp L DATA -r..Pct-,&L F-IT - LUSE ItaGXJ <.-Aj .. + 1�Zt/a.t_L Acrt✓A. _ tsc� s.F. M S-7G i BOI- O.Vl 4.2icA.Y r:;o Sf=. I t To-r,&L. TEE-SiGl.1 t 425 E o r4A14 � o Loa IOA.b y" pry 7 , 970 _ . II+hl 'CCU�"v fig:• i �'.<. ,�: Srle6olL. 4'r'�P& '1 ST. 1W. GAL. ��T• { -box ) 4G J T-Akse- l a I tuv44 t000 9S� ,�,y twv. SA i� PIT i W�"r"u •; 111 WASHScD Ao� 1 _ G•'o' -- I C E Z T I i'=1 E C) P L(!:)-r /s,hi - _.. . pl—ik Q I I~P V-E.k i GC. F %4Z.ti�c 01,1 Gc �r�t its W iTI-A TI_1G; -51 DIE l..i►-4C— Lo7 { 4 t aun SE�c-I:Yti�I` t}"cCJ�t���L.�T� 01= T►a�. B -- t �.?(.TG. T141'a PL-Al -! ! c-1C�.�' t?,A=,E L7 P4.-i P-a.i GSTEfL�/El.4.l~ a IIrC�•S�, } t_" Gti.l t.La A.1�t-.*L_I C/�.,hi"T` �1 � �* I 1u t)r�l'i_��/ t L": lt�T I_ii.tC=:�r ___ �- c4p XV11>4 deck bath 1 J L IF kitchen , I 16'-4" x 12'-0" bedroom 1 °CD Oo dining x ob bath 2 I �P I I — — - — — — — - — -2 1 /21121-211 _ . - . _ . - 8'-11 " . — . — - atI-c.U: n=F7 N .Q 00 N I Ud 3'-3 1 /2 I room living - I � II � I = bedroom. 2 bedroom. 3 ' a I N N DN.