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HomeMy WebLinkAbout0034 MILNE ROAD - Health 41Vltlne R � s ,: �Y IIA Osterville ��� � �� A 118 026 r 0 TOWN OF BARNSTABLE I.00TION 3y Imo,l nc Rd • SEWAGE # BOOS - 3L/S VRIAGE osicr y'M c. ASSESSOR'S MAP & LOT //8 " 2Co INSTALLER'S NAME&PHONE NO. PoScrj G i)-'oy SOS - q77- 0653 SEPTIC TANK CAPACITY _ JSOO Q a I LEACHING FACILITY: (type) SOO 9cJ cha�r+nS (size) /3 X PN X 7- NO. OF BEDROOMS .3 BUILDER OR OWNER R,chara Bc-k )marl PERMITDATE: �J-a I -n� COMPLIANCE DATE: 'R t Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �a 60 � fA � G-� DGp � bD (A (^ 1t ,. vX (mot oo f CLN O* eF C I O w � Q S,S 1 TOWN OF BARNSTABLE LOCATION � , �.\IC �� SEWAGE VILiAGE p (' V' ,1 ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY ��o � ,s� �� LEACHING FACILITY:(type) (size) NO. OF BEDROOMS •PRIVATE WELL O PUBLIC_W_$-T----ER BUILDER OR OWNER 0 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No L� y-3 'Ile i O n - I I SP oac� Commonwealth of Massachusetts P W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rt 'M 34 Milne Roadrnv Property Address W Beverly Behlam Owner Owner's Name O? information is s required for every Osterville Ma 02655 9-7-16 page. City/Town State Zip Code Date of Inspection W rU W 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 forms A. General Information �p on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 Company Address Sandwich Ma 02563 _ City/Town State Zip Code (508)477-0653 S113640 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 9-7-16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 S Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �.� 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma 02655 9-7-16 page. Cityrrown 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: ® 1 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 was in working order at time of inspection. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �.N 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma `02655 9-7-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced' ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times'a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required,by the Board of Health: ❑ Conditions exist which require further evaluation'by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass, unless Board of Health determines'in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments M 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma 02655 9-7-16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 1 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma 02655 9-7-16 page. City/Town State Zip Code Date of Inspection B. Certification (coot.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for.Voluntary Assessments M 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is Osterville Ma 02655 9-7-16 required for every page. City/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 ❑ ® 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? El ® 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)] D. System Information 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): 340 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma '02655 9-7-16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 years usage d See below 9 ( Y 9 (gp ))� Detail: 2015-76,000gallons 2014-81,000gallons Sump pump? ❑ Yes ®. No Last date of occupancy: Current • Date. Commercial/Industrial Flow Conditions: Type of Establishment: NA 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 Industrial waste holding tank present? ❑ Yes ❑ No I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma 02655 9-7-16 page. City/Town 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: No pumping info , Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for.Voluntary Assessments 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Osteryille Ma 02655 9-7-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 2005 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 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: 1500gallons Sludge depth: 8„ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma 02655. 9-7-16 page. City/Town 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 28„ Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Measured 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 was in working order at time of inspection with liquid level equal to outlet invert. Tank should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma 02655 9-7-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma 02655 9-7-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plan). 011 Depth of liquid level above outlet invert 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.): D-box was in working order at time of inspection. No sign of backup or cart'over was present. 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.): NA * If pumps or alarms are not in working order, system is a conditio6al pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 34 Milne Road a Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma 02655. 9-7-16 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) j Type: ❑ leaching pits number: ® leaching chambers, number: (2) 500gallon chambers ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology-. . Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of . vegetation, etc.): Leaching was in working order at time of inspection with sign of back up. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA 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 ry t5ins-3113 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 ° 34 Milne Road M Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma 02655 9-7-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Osterville Ma 02655 9-7-16 page. City/Town 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 ❑ drawing attached separately RER DRIVEWAY H DECK Al 30' 87.2 ` A2-3 ' 52= 18' E3. 5' A4•36t. S4=34 A5- 1 S *30' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts. W Title 5 Official Inspection Form =, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,^M 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is Osterville Ma 02655 9-7-16 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) ' Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW 144" 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 5 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: Plan on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 34 Milne Road Property Address Beverly Behlam Owner Owner's Name information is required for every Cisterville Ma 02655 9-7-16 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 ® System Information —Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 No. (�d U Fee I U y 14 COUMONWEALTH OF MASSACHUSETT;S Entered in computer: e- Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Z(ppfication for 33igpo.5ar *potem Con!5truction Permit Application for a Permit to Construct( )Repair( )Upgrade(")Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 3 4 1 rl C wner's Name,Address and Tel.No. Q5' trc 4111� + c hard Bell mn n Assessor's Map/Parcel Mq p# its ?art-el �t 2(,0 3`t M t►n e d, 05}e c-v t 11 e S o S-y 28- 8 ?i} Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. FZob��+ Cr" i 1 - Bt3 ExcaVcl+ton D4vld 3- M 5crn Dt3C:.nv►'ro r\mcr\+cL1 le5ig n 5 I'1 - e4 heresy LrU -I-o(-e5+r1q te, Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow 3 3 D gallons. Plan Date 71 2.0 10-5 Number of sheets Revision Date Title 5 t je4- 5e_waa( �jDkcLn 1311 M►l ne Size of Septic Tank 1500 0 Type of S.A.S. 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 issued by this Board of ealth. Signed Date 7 I z 1 I D Application Approved by °W Date Application Disapproved for the following reasons Permit No.2ej54".3 YQ Date Issued rZ1 ;I_( ———————————————————————————————--—————— 1. :ai � ( 1 No. J %_ Fee �HE COMMONWEALTH OF MASSACFRJS.ETT'S Entered in computer: Yes 4 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZLpprtcation for Migpool 6pgtem Construction Veriutt Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components ins �c Location Address or Lot No. ner' Name,Addr ss d Tel.No. p51 erviIt(-" chcir-d f�L'M mn n Assessor's Map/Parcel /\/\CI Al 1 18 n r C J 1 + 2(G 341 A�i 1 ne 2 d, fi5 I e r v 1 I r@ 50 s - LI 2$- S-W 4 In�s aller's Name,Address, d Tel.No p s finer' N e,�d�ess an Tel.No. 11 1��i\l rA s ,Aqd Ca l K\0tD-eCI &7iIrtY- �i � XcCIVCOton DC3GInv�r�r�nl�ntGt1�e51 n5 I'-I -rec, ljerr , try tU1e51c1ctle 506 - 123 Zil ' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( .) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 3 U gallons. kO 1 Plan- Date 7 umber of ee s Revision Date - Title �11 Size of Septic Tank ,y i Type of S.A.S. 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 I 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 iss, e, b th'st, Bgard of�eath.. 71.a 1 I©�' Signed lam" Date Application Approved by T Date J0 j1 d, Application Disapproved for the following reasons Permit No. ut7 Date Issued (J THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS T RTIFY, that then-sit Sewage Dispos System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by O X•.t ci U n I t�� I U5` e(V I I I at ► h �ben constru4fftg,d,inf� rdance 20 with the provisions of Title 5 and the —r Disposa Syste�j Construction Permit,No. r, ated !! Installer r�e L'T 1 1 U t )" Designer The issuance of this permit shall pot be construed as a guarantee that th Sys wi yction as designed. Date �� 7 1 Inspecto —� No. �V�J �3 (0 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Digogal 6pgtem Cong;tru ton hermit Permission is hereby fir me o onstruec ) air( )Upgrade �)Abandon( ) System located at _� I�n ��� 5, e V 1 1 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: Construction must be completed within three years of the date of thi p t.Okv- Date: �l f Approved by 774 9/16103 Notice: This Form Is To Be Used For,the Repair Of Failed - Septic Systems Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM r -_ hereby certify that the engineered plan signed by me dated 1 ID concerning the propevocated at U�4 G, u•meets, all of the following criteria: w , • This failed system is connected to a residential dwelling;only_ There are.no commercial or business uses associated with the dwelling. u • 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 of may conduct deep+= test holes and percolation tests at the site without a health agent present. • There is no increase inflow and/or change in use proposed • There are no variances requested or needed. ° k • The bottom of the proposed leaching facility will be located no less than Sfive feet above the' = m ximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] Please complete the following: w, A) Top of Ground Surface Elevation-(using GIS information) B) G.W.Elevation +adjustment for high G.W. DIFFERENCE BETWEEN A and B ' x, '2,3 SIGNED DATE: � 26M, NOTICE` Based upon the above information;a repair permit will-be issued for bedrooms maximum_ No additional bedrooms are authorized,in the future without engineered septic system plans. Cam. l.J t- h. gASepticlpercexemp.doc F� ij . . . Town of Barnstable Regulatory Services h� c� , .......... . Thomas F. Geiler,DirectorLE,• BARAB • 9 . Public Health Division rED �a Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Designer: 1 D 6. A�5� Installer: � '�`�T oll Address: . •�.I Lv�WG� 2 Q � Address: F', 6 4_10W I( LH A� 6z52-;,7 _ On 1' � ( was issued a ermitto install a (da ) (installer) 1' . septic system at 13 MIUWL q0 A )gsed on a design drawn by (address) r �A'111 l� dated (designer) l�I certify that the septic system referenced above was installed substantially accoT t-�to the design, which may include minor approved changes such as'lateral relocation,of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with n ajor changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State&Local Regulations. Plan revision or certified as-built by designer to follow. $ i vet (Instal er's SipaV I - y t (I si er's Signature) (Affix Desi s Stamp:Mere) PLEASE RETURN TO BARNSTABLE-PUULIC`H]�ALTIO[ bDWISION.' /C •R CATE OF COMPLIANCE WILL NOT BE ISSUED,UNTIL .BOA' THIS FORM' 'AS- BUILT CARD ARE RECEDED BY JHE BARNSTABLRPUI%LIC HEALT D . ION. t THANK YOU. Q:Health/Septic/Desigaer Certification Form 1 i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ............I...OF ---WP Appl ration for Dippnsal Works Tonstrurtinn Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal system at: . =e-----... ......... ....... ................ s ` -------------------..__.._........:_.. ...... Y��;.rSaS..ocati ............ ........•.............. , or Lot No.----_-.----_-_•-•-•------.----—........_..._ �11 �x.Y--1---- ,�� Address .------•---- -- 1 {. a�v?...........................................r Installer Address Type of Building Size Lot............................Sq. feet aDwelling—No. of Bedrooms...... Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ...............j............ No. of persons............................ Showers ( . ) — Cafeteria ( ). a' Other fixtures ......:.............................................................. •---- 0 WW Design Flow........�....................•..gallons per person per day: Total daily flow._.....` ��...Q_.:._.._............gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width.......:........ Diameter................ Depth................ x Disposal Trench—No..................... Width....t-.------------- Total Length.....................Total leaching area...................sq. ft. . 3 Seepage Pit No.......A............ Diameter..... .d_._...... Depth below inlet...... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results. Performed by........................................................................... Date........................................ 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........................ x ............---•••---.......•---•- ..............................-.................................................................................. 0 Description of Soil........................................................................................................................................................................ x W ------•---------••-•---•••-- ............•----_._ .._.r-- --------------- UNature of Repairs or Alterations-Answer when applicable....__.j4i�.b.......lO a....:. � ...W_ a...................... O we —4 -----.c.�....-•-- 2 _ ..�j_---C............I ...).,...........................:.........................................:................•----- Agreement: The. undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITIS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Comp been issued by es health. Si ned.. -_. .. ............... aka�--------•------- Application Approved By......................... 2} t Date Application Disapproved for the following reasons:---•---•.................:::..:..................................:........................................__.. ..................•------.---•-•-----...................-----....--•-----•--•---•---•-------•------------•-•-•--•--•-.............._._..•--•--•-----•-••---•--•--------•---•---•-•- --••-......._ Date Permit No.-------- C `. ....1.... Issued_................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD , OF HEALTH a bi "►«, — ... � C .�1.�1`. ...---....0F............. .•�l..!1�� Z. .LD`�`......................... •..... Appliration for Disposal orks Tonstrudiori fIrrut #., Application'is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal- Systm at: rr,,Location-Address ( or Lot No. ........... CL� :.�..r.:tS.._- a f?._�n\•in!�C�ram.'----•----•-•- ....................... --^.................C��t�a+Y�.P ..__... --................................. Own ••- Address a -.� ==tY.�: •a........-�. :� �°: �.............. ..... � .c:"�^-.?r..—` ........................................... Installer l- Installer Address Type of Building _ Size Lot................ q. feet aDwelling—No. of Bedrooms._._._-7.................................Expan'sion Attic ( , ) Garbage Grinder ( ) Other—T e of Building ............................. No. of persons............. ......... Showers — Cafeteria a' t Other fixtures ----------------•- -•...................--.---•- . WW Design Flow.......Z..�..........................gallons per person per day. Total daily flow.....-_..s��..� ..................gallons. WSeptic Tank—Liquid ca.pacity.............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—I o..................... Width....................Total Length........... ........Total leaching area...................sq. ft. 3 Seepage Pit No..................... Diameter.....�._.__........ Depth below inlet.....0........... Total leaching area.................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................-:.............. ,`�a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water....................... f= Test Pit No. 2----------------minutes per inch Depth of Test,Pit.................... Depth to ground water........................ x ....--•---•-=-- ----------------------------------------------------------------------------------•---.....................---.............._...--------- Descriptionof Soil......................................................................................................................................................................... Z W "------------------- ....----------- .----------- 4f-------------.---.--.---------------•----------------------------•----••--•------•---•------.-----•----- •------------ •-------------. ........---•------------------------------------•-------------------------------•---......-------------------------------------------------•-------------...........------....................•--•...--- U Nature of Repairs or Alterations-Answer when applicable.._..._ ?D`Q.......1!Tc3?3.....:P ._._ !..t7........................ .............. T Q v-f' ......•--------------- ......................... Agreement: The undersigned agrees to install the aforedescribed Individual'Sewage Disposal System in accordance with the provisions of TI'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-boar-dCof health ........._." Application Approved By----.... .......�' ` :� ................ Date Application Disapproved for the following reasons:............................................................................................. .............___ ..........................................•--•--.....---•---------•--.........------•------•---------........-----------------•-----------•-•---••--•-••---------•-•-----------......--------••--------- Due i Permit No........ �^ ---•--�--------------��---�._.. Issued......................................................_ ate ------------------------------------------------------------ THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH .U ............OF..................................................................................... (Irr#if iratr of Tautplitturr THIS IS—TO CERTIFY (That the fIndividual Sew age Disposal System constructed ( ) or Repaired � ....... ( ) by................ x ��?_t'...�. ------- ----•------..---_.--..-..----..--.---.---------.----------------.-------_.-------_ .• / r- A .."`. Ins t at. �......_.....ds.'±1�. --------- =- 's-------------------------••----••-•-----...••-•--........--•--•----•-----.................. has been installed in accordance with the provisions of TITLE of The State Sanitary Code/as described in the application for Disposal Works Construction Permit No........ ..�..".0 _.. dated.... YI—��._ ........... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GiJARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...................l.(' �-� `9 7 ..--•--- ........................ Inspector.................................................................................... k THE COMMONWEALTH OF MASSACHUSETTS BOARD OF- HEALTH '. �j ............................oF.......................... No......................... a - FEz....,r:�-------- Uisposal Works Tonstrudiott f rrmit Permission is hereby granted..._. .....��`� ��—'=r. ............. . to Construct ( ) or Repair ( )-an—an Individual Sev► ge-Disposal System at No.:-• ���+r7 =~� ....................nc ................................................... =-- .. Streets - Y. as shown on the application for Disposal Works Construction Permit No. - ..�__..D'ated.._.. 1��/ ---- l/l/ •-- Board of Fleal'th DATE..................... ` -------------•----------- t /f ASSESSORS MAP: � � _ y}- TEST HOLE LOGS PARCEL: ZjD -- _---____-- _- NOTES: _ ^ SOIL EVALUATOR m G �► FLOOD ZONE: dl_-_-_._LAQ�t,�1��1�C.�_ _--__-- WITNESS: IwoV L 6,04 JO �► REFERENCE: _+ _ � _ DATE: _ `� 2L 1) The installation shall comply with Title V and Town of Barnstable Board of PERCOLATION RA; E: wit ( Health Regulations. 2) The installer shall verify the location of utilities, sewer inverts and septic TH- 1 TH-2 components prior to installation and setting base elevations. � y�, 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot.l0 9 — 4) This plan is not to be utilized for property line determination nor any other purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. - 6) Parking shall not be constructed over H10 septic components. LOCATION MAP( t ) .�r 7) The property is bounded by property corners and property lines. t9 ^`"'��// L# 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. 2 ` },, 9) The existing cesspool(s) shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean washed sand per Title V � 10)System components to be 10 feet from water line. 11) If a garbage grinder exists it is to be removed and the responsibility of the / 5 T I SYSTEM DES I G N owner to ensure such. m � � ✓ ff FLOW ESTIMATE l LBE';ROOMS AT I t V��� GAL/DAY/BEDROOM - GAL/DAY SEPTIC TANK I&C,L/DAY x 2 DAYS - &X GAL USE1', M GALLON SEPTIC TANK SOIL l3SORPTION SYSTEM , L') 61 : `_ 61 100 b .- i DE AREA: fi M o o �J l I OTTOM AREA: 1 � i )22 F��J�v \ { / \ �10� SEPTI ; SYSTEM SECTION o L5 uww" to �( I ; .— _ r, ' �- � o� j!j '! + �' b ��X � IZnMA� w�4X• �"�wu� �� p 'max 11/ ll 1 jo" W'� " b �,"�x�uE.u�o % � �1 0 E Z$� , o. •• D-BOX �I��1 �� ✓✓ V GAL �, 3 z8�2� AR5 SEPTIC TANK or, ► may, 24AD SITE AND SEWAGE PLAN LCTION : ILh6 VOAC> ; PREPARED FOR . 6 RJ &L*VIA Im SCALE: DAV I D B . MASON R'S DATE: a ° DBC ENVIRONMENTAL DESIGNS W DATE HEALTH AGENT EAST SANDWICH . MA ( 508 ) 833- 2I77