HomeMy WebLinkAbout0275 NORTH BAY ROAD - Health (2) L'North Bay Road
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Town of Barnstable
CFTHE r Regulatory Services
Thomas F. Geiler,Director
Public Health Division
BA STABLE, - Thomas McKean,
Director-mom. 200 Main Street. Hyannis, MA 02601
1639• ♦�
ArFD MA'1 A
Phone: 508-862-4644
Email: health o town.barnstable.ma.us
Fax: 508-790-6304
Office Hours: M-F 8:00—4:30 f !�
o
January 27,2011
Christopher and Angela Winchenbaugh RE: Underground Storage Tank Removal
49 East 0 Street,Unit 7C Order,275 North Bay Road,Osterville,MA
New York,NY 10028 Map Parcel 072-010,
Tank#1,Tag#00213
Dear Christopher and Angela Winchenbaugh:
The Barnstable Public Health Division(BPHD)is in receipt of a copy of the"Application and Permit".
for storage tank removal and transportation issued by the Centerville-Osterville-Marstons Mills Fire
District;and the"tank yard"receipt demonstrating that an underground,storage tank was removed from the "
above referenced address on or about December 10,2004.
The Public Health Divis ion'appreciates your attention to this matter and has updated its data base to
reflect this fuel tank status change. Should you have any further questions please contact Cynthia Martin of
this office at 508-826-4645. S
s ean,RS,CHOJ
Director of.Public Health
ry
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1 1
°Ft"E T°�ti Town of Barnstable
Regulatory Services Barnstable
* r
BARNSrABLE,
� Thomas F. Geiler,Director 1A"inerfcaCity
Public Health Division ' I
lFn�,w+A Thomas McKean,Director ,tam
200 Main Street
Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
November 23 2010 `
Christopher F. & Angela F. Winchenbaugh
49 E 86TH ST, Unit 7C
New York,NY 10028
RE: Underground Storage Tank
275 NORTH BAY ROAD,
OSTERVILLE
Map/Parcel: 072-010
Tank Number: 1
Tag Number: 002.13
Our records indicate that your underground fuel (or chemical) storage tank exceeds thirty
(30) years in age, and has not been removed as required by the Town of Barnstable Code
Chapter 326, Section 3,,Fuel and Chemical Storage Tanks.
You are directed to remove this tank within sixty (60) days from the date of this Notice.
Upon completion of the tank removal and within ninety(90) days of receipt of this Notice',
please submit to this office a copy of the permit for storage tank removal issued by your local
Fire Department. This copy of the removal permit serves as documentation that the
underground storage tank was properly removed and disposed of.
You may request a hearing provided that a written petition requesting same is received by the
Board of Health with teen (u10) days after this order is served.
Per Order of the Board of Health
/��o'�✓J �� � Thomas A. McKean, PS, CHO
Health Agent
411d �-
� u
:\r tat\Underground Tanks\let Undergmd tanks yr Nov2010. oc
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Board of Health '
Town TOWN OF BARNSTABLE Ae o
of`Barnstable
�;tfl, BOX 534 UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS O
Hyannis, Massa u
seqs
n26or
NAME102.4 1 lb . C1 G ► / ,•
ADDRESS 9" GR On VILLAGE
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE:
OR CHEMICAL
UAIAM&CAaotmj jN /Q a ej Ayos �
(Give same information for any additional tanks on reverse side of card)
,;
DATE OF PURCHASE OF EACH: 1. 2. 3. 4.
DATE OF FIRE DEPARTMENT PERMIT:
TESTING CERTIFICATION SUBMITTED:
PASSED O K= 10-Z 1-$a ,DID NOT PASS
r'
A P P R 0 V
Barnstable Conservation Commission
�or a oct Tom
P-0. gO A.R r T..-
Hyar-n's, Rim
csachuseffs O26OT
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E'
THE COMMONWEALTH OF MASSACHUSETTS
...........:.........................OF.......:..................................................................
FIRE DEPARTMENT
FIRE PREVENTION DIVISION
..... t. . .. 19.
'i APPLICATION FOR PERMIT
TO
INSTALL—ALTER FUEL OIL BURNING EQUIPMENT
To the Head of the Fire Department:
Application is hereby made in accordance with the provisions of Chapter 148, General Laws and
t Amendments thereto, and Regulations made under authority thereof by the undersigned for permit;
to install — alter, for the person or persons and at the location named herein, certain equipment for
the keeping, storage or use of fuel oil or other inflammable liquid products used for fuel as described
below.
...9-4 �'..�.. .'_
Name ..... . ...�...... ..).A0.... ...... ...... ................................. .............
A 4
Owner or Q_ccqpant
Address ....Z... ...... �........ A.... ....... .......... ..,�'�9��...,��''s..:....�,�.
Description — Name .... ,.' .......C. .J)...../0.0................................
Manufacturer54 .' ... l.... ...... ...........
BURNER: VV �A� �
Type ............... Model or Size Q.®... 4.V .4 N lyb,�
Location..49 AAA*/�r....... Mass. Approval No..A,
Typei+46,VIVA..Capacity/Q0®gals. (or) Size..............
STORAGE TANK: r. 1
- --.-- — _...- Location
Amount of fuel required for testing purposes/(. .......gals.
This application is made with full knowledge of the current requirements of the regulations
governing suchinstallation, which will be made in compliance therewith. ; • f
4.40
Appl. Rec'd. ..............................................
By S.14A.-��r�� .t 3 ...................
Permit issued �y
Permit No. Address �Cbe.(..... ::...
............................................... ,p
Certificate of Com eten�cy No.. �...7.6.0t
NOTE: If this application involves alterations to existing equipment, de��be fully re t rse"side.
pp1,
• FORM 244 HOBBS $ WARREN, INC., PUBLISHERS
i
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r
Make application to local Fire Department. ( 2�) L
Fire Department retains original application and issues duplicate as Permit.
u � LW/C
y
APPLICATION and
PERMIT-
for storage tank removal and transportation to approved tank disposal yard in accordance with the r
Of M.G.L. Chapter 148, Section 38A, 527 CM application 9.00, a lication is hereb made.b p ovisons
y y
Tank Owner Name (please print .C
--s�SZ�I7 M r C o r m i r k X
Address 275 North B ay Road, 9neture i applying/orpermit
Oyster Harbors , MA 02b55
Street City
- • • • Sfate Zip
Company Name Enviro—Safe- Corporation
Pdnf Co.or Individual
Address 14B Jan Sebastian Dr -Sandwlc � PrintPant Address Sa/1
Signature(if applying for permit) Print
Signature(if applying for permit)
f-1 IFCI'Certified Other r IFCI'Certified rl LSP#
Other
Tank Location 275 N o r t h B .
a . Road,; Otster Harbors , MA
Sleet Address +.. City
Tank Capacity(gallons) 1000
Substance Last Stored #2 °o i 1
Tank Dimensions (diameter x length)
Remarks:
w
Firm transporting waste Enviro—Safe Corp.. 329
State;Lic.#
.Hazardous waste manifest# E.P.A.#. MAD 9 8 5 2 6 9 3 2 3
Approved tank disposal yard Turner Inc. 002
Tank yard#
Type of inert gas . Tank yard address 235 Commercial Street Lynn ," MA
City or Town Osterville
FDID# 01920 'Pe'mit#
Date of issue 12/8/2004 Date of:expiration 1 2/27/onr%
Dig safe approval number: 200449054,
Dig S f Toll F . e er-800-322-4844
Signature i Title of Officer granting permit
After removal(s) ("Consumptive Use"fuel oil tanks exempted)send Form FP-29OR signed by Local Fire Dept.to,UST Re ul ,.
Compliance Unit, Department of.Fire.Services, P.O.Box 1025, State Road, Stow,MA 01775. 9 atOry
International Fire Code Institute
FP-292(revised 4/97
(Im D, na, ,._ .
e,�iatxe,ct
RECEIPT OF DISPOSA•�L OF UNDERG D'STEEL'STORA E TANK �, I
.Fam FP 291
, .1 �.. , �..y_. �� VAT f
i
NAME AND ADDRESS OF`APPROVED TANK YARD + j� 1 ��} ,i . y� Arn,al S$... i
_ - rr —
e if i +
unn 01805
APPROVED TANK YARD N6. d 3 —
ti-- TO Yard Ledger 502 CMR 3'03(4)dumber. ra
personally ezammed the undei prQund steel stdrage to k delivered to fliank yard'by firm;cotporabon orpartnership and aces tedsae'tn� fo 11.vante with Fue Prevention Regulation 502
00 , wsio s for 9 F pe It waCMR 3 prove Una round Steel Stdra a Tank dic aptling ards ali {met OCAL Head of Fire Department.
ls tank to this yarNam a d offiGal title of appr tank yard owner or ow ers thonzed r resen
$IGNATUR - -
E I c TITLE f 2 f t DATE:SIGNED I
This signed recei t of dis osal must be retur I 9 P P - reed to the local head�f the fire depa ment�F ID I fI 11 pursuant to 502 CMR
EACH TA "Til
2-
TANK DATA •: I �•'. 4 t ,� ����.
T K'REMOVED F�tUM
Gallons -
,, P
Previous Contents , (Ivo.a■a street)
(CItY or To"?
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Serial#(it available) jI !� { )ireartmen
r
� � •, t Permit
Tank LD.#(Form FP-290) x 1
m
Owner/Operator to mail revised copy of Nottficahon Form' 290 or.„ P4 1. to UST Compliance,
Office of the State Fire Marsha P O. Box 1025'State Roa Stow, M
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2001 JUN 26 AM 9: 22
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C.B FND.
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401
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;. a OF LAND IN
4 ` t STE RV I LLE
SCALE: 1 " = 60' DATE: DEC. 18, 2006
SAGAMORE SURVEY ASSOCIATES
0 30 60 120 180 P. 0. BOX 28
SAGAMORE BEACH, MASSACHUSETTS
1 " = 60 `
WK2489
• COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AfFAIRS�
DEPARTMENT OF ENVIRONMENTAL PROT CTIOR,
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TITLE 5 '
OFFICIAL INSPECTION FORM:-NOT FOR VOLUNTARY ASS SSMINTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FO
U PART A
CERTIFICATION
Property Address: 275 North Bay Road
Osterville. MA 02655
Owner's Name: Joan McCormick
Owner's Address: 4/5/
Date of Inspection: October 19, 2005
Name of Inspector: (Please Print) James M. Ford
Company Name: Tames M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT.
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of 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
Needs rther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: October 23 2005 .
The system inspector shally*taof 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.
Notes and Comments
**"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.
Title 5 Inspection Form 6/15/2000 page I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISP
OSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 275 North BE Road
Osterville. MA
Owner: Joan McCormick
Date of Inspection: October 19 2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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 `
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 275 North Bay Road
Osterville:MA
Owner: Joan McCormick
Date of Inspection: October 19, 2005
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
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 and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of atmnonia 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:
3
-. c
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 275 North Bay Road
Osterville. MA
Owner: Joan McCormick
Date of Inspection: October 19 2005
D. System Failure Criteria applicable to all systems:
You must indicate either"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 ''/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped—
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate 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.]
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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.
4
Page 5 of 11
A
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 275 North Bay Road
Osterville MA
Owner: Joan McCormick
Date of Inspection: October 19 2005
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?
✓ 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:
Yes No
✓ _, 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(3)(b)J.
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 275 North Bay Road
Osterville AM
Owner: Joan McCormick
Date of Inspection: October 19 2005
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Number of current residents: 1
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of infonnation:__ Tank pumped after the inspection for maintenance
Was system pumped as part of the inspection(yes or no): 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).
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Installed on 1 012 7180-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
v
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 275 North Bay Road
Osterville MA
Owner: Joan McCormick
Date of Inspection: October 19 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 2'
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no):
certificate) (attach a copy of
Dimensions: _ 1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 6"
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: 10"
How were dimensions detennined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were resent. The li uid level was even with the outlet invert. There did not a ear to be any signs of leakage.
The tank was pumped after the inspection for maintenance
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 275 North Bay Road
Osterville MA
Owner: Joan McCormick
Date of Inspection: October 19 2005
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: allons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level and clean. No solids were resent.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
8
x.
Page 9 of 1 I
i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 275 North Bay Road
Osterville MA
Owner: Joan McCormick
Date of Inspection: October 19 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 6'0000 gal)
leaching chambers,number:
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.):
One pit(#4)had 6"ofliauid on the bottom The scum line was at the same level The cover was 10"below grade The other
pit 05)had 6"ofhauid on the bottom The scum line was at the same level The cover was 10"below krade. There did not
appear to be any signs offailur e The bottom to grade was 9'
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on.site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (locate on site plan)
Materials of construction.-
Dimensions:
Depth of solids:
Com vents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
9
av • Page 10 of 11
OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address: 275 North Ray Road
Osterville MA
Owner: Joan McCormick
Date of Inspection: October 19 2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch 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.
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t
r,. Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMAT
ION continued
Property Address: 275 North Bay Road
Osterville MA
Owner: Joan McCormick
Date of Inspection: October 19 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 18+/_ feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: topoQrgphic and water contours snaps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Usin Barnstable to o ra hic and water contours ma s the maps were showin a roximatel 18'+/-to ground water at this
site.
r t
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied,relating to the system, the inspection and/or this report.
11 ,
1
----, , ^ TOWN
�,OFB�ARNSTABLE
p
I 0 "! �. ^!�I • SEWAGE #
VILLAGE cservl ASSESSOR'S MAP & LOT o-7a O/ a
INIOTALLER'S NAME&PHONE NO. G d?= �—
SEPTIC TANK CAPACITY SUb
LEACHING FACIL=: (type) a' Gxeo P 7 s (size)- / vw !941.
NO. OF BEDROOMS
BUILDER OR OWNER -O411 MC C,Dr✓✓!tC k
PERMTTDATE: COMPLIANCE DATE:
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 leac710^
g facility) Feet
Furnished by�/1 SDG FOrG/
At- /S _
3 a 1 G aq
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
F
CEIVED
V 2 12002
TOWN OF BANNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION 7 �]
Property Address: 275 North Bay Road
Osterville, MA 02655
Owner's Name: Joan McCormick
Owner's Address: Same
Date of Inspection: October 31, 2002 '
Name of Inspector:(Please Print) James 41. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map:072
Osterville,MA 02655-0049 Parcel. 010
Telephone Number: (508)862-9400 Lot.2
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of 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
Needs Fur er Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: November 9, 2002
The system inspector shall submi opy 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.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 275 North Bay Road
Osterville, AM
Owner: Joan McCormick
Date of Inspection: October 31, 2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
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.
Answer yes,no or not determined(Y,N,ND)in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
obstruction is removed
ND explain:
2 .
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 275 North Bay Road
Osterville, AM
Owner: Joan McCormick
Date of Inspection: October 31, 2002
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
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 and volatile organic compounds indicates that the well is free from pollution from thaffacility 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:
I
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 275 North,Bay Road
Osterville, AM
Owner: Joan McCormick
Date of Inspection: October 31, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of tunes 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 f of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate 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.]
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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
I 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 275 North Bay Road
Osterville, AM
Owner: Joan McCormick
Date of Inspection: October 31, 2002
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?
✓ 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:
Yes No
✓ 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(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 275 North Bay Road
Osterville, AM
Owner: Joan McCormick
Date of Inspection: October 31, 2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): S Number of bedrooms(actual): S
DESIGN.flow based on 310 C.MR l 5.203 (for example: 1.10 gpd x#of bedrooms): SSO
Number of current residents: 1
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): ipd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped approximately 8 years aQo-per owner
Was system pumped as part of the inspection(yes or no): 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)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Oct. 27180-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
9
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 275 North Bay Road
Osterville, MA
Owner: Joan McCormick
Date of Inspection: October 31, 2002
BUILDING SEWER(locate on site plan)
Depth below grade: Approx. 3'
Materials of construction: _cast iron ✓ 40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: Approx. 2'
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1500 Qal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: I"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11 .
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 275 North Bay Road
Osterville, MA
Owner: Joan McCormick
Date of Inspection: October 31, 2002
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was broken down structurally. A new D-box was installed(see Permit No. 2002-510).
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
:y
Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 275 North Bay Road
Osterville, AM
Owner: Joan McCormick
Date of Inspection: October 31, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2-6'x 6'(1000 gal.)
leaching chambers,number:
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.):
One pit 04)had approximately 6"of water on the bottom. The scum line was at the same level. There were no signs of failure.
The cover was approximately 10"below grade. The other pit 05)had approximately 4'of water on the bottom. The scum line
was at the same level. The.cover was approximately 10"below grade. The bottom to grade was approximately 9.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
r
PRIVY: None (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.):
9
4.
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 275 North Bay Road
Osterville, AM
Owner: Joan McCormick
Date of Inspection: October 31, 2002
Map:072
Parcel:010
Lot:2
SKETCH OF SEWAGE DISPOSAL SYSTEM .
Provide a sketch 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.
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10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 275 North Bay Road
Osterville, AM
Owner: Joan McCormick
Date of Inspection: October 31, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 18' +/- feet
Please indicate (check)all methods used to determine the high ground water elevation:
i
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the leach pit to grade was approximately 9. Using the Barnstable topographic map and the Cape Cod
Commission water contours map, the maps were showing approximately 18'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as o the date o inspection. This report is
P P P Y P P .f f P P
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
�- -- TOWppN OF BARNSTABLE
LOCATION pt�� n O r-- \ I,7 Ay RC SEWAGE # 510" auoa
VILLAGE U Sre-r\j ASSESSOR'S MAP & LOT U �—01
INSTALLER'S NAME&PHONE N0. Gw on Qtivh(JuS
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type E!V Ayr (size)
NO. OF BEDROOMS
BUILDER OR OWNER CIrMILk
PERMITDATE: o I d 1 COMPLIANCE DATE: I U
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
Foy '
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C3- ao.(
(33- ;0, ,
A4- ag
AS' 3�
Fee
No.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes` tv//
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Z.pplication for Migpool *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair(�)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Add s or Lot No.,�°IS �12k"H A y d Owner's Nam,es,�}}Address and Tel.V9. )I
05ICUi7 JoAw
Assessor's Map/Parcel ®j� — a 6 0 l�a�� �S Nt1 KO� Ay RaA
Installer's Namy,Address,and ITel.No.,� h ' �t/S Designer's Name,Address and Tel.No.
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 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature,of Repairs rAlterations(Answer when applicable)
I'D-Swe
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 is by t is BoardV Health.
Signed N Date 0126102
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
��••-- i
44
No. Fee_Lw
THE COMMONWEALTH OF MASSACHUSETTS,', . Entered in computer: Ye
PUBLICIHEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
G
t '
ZIpprication for ;Digpogar *pztem Con.5truction Permit
Application for a Permit to Construct(, )Repair( )Upgrade( )Abandon( ) ❑Complete System `❑Individual Components
Location Address or Lot No. me,Address and Tel.'Owners Na No.
� SAY �oac�
Assecs�'dr 6si'vI�'aY/fl cel � _ 36AW. ''I o�� °QpAGi , o.STC,
ola o1G I,a'f� s N6K ^
a Installer's Name,Address,and Tel.No. -pus Designer's Name,Address and Tel.No.
1� UJ.RAA]uS
ij
�a655
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 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
r.
s
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 Health_.. Nll.... 1
Signed Date
Application Approved by mil Date
Application Disapproved for o ing easons� r
Permit No. .-.r Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance ~ NF �D -86X
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired O Upgraded( )
Abandoned( )by _
at 30Aly -'0c 4
has been constructed in accordance
' with*the provisions of itle 5, nd or ispo a 'ystem o struction Permit NoG� �-� ated
Installer Designer
The issuanc s permit sha t not be construed as a guarantee that the.system will function as designed.
Date I. , , Inspector (A�) o
-----®1----------------------- Fee----��
.THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION 'BARNSTABLEs MASSACHUSETTS
• M1ti
'=i5pogal'&pgtem Con0truction Permit NZ+A, '� 41
Permission is hereby granted to Construct O Repair( )Upgrade( )Abandon
System located at
f .0
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 conrtlitions.-
-Provided:Coristructi 'must be ompleted within three years of the date of this? t
Date. Approved b '1 >
PP Y
/' -
{
TOWN OF BpARNSTABLE CC,
LOCATION_ olds AOr Bati RC SEWAGE # S10" au�a-
VILLAGE U ST•GrJ, ASSESSOR'S MAP & LOT 0 ) D
INSTALLER'S NAME&PHONE N0. C�GiGoI1 ��w+�JUS
SEPTIC TANK CAPACITY tl�lb
LEACHING FACILITY: (type) t7"�Ox rtoA►lr (size)
NO. OF BEDROOMS
BUILDER OR OWNER CC
PERMITDATE: o)- COMPLIANCE DATE:
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
g
R d 13a- a3
a C,3- aaco
A4 a•8
S A'V_ 3 .
L0 C A T.10N �� � S E W A G E PE RMIT NO.
.11z- 7-jr tidRrN3A-'1 .�v. o ��.r� AlA-R/3a�s 75-9.3
V I.L L`A G E
INSTA LLER'S NAME i ADDRESS
�dA/ .4.4
i
tit/,. �•�.Q.yS�-.�f3 CG wig� s,
BUILDER OR, OWNER
G L�.O� /S = .lJ d D L i r7- ���. ✓/1.
4 Q o i✓ -/
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED /U� �7—a4elO
a ,
' 1
No.. ...........
M
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Town Barnstable
OF...................................... .
Appliration for Di-spniia1 Works Tomitrurtion Vautit
Application is hereby made for a Permit to Construct (x ) or Repair ( ) an Individual Sewage Disposal
System at:
North Bay Road Lot 2
..............................................................................•----•---•---------- •....................---••-----------•------••----•---......------..........................----•-
.- Location-Address or Lot No.
/_ L/_/�., _..�3 ,1/� �CRvri/cam D nsc�aow„�N
Y.. ........_ ..........................•-•------------.-..._ .. "y.._.......... ........... .......
Owner Address
W J D f-/ ni p G o W L,vvr S 71...m �.f:r..I.. -r_'-'_/ �5....
................ -•--•------ ---........•--•-.----- ---- •• --.-- -
Installer Address 32,535
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms------------------L4........................Expansion Attic ( ) Garbage Grinder C e�
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q, Other fixtures --------------------------------------------------------------------•••-.
55 w/G.G-* _�bt�...... ........
W Design Flow................................... ... .gallons per erso r Tota 1 flow...-..................___......__........ .. ns.
g l5b�g P P ic�g6 Y �,` 4
WSeptic Tank—Liquid'capacity............gallons Length_------------- Width-----_--_--- Diameter................ Depth.............._.
W Disposal Trench—No..................... Wid _.�..__...__.___.... Total Length....... Total leaching area.______.. . sq. ft.
> Seepage Pit No.--_-__2....__ .. Diameter.................... Depth below inlet...... Total leaching area.....:ld__....sq. ft.
Z Other Distribution box O Dosing tank ( )
Percolation Test Results Performed b}rape.__C-ad...Skismey...Cans.11t—aI? SDate....2XI9.........1........
Test Pit No. 1...2..........minutes per inch Depth of Test Pit.... �_.._..._... Depth to ground water.:......10•_ ----.
Test Pit No. 2....2..........minutes per inch Depth of Test Pit__.N_..____... Depth to ground water..._._..1..�........
---•------------------------------••------------------------------------------------------------•----•---•---•----•••--........• fir '
O Description of Soil... ,_loam, 0.5_-10,_0__•clean___med.._-brown sand r ip
U ---•--•-•••••.......--••--........•.... •........ .......• ........ ................ ............. ........ ........................................
W -----`--•-------------- -•--------------------•---•---------------------------.......•--------•-•----••---••------.......................••......•.... •-•---� -- ----i2E g.C.....--
UNature of Repairs or Alterations—Answer when applicable.................. ............. . .............1E___--CHAPMAN-
'k .o .A No. 27654.0
....................................•........_.....------...._--•-•-•-----------..................---•----......--
0F� ����
Agreement: G�STE�
s G
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in a F
the provisions of TITi s. 5 of the State Sanitary Code—The undersigned furtt:er agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Si ned .......
m /
Application Approved By....... Date
. .. /-.... , h-�.�'"_'..7.%_....
Date
Application Disapproved for the following reasons-------------------------- --------------------------------------------------------------------------------------
-•----...-•---•--------------••--•-•------•-•------•--------.........._...------------------------................................................-v -------- -------- -----
- Date
PermitNo......................................................... Issued----............=-=------••--••--••--•---••-----..........
Date
T,
No.......... Y _
THE COMMONWaFI!IM4W ASSACHUSETTS
k. BOAR® OF HEAL
TH
.,rr�:,:..,
?, . Town Barnstable
` °h'y �" ,c� 1l lint ilatt for UiipIIiial 10orkfi Tomitrurtion amit
y j,-j1 pplic�ation is hereby made for Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
� Systr at
' J �$Y,' North BayRoad Lot 2
:L' Y1t'................................................. ...................................... ..................................................................................................
js1a 1 Location Address or Lot No.
-----------------------------------
S
2 b Owner Address ................
n
;t� r
'k ..............................................N
P 1 Installer Address 2'
f Building Size Lot......................___.Sq. feet
elling :No. of Bedrooms............:....1y........................Expansion Attic ( ) Garbage Grinder ye�
Q+ 3 t1t+�� r—Type of Building No. of persons____________________________ ShowersCafeteria ( )
K 'atk>. r xtu 7__________________________________________............................................. __ .__ .____.__________________.
w X. -
S e �0. Flow..... ... gallons per pgrso�,,p�y .Py. Tota y flow._�.................6� -_---••- 1 Qns.
'cN ank—Liquid'-c �acity l���gallons Length__......... Width---_----------- Diameter—............. Depth................
DisposalfTrench— o. k ____..�Wi thh_ ___________ ____ Total Length....._ _.1...___.__ Total leaching area______ _ _ sq. ft.
Se
page`P't 1Vo. U� p 4lII' sq..................... Depth below inlet.................... Total leachingarea.................. ft.
Z Other Distribution box > ) Dosing tank ( )
P44colation Test Results'f Performed b�.ape...C.A.d..,S.UrVe.Y... QX15U11aXAiS Date...2__$•_ ...................
Test Pit!No: 1...2 .__.minutes per inch Depth of Test Pit.._10.._....... Depth to ground water.......10_t__._..__.
Test Pit No. 2...2 2-min utes per inchx�Dep th of Test Pit_..10 f._______. Depth to ground water .``._..�.10R
Pa' �� '�Z 0
o Description of Soi1..0_a.0 t�. 5' loam. t.5.41Q.0 clean med. brown sand, gr �,��
x rt a _•_RENWICK---
e o
U B.
W -- ---• --- --- ----------- ------ ------ �......•--•-'
x ,� •. �• c, �1fAplVfil7�1 r�n'y
U Nature of Repairs or Alterations 'Answer when applicable....__..., -- _ ----------------
•---•--•-•-•... �� ... .. ._ .. .... ............... . ............•--•---•------•-- �tJF �ST
Agreement a t+ SS/ANAL ENG
The undersigned ;agree o install the af6VMescribed Individual Sewage Disposal System in a
the provisions oNTITTIa, 5 of the State-6anitary Code—The undersigned further agrees not to place the system in
operation uptil a Certificate of Compliance has-been issued by the board of health.
. --•-
Application Approved`'BY ✓ �% x-•--•-•--•----•----- ,+�"SG "
X#U. 44. Date
Applicatio&Disapproved for the following reasons: fi:.'-----------------------------------------------•----------------------------••-•••-••--_-----
{
..............••-
6* Date
Permitl�je...........................-- ....................... Issued-.......................................................
Date
'.
10,
THE COMMONWEALTH OF MASSACHUSETTS
- BOAR, HEALT .
.. O ...., ...7k F
if ratr of ff,ompliattrr
IS,TO Eli ;IF , That the Individual Sewageibisposal System constructed (1w) or Repaired ( )
by
•_.. _..........
Installer - -
at
.
has been installed in accordance"with the provisiol s'of T = r of.The State S itary Co zib the
applicatioi%,for Disposal Works Construction Permit No. ` �...............:. dated.'....._�� .�
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM-WILL FUNCTION SATISFACTORY t ,
DATE.--- Ll. '.!�t.7.............................................. ' Inspector •--•- .......................................................................
THE COMMONWEALTH OF MASSACHUSETTS lF^
BOARD OF' EALTH
r
........ �.. .;fOF............. ....
! I
.... ....
No. .. ..... FEE.
Wt6pos or
Permission.is ereby granted---- ---�..... - ---- !Q1.0truffion
�--------------------•-----------•--••-...................................�+...-•---•-- �to Constr t or pair. ) Ind al Sewage i po System
at No.. 4��-------
Street
as shown on the application for Disposal t�orks Construction Per No _ °TDated_ f ^".__ ..
a. �. or
ar ea t `
f
of 1 h ,
' 'DATE --- •z........................... ........................ _ ,;'• r
FORM •1'2S5 HOBBS & WARREN. IPIC.„ PUBLIS.HERS ` r
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GAL. • ''e PRECAST OR I ' ?h`G Z< ,.�.,y S.Er -t�'.¢ � '�'qr/� '�?.E +•+`T, .
SEPTIC �, . BLOCK e t3F T"�d -, =y' � �'.�G.�?:ee:S'T.Y,G�E� s^•�f� z .
TANK SEEPAGE PIT rK
20' MINIMUM
FOUNDATION I I %c�J' jA'vMFS \yu;
I Y2" WASHED STONE P i
l n CAF'ci EY
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ELEVATION $KETCH �`" i0 -- _ ��" `'� �"
SCALE 1"= 4,
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I
E L E VAT I ON SCHEDULE i
PROPOSED SITE PLAN i
I INV AT FOUNDATION = 5�. �-c, III
SEWAGE SYSTEM DESIGN �
Q INV INTO SEPTIC TANK = 83IN
i
3 1 NV OUT OF SEPTIC TANK = I
4 INV N70 DISTRIBUTION BOX = 55 SCALE I = .'�' � ;K 19 � � 1�a 0•t7;r.= 4c- a
.. R� ,
-• SCALE I��: 4' 5 NY OUT OF DISTFIIBUTION BOX - S3,3t3
;t'to,- . .o///s,/�Q o
PARC. RATE o.'ea�r .� • •F CAPE COD SURVEY CONSULTAfJTS }
6 NV INTO SEEPAGE PIT - F.0Z.
TEST BY _ _ter.:�._, C.c. w. ROUTE 132
TOWN INSPECTOR : _ � ��- T BOTTOM OF PIT zZ HYANN!S, MASS
BACKHOE OPERATOR
A WVIS ow So3YUw SURVEY C043uttARt3, 1ec
VEST MADE ON __�'` f3 y _(.,4f y _ t7cr ig /9,6� 8 BOTTOM OF STONE LAYER
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