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HomeMy WebLinkAbout0256 PARKER ROAD - Health 256 Parker Road Osterville y A = 116 067 ° 10 47 a v c . � y 0 < o x. a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address t. Dabbelt Owner Owner s Name }.; information is � required for every Osteryille MA 02655 7/8/19 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information S14r Sq 8S- Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7/8/19 Inspe s igna ur Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner Owner's Name information is required for every Osterville MA 02655 7/8/19 page. CitylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health.- *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 18 f Commonwealth of Massachusetts (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner owner's Name information is required for every Osterville MA 02655 7/8/19 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 f Commonwealth of Massachusetts �o (o Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner Owners Name information is required for every Osterville MA 02655 7/8/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection. Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or.privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water , supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner information is Owner's Name i required for every Osterville MA 02655 7/8/19 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ®' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less than Y2 day flow ❑ ®` Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ®. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes -No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ , the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone.II of a public water supply well t5insp.doc•rev.7126=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts i? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner Owner s Name information is required for every Osterville MA 02655 7/8/19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary cont. P rY (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ❑ ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® " ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Ip Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner information is Owner's Name required for every Osterville MA 02655 7/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings,-if available(last 2 years usage(gpd)): Detail: Sump Pum ?F ❑ Yes No P Last date of occupancy: Occupied Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 f Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner information is Owner's Name required for every Osterville MA 02655 7/8/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow.(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Pumped June 2019 per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts io Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �o 256 Parker Rd. Property Address Dabbelt Owner information is Owner's Name required for every Osterville MA 02655 7/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 2003 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 18" feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet feet Comments (on condition of joints, venting, evidence of leakage,etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner Owners Name information is required for every Osterville MA 02655 7/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: E 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: 1500g Sludge depth: trace Distance from top of sludge to bottom of outlet tee or baffle >12 Scum thickness trace >2" Distance from top of scum to top of outlet tee or baffle >2., Distance from bottom of scum to bottom of outlet tee or baffle 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.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form c Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner information is Owner's Name required for every Osterville MA 02655 7/8/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grader feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: l Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner Owner s Name information is required for every Osterville MA 02655 7/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 011 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 is 2' below grade, cover raised to 10", very good condition t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner Owners Name information is required for every Osterville MA 02655 7/8/19 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner information is Owners Name required for every Osterville MA 02655 7/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Chambers were video inspected and are damp at this time, no indication of past hydraulic failure, top of chambers is 3' below grade 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer. Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments V� 256 Parker Rd. Property Address Dabbelt Owner information is Owner's Name required for every Osterville MA 02655 7/8/19 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions t. Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner Owners Name information is required for every Osterville MA 02655 7/8/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 f t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 TOWN OF BARNSTABLE LOCATION o�1'to f�4�.Lv /� SEWAGE VILLAGE ASSESSORS MAP&LOT INSTALLER'S NAME&PHONE.NO.&,�j/ed ; eawl k- W VWK SEPTIC TANK CAPACITY Irry GAL LEACHING FACILrfY:(type)3yAl<4t44 13 NO.OF BEDROOMS_ BLJ[L.DER 0�� PERMITDA J COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of leaching Facility S Fed Private Water Supply Well and Leaching Facility (if any wells exist j on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist i within 300 feet of leaching facility Feet Futnisbedby Af/�? t!aali �rc�� ILI fG si, �&� OOO . g� t . i c Commonwealth of Massachusetts ,�-p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner information is Owner's Name required for every Osterville MA 02655 7/8/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water, ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >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: 2003 NGW 144" Date ❑ Observed site(abutting property/observation hole within 150,feet of SAS) ® Checked with local Board of Health-explain: 4' seperation per 2003 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping, the site is at 34'msl and nearby surface water is at 3' You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts ,. ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 256 Parker Rd. Property Address Dabbelt Owner Owner's Name information is required for every Osterville MA 02655 7/8/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/2612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 _ OTOWN OF BARNSTABLE LOCA''ION SEWAGE # _5 p VILLAGE �� ASSESSOR'S MAP & INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ' LEACHING FACILITY: (type) aS v(size)_ NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet J g Y 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 � � I AA 9 A5 cad ��a e TOWN OF BARNSTABLE ATION aS6 �4,,r,- A) SEWAGE '�gl,LAGE eYl-vl lle ASSESSOR'S MAP & LOT '" (o INSTALLER'S NAME&PHONE NO. CeWArk, W-SW6 SEPTIC TANK CAPACITY 1G�� LEACHING FACILITY: (type) feV 41 C/a.�L (3J (size)ALE X 37s �a NO.OF BEDROOMS_ BUILDER OC NER >> eefPERMITDA r�� Z - COMPLIANCE DATE: 2 ®3 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S� 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 Ee"y"Ce-) 7 'I- 0 00 s 03 Fee ( THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpprtcation for �Digpool bpotem Cootruction Permit Application for a Permit to Construct( . )Repair( Upgrade( )Abandon( ) LP Complete System ❑Individual Components Location Address or Lot No. �;6 ! /`,asp�' COL • Owner's Name,Address and Tel.No. As s s Map/Parce C'✓�5/C �!/�//� Og� e�AA�� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J69111-Vlo�1 C��s /9 77 � 39 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Buildin i G�/� tM410 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow Z 'ld gallons. Plan Date ��l? Number of sheets Revision Date Title 1 Z �/" �� ne Size of Septi(Tank 165'!�/� Type of S.A.S. `✓�0 G��� Description of Soil /Z° j•✓r/r 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 issue y this Bo of ealth. _ J Si ed Date S / l v�5 Application Approved by —Date-5/1-3 /6-2) Application Disapproved for the following reasons Permit No. C Date Issued 3 �f411 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes } ✓� PUBLIC HEALTH DIVISION =TOWN OF BARNSTABLES MASSACHUSETTS a ~ t 01pprtcation for Dtgpoal *pztem Congtructton Permit Application for a Permit to.Construct( . )Repair Upgrade( )Abandon( ) P omplete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. . 2.sd Owner's As 1700 Map �l 5I-PI-1111/ Installer's Name,Address,and Tel,No. 1� Designer's Name,Address and Tel.No. 7-7 399 Type of Building: ' Dwelling No.of Bedrooms Lot Size sq.ft.(, Garbage Grinder(/�� Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures l P l49e ,J Design Flow /Z� gallons per day. Calculated daily flow gallons. Plan Date 7 Number of sheets Revision Date Title ,P _ !' Z . �j' i' a✓� >v// E Size of Septic Tank / 4%' Type of S.A.S. 37` Sd0 C Cyr/ i'S Description of Soil Nature of Repairs or Alterations((Answer when applicable) t Date last in pected: 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 issue y this Bo of Health. Signed - Date Application Approved by Date 5A O) Application Disapproved for the following reasons 4 f4 Permit No. C Date Issued e THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( !/)Upgraded( ) Abandoned( )by Gv ® � at Z G�'!� . !� &_�-S�r"�'(// has been construct in ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated S 1 G � 1 Installer Designer The issuance oAls p t shall not be construed as a guarantee that the system ill c ' Nd �. Date JQ Inspector 1 �CY 3 -------------------------- No. Fee. S LJ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Dtzpoar *pg;tem Con5tructton Permit Permission is hereby granted to Construct )Re air(t/)U_pgrr de( )Abandon( ) System located at ��1/_ �Qr��1� r Pg • 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:Constructio must be completed within three years of the date of this ermit. q Date:_._� / /a Approved by�`— TOWN OF BARNSTABLE owe �k ."LQCATION loot r k er SEWAGE I� - #�a a e 'VI0,AGE . . rS � 1'U��/+%� ASSESSOR'S MAP & LOT 116 6 INSTALLER'S NAME&PHONE NO. r h SEPTIC TANK'CAPACITY -1 LEACFIING FACILITY: '4000 , C. OMbeos rc (type) (size) N" NO.OF BEDROOMS_ nn R' BUILDER OR OWNER �4S 7: �� lSut /ofe -Or S PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(if any wetlands exist within 300'feet of leaching facility) Feet Furnished by 6 Pdroi,c ;.a A TOWN OF BARNSTABLE LOCATION o'rS6 �4rlrrr ' SEWAGE -7/l VILLAGE ASSESSOR'S MAP & LOT t 1(0—QG'7 INSTALLER'S NAMEA PHONE NO. SEPTIC'TANK CAPACITY /sue 6014 LEACHING FACII.TTY: (type) 5'cty4l 4� (size) 3 ,r'.Va' NO.OF BEDROOMS BUILDER O OWNER �f PERMTTDA ���%J COMPLIANCE_ DATE: 2 0 3 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) i Feet Furnished by Lana gelyr6r3 j A 6 !33 37 6 000 i J Q TOWN OF BARNSTABLE LOCATION � � SEWAGE # VILLAGE_ C ASSESSOR'S MAP & LOC INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY22 LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: 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 ......... COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 256 PARKER RD. OSTERVILLE l�� -�CU Name of Owner ANN KELLY a° ' Address of Owner: 39 PROSPECT ST.WELLSLEY MA.02181 Date of Inspection: 8124199 Name of Inspector:(Please Print)JOHN GRACI S o I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: n/a Mailing Address: n/a Telephone Number: n/a � 1 CERTIFICATION STATEMENT y 1 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 inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: X Passes The inpection Is based on criteria defined In Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is _ Needs Furthe Evaluation By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:8/24/99 The System Inspector,shall bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection. 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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING AND MAINTAINED EVERY TWO YEAR. revised 9/2198 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 266 PARKER RD.OSTERVILLE Owner: ANN KELLY Date of Inspection:8/24/99 INSPECTION SUMMARY: Check A, B, C, or D A. SYSTEM PASSES: 1 have not found any information which indicates that any of the failure conditions described in 310 CMR.15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: nLa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass inspection if(with approval of the Board of Health): _ broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced nLa The system required pumping more than four 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) , Property Address: 256 PARKER RD.OSTERVILLE Owner: ANN KELLY Date of Inspection:8/24/99 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 the public health,safety and 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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of'a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance nLa_(approximation not valid). 3) OTHER nta revised,9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 266 PARKER RD.OSTERVILLE Owner: ANN KELLY Date of Inspection:8/24/99 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Lla. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,is in Hydraulic Failure. E. LARGE SYSTEM FAILS: 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 266 PARKER RD.OSTERVILLE Owner: ANN KELLY Date of Inspection:8/24/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste Flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.The size and location of the Soil Absorption System on the site has been determined based on: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)) X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 256 PARKER RD.OSTERVILLE Owner: ANN KELLY Date of Inspection:8/24/99 FLOW CONDITIONS RESIDENTIAL: Design flow:94Q g.p.d./bedroom Number of bedrooms(design): 4 Number of bedrooms(actual):4 Total DESIGN flow: 44Q Number of current residents:4 Garbage grinder(yes or no):NO Laundry(separate system)(yes or no): NQ If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no): YES Water meter readings,if available(last two year's usage(gpd): nLa Sump Pump(yes or no): NQ Last date of occupancy: n(a COMMERCIAL/INDUSTRIAL Type of establishment: nLa Design flow: Wa gpd(Based on 15.203) Basis of design flow: n& Grease trap present:(yes or no):DLO Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ Water meter readings.if available:Wa Last date of occupancy: nla OTHER: (Describe) nLa Last date of occupancy: n& GENERAL INFORMATION PUMPING RECORDS and source of information: DLa System pumped as part of inspection:(yes or no):NQ If yes,volume pumped n/a- gallons Reason for pumping: n& TYPE OF SYSTEM X 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: n& APPROXIMATE AGE of all components,date installed(if known)and source of information: 1950 Sewage odors detected when arriving at the site:(yes or no): NQ revised 9/2/98 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 266 PARKER RD.OSTERVILLE Owner: ANN KELLY Date of Inspection:8/24/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 2 Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: Wa condition of joints venting,evidence of leakage,etc. Comments: ( 1 9. 9 . ) nta SEPTIC TANK: X (locate on site plan) Depth below grade: HE Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) nLa If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ nLa Dimensions: 6'X6'BLOCK CESSPOOL EMPTY Sludge depth: L Distance from top of sludge to bottom of outlet tee or baffle: 3E Scum thickness:4 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: A How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) ,MAIN CESSPOOL AND ALL COMPONENT ARE STRUCTURALLY SOUND RECOMMEND PUMPING SYSTEM FOR MAINTENANCE EVERY YEAR, GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: Wa Distance from top of scum to top of outlet tee or baffle:_n(a Distance from bottom of scum to bottom of outlet tee or baffle nLa Date of last pumping: nLa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) n& revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 266 PARKER RD.OSTERVILLE Owner: ANN KELLY Date of Inspection:8124/99 TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: nLa Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) nLa Dimensions: nLa Capacity: nta gallons Design flow: nLa gallons/day Alarm present: NQ Alarm level:jiL& Alarm in working order:Yes_No_: NO Date of previous pumping: nLa Comments: (condition of inlet tee,condition of alarm and float switches,etc.) nLa DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:nLa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) 1]I� PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NQ Alarms in working order(Yes or No): NO Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) n(a revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 256 PARKER RD.OSTERVILLE Owner: ANN KELLY Date of Inspection:8/24/99 SOIL ABSORPTION SYSTEM(SAS): _ (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: nta Type: leaching pits,number: 1000 H2O PIT leaching chambers,number: 1l(a leaching galleries,number: _nLa leaching trenches,number,length: nLa leaching fields,number,dimensions: nLa overflow cesspool,number: Wa Alternative system: nta Name of Technology: 11La Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) Leach nit and all components are structurally sound and functioning properly, CESSPOOLS: _ (locate on site plan) Number and configuration: nta Depth-top of liquid to inlet invert: Wa Depth of solids layer: nLa Depth of scum layer. nLa Dimensions of cesspool: nta Materials of construction: nLa Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) Materials of construction:n& Dimensions:n(a Depth of solids: nLa y Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) n/3 revised 9l2/98 Page 9 of 11 j .. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 266 PARKER RD.OSTERVILLE Owner: ANN KELLY Date of Inspection:8/24/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) n/a roart� r II YI 1 • ►y �a ) revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 266 PARKER RD.OSTERVILLE Owner: ANN KELLY Date of Inspection:8124/99 NRCS Report name: WA Soil Type: n& Typical depth to groundwater: n& USGS Date website visited: n& Observation Wells checked: MQ Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps _ Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAP AND CHARTS revised 9/2198 Page 11 of 11 DATE: _2/3/97 PROPERTY ADDRESS: 256 Parker Road , Osterville ,Mass . DFEB7. 02655 EA , On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 2 61x6' block cesspools and one 1000 gallon precast leaching pit packed in stone . I Based bn my InRORction, I certify the following conditions: 1 . -This is not a title five septic-:system. .2. This is a- sewage system. - • 3 . 1 -61x6' block cesspool andf one 1000 gallon precast pit as an overflow for the main house . Pit is dry 4: -6'x6 ' block cesspool_f.or—cottage_._-Cesspool is dry. 5..'The sewage system is in proper_.working, order resat the.._pre.sent- time --- SIGNATURF: G`i( Name: J. P.Macomber Jr... i Company:_'• P_Macomber & Son—Inc .. , Address:_ Cente•rvilhe LMass__02.632 Phone:---5OZ-7-75-�3338------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY • CS.EBPOH P. MACOMBER & SON, INC. TankrC�sspoolrleschtleIds Pumped & InsUlled Town Sewer Connections x 66' Centerville, MA 02632-0066 775-3338 775-6412 Ul Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of !Invironmental Protection Trudy Coxe s.v.t.ry :., .. Davld B. Struhs U.Go..r..� Comnlrslorri e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Proper<yAdd.. 256 Parker Road Osterville ,MAss Addre" of Owner. Date of Inspection:2/3/97 (If different) Name of laspector.Joseph P.Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son Inc. Box 66 Hnterville ,Mass . 02632 508-775-3338 CERTIFICATION STATEMENT I artily that I have personally inspected the sewage disposal system at this address and that the information reported below is true, &=unite and complete as of the time of inspection. The inspection was performed based on any training and experience in the proper function and maintenance of on-site"wage disposal systems. The system: �— Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority inspector's signature: /` Date: i� The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design Dow of 10,000 go or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner.wd copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A B, C, or D: A) SYSTEM PASSES: —Z,,.hive not found any information which indicates that the system violates any of the failure criteria as defined in 310 CUR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: _d4 One or more system components need to be replaced or repaired. The system, upon oompletion of the replacement or repair, passes inspection. Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination In all Instances. If*not determiasd',explain why not) ,vim Ov The septic tank is mstal, cra:ked, structurally unsound, shows substantial infiltration or exfiltmtiont, or tank failure is imminent. The system will pass inspection it the existing septic tank is replaced with a ponforming septic tank as approved by tLe Board of Health, (revised 11/03/95) 1 One VAnter Street a Boston, Massachusetts 02108 a FAX(617) 556-1049 a Telephone (617)292.55W C� Pnnied on R"Ied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) PropertyAddre•a: 256 Parker Road Osterville ,Mass . Owner. Richard Mutrie Date of Inspection: 2/3/9 7 D) SYSTEM FAILS: • Al I have determined that the system violates on•or more of the following failure criteria as dadnad in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the fail"". Backup of"wage into facility or system component due to an overloaded or clogged SAS or cesspool. �U Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. ��We- Static liquid leve�htb. 't-ribWio�n box invert outlet iart d to as overloaded or clogged 8A3 or cesspool. 4* r 120 Liquid depth in oesrpool:ii;leWthan 6"'below invert or available volume is lass than 1l2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pips(s). Number of times pumped AlU Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 60 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system"r,,w a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a aignificaat threat to public health and safety and the environment because one or more of the following conditions esist: the system is within 400 feet of a surface drinldng water supply CYlr the system is within 200 feet of a tributary to a surface drinldng water supply AZIT 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) The owuar or operator of any such system shall bring the system and facility into full compliance with the prouadwater treatment program requirements of 314 CMR 6.00 and 6.00. Please consult the local regional office of the Department for fiuther information., SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Prop"Addresa 256 Parker Road Osterville ,Mass . Owner. Richard Mutrie Date of Inspection; 2/3/9 7 ' Check if the following have been done: ` ,Pumping information was requested of the owner,oocupant,and Board of Health. JL/Nons of the system oompoWts have bees pumped for at least two weeks and the system has been receiving normal flow rate during that period. logs volumes of water have not been introduced into the system recently or as part of this taspecticn, VA As built plans have been obtained and examined. Note if they are not available with N/A , The UcMty or dwelling was inspected for signs of"wage back-up. ZThe system does not receive non-sanitary or industrial waste flow ZThe site was inspected for sips of breakout. system oompoasnts,,i9kudiag the Soil Absorption System, have been located on the site. A/ONL_The saptic�taalctaalc maahales were uncovered,opened,and the interior of the septic tank was inspected for condition of bafn or Ztoes material of construction, dimensions,depth of liquid,depth of sludge,depth of acum. Tb4 size and location of the Soil Absorption System on the site has been determined based oa cdsting information or a teed by non-intrusive methods. The facility owner(and occupants, if different from owner)were provided with information on the proper maiatenaaa of Sub- Susfaa Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION PrapertyAddreas: 256 Parer Road Osterville ,Mass . Owner. Richard Mutrie Date of Inspeotiaw 2/3/9 7 FLOW CONDITIONS RESIDENTIAL Design now: Number of beam,: Number of current rosidents:I& Garbage grinder(yes or no):—" Laundry connected to system(yes or no):14 Seasonal use(yes or no): r1 Water meter readings, if available I--- !b,lJ1Sa lvyb — Last date of oocupancy:JLlt� COMMERCIAL/INDUSTRIAL- Type of establishment: W4 Design flow:_,&. gallons/day Grease trap present: (yea or ao)d& Industrial Waste Holding Tank present: (yes or no)/�� Noa-sanitary waste discharged to the Title 5 system: (yea or no) ! Water meter readings, if available: AJi4 .4/A Last date of occupancy: /U OTHER.(Describe) Last date of occupancy: 41W GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)!kO r 1' y,-j tot j-0 ty{ 17 yes,volume pumped /V ns �-�s j+ Y `�" '""-/�• Reason for pumping: _ iU TYPE OF SYSTEM 0 Septic tank/distribution box/aoil absorption system Single cesspool°v Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE ,A E of components,4atj ia:talled(if known)and-sourca of informs ' a. Sewage odors detected when arriving at the site: (yes or no) (revised 11/03/95) 6 z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION (continued) Property Address: 256 Parker Road Osterville ,Mass . Owner: Richard Mutrie Date of Inspection: 2/3/97 SEPTIC TANK:/1/O'tJ"`f- e . (locate on site plan) Depth below grade:_42 Material of construction: /Xconcrete _metal _FRP—other(explain) Dimensions:_ Sludge depth. Distance from top of sludge to bottom of outlet tee or baffle:-&.4 Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: 1 _ Distance from bottom of scum to bottom of outlet tee or baffle._ Comments: (recommendation for pumping, condition of inlet and qutlet tees or baffle. depth of liquid IPvel in relation to outlet invert, structural •rity, evidence of leakage, etc.) Septic 'tank is not present. GREASE TRAP. .V'04Je- (locate on site plan) Depth below grade:' Material of cons(risni6n�l7/2:oncrete _metal _FRP _other(explain) Dimensions-. Scum thickness: Distance from top wi scum to top of outlet tee or bah•le:Wll Distance from bottom of srum in honom of outlet tee or 6hle: Comments: (recommendation for pumping, condi—n of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, et Grease trap is not pres n . y: (revised 1/1$/95) 6 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (oontinued) PropertyAddrw&- 256 Parker Road Osterville ,Mass . Owner. Richard Mutrie Dale of Inspeotion:2/3/9 7 TIGHT OR HOLDING TANI AOC (Iomta on site PISA) Depth below grads:,,, 4 Mateial of ooastradioa: ooaerete_metal_FRP_othar(aaplaia) Dimaniioas: Capacity ns Design flow achy Alarm kvel• j1h Comm.ats: (oonditioa of inlet toe, condition of ahem and float switch", etc.) fight or hoiing tan no presen . DISTRIBUTION B0X-&&Alf, (lomte on site plan) Depth of liquid level above outlet invert: A W Commaa4: (note if level aad diitr' utioa is equal, evidsam of solids carryover,evidence of leakage into or out of boa,etc.) Distribution box no presen PUMP CHAMBER:-&*—' (locate on site plan) Pumps in working oidar:(yes or no) Comments: (note condition of pump chamber, oondition of pumps Lad appurtenaaow, etc.) Pump Chamber noT present (revised 11/03/95) 7 :', •, , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) PropsAyAdaress: 256 Parker Road Osterville ,Mass . Owner. Richard Mutrie Date of Inspection:2/3/9 7 SOIL ABSORPTION SYSTEM(SAftzl (locate on sit*plan,if posab, ;e:caval not regnired,but may be appra dmatd by non-iatnuiw methods) If not determined to be present,cgdaia: e Type Lachi pits,number. leanhin chambere,number: 1whin gLueries,number: leachia trenches,number.l*ngth leachia�fields,number,dims ;;- overflow owspool,number:_ Comawats:(note condition of soil,signs of hydraulic failure,level of condition of Sand & gravel:No suns of Hydraulic�f ure ;No ssig�ns or pon ing; All vegetation is normal. House is vacant. CESSPOOL&A" (locate on she plan) Number and ooafigurstion Depth-top of liquid to islet is Depth of solids — Depth of scum layer. Dimensions of oeaspooL• r Material of constriction A"o['r _T 14� it Indication of groundwater. zIAAt inflow(cesspool must be pumped as part of iaspeatioa) Comments:(note condition of eofl,signs of hydreulic failure,level of pondin;,condition of v*gvtation,etc.) Sand & Gravel !No signs of hydraulic failure ;No signs of Ponding; All vegetation is norms . PRIVY: Goests on site plan) Material.of oonsa jctj=. NA NA Depth of solids. NA D:measions. Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Privy is, no nr sent. V, (revised 11/03/95). 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION .FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L=SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' Centerville Osterville Marstons Mills 1 Water Company 428-6691 ao0'/ lid 0 lvee- DEPTH TO GROUNDWATER _14'+ depth to groundwater r,qthod of determinA�fon or ,approximatioz: TZMTTed new �, g oi; eea e :. � i Nro wa er, e coun rau .,_ 'L >•nrinr+r.—nfT�+••-.TrRrrmr•ns.nlllert+7+Rrr+rr.1Rl+.nrrsrnnlT rerR7I Tf�7r►a1.l►+ T1rr-r-a-1s--:..�. �... TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION ��•T^1�T""'.—T.1 tT.�.�TT\T Tf11'If.ITI T'\TiR1If'1"ITT.�—.;'f�.RT\iT1R�TITTR7gf�'.VW1r@V7 Iwo=0 � -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 256 Parker Road Osterville ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL i /d���� OWNER' s NAME Richard Mutrie PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J. P.Macomber & Son In't'.' COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street To►n or CSty State LIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of.-inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : XXXXXXXXX System P SAP SA SED'V4 The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection wtlich I have con -acted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature ZDate 2/6197 =�c'�s.xssr One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or"' 'Perator shall u d within one year of the date of the inspection, unless allowed ortrequiredm otherwise as provided in 3.10 ChIR 15 . 305 . partd .doc s V _ sbyY .y�l THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the - ion of Water Pollution Control /J TOW N OF FARNS'I'ABLE ��� LOCATION of✓�� VILLAGE t � 9� ASS SSOR'S MAP & LOT,f NE NO:PH ++�NAME& O SEPTIC TANK CAPACITY ll LEACHING FACILITY: (type) i !/l �: � X1' (size) NO.OF BEDROOMS BUILDER OR OWNER PDROMDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facilit (If any etlands exist within 300 fe t of lea g, cilit Feet. C Furnishe y f ���.a.. q r i l�- � �1 � J 1�d � � _ .� ,�� � /� ✓ t �� 1 1 `� ' ro � \ - � �h 9a, 0 . :o , . �n.� LO C AT 107N SEWAGE PERMIT NO. VILLAGE 0'ldz� INSTA L� RS NA�� ADDRESS BUILDER c�OR 0 NER /dtc. DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �� �JC .r. r i a Leoff4el- �1rf S ' 3` I THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ................... .... ................OF........................................... Applira#ion for Dispnott1 Workii Tonstrurtiun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .... `.�' ......�� . , -....-6. ------..a z a—k----•--•--------•----•--•-----------•------------------------••-•--------------..------------- cat'on-Address or Lot No. .(l......... ..... _Vl-._ ddress l/ v Installer Address d Type of Buildings Size Lot............................Sq. feet U Dwelling No. of Bedrooms................................ .Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures -----•-------------------------- . WDesign Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity............gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. ..........:......... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage-Pit No..................... Diameter.................... 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...............0........ R+' --- -------- ............. O Description of Soil----------� .....-----_. .11't -------------------------•-------------.------ ------------ --.......--•----- x U ...........................................-.......................................................................-----•--••---------------------•---................................................. ---•--------------------------------------------•--- ---------------------------------••----------------------------- -- --....... t--- V Nature ofiRe��airs o rations—Answer when applicable.__ i` .". �0.........._. lb'_�I�.../ ........... ,� V Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has begh issue th oard f health. .� ..---- --- --' ---- -•-- Date ApplicationApproved ---- -• - ------ ---------------------•---------------•...----------------=-.....0...... Date Application Disapproved for a owing reasons-................................-...................•..........................•................................ ......................•................... ..... ........................•--------...--•--------------------------------------------------------------------------------------------------.....------ Date PermitNo...........................................•............. Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...---•............... ....................O F............................_......._.. Appliratiun for Disposal Works Tomitrurtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at Location Address or Lot No. Owner y Address a �''• Jf'a" :i.r rlk`$tits }• is 1 F ,--••--•-• �'C r.° ' ,'. Installer Address UType of Buildi Size Lot............................Sq. feet �-� Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons____________________________ Showers — Cafeteria Otherfixtures .----•--------------•--••-----------------------....--.-----•-------------------------•- ............................................................. Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-________._-_- Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.........•........... Diameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ rX4 Test Pit No. 2................minutesper inch Depth of Test.Pit....._.............. Depth to ground water........................ O .. > �,v ? Description of Soil......... _3_r'�____t .........a._ _= ! W - - - - -- -- -- •--------------•------••----------- --------•-- U Nature of Repairso 4herations—Answer when applicable._0--^.A '` f�a�` .............' ............ � ....---------------------------? -•--•-------------------------------•-•---•--••--- ................................................••-...... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the�board pf health {' �If d tr f / .. __ Date Application ApproveddB)`-c e="" .......... --- -= ----------•-•--•• -• r ............... Date:Application Disapproved for he owing reasons:......._............................................................................................. ........ _________________ -------------------------•------•-•---------------------••---------------_ ----- ------ Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tatifirate of Toutpliattre THIS S TO CERTIFY T at the Individual, �pwage Disposal System constructed ( ) or Repaired ( ) c 1 r Installer j at...... C.� ...... has been installed in accordance with the provisions of TI F 5 of he State Sanitary Code as described in the application for Disposal Works Construction Permit No... "`_ff_ ___.......... dated-----------------------------_............ _._.._ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................................................................................. Inspector....................... (' .................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ... �'' t ,t� �........OF....... No '... . .......... FEE �4 s•G�....... �i��ro� l urk�' dun #rltr�iun �(eruti� C Permission is hereby granted:.._LA.��__�� �f ....... ..1���� ... � f....................................... to Construct ) or epair (�an Ipdivid l Sewage Disposal Systenj at ....._. --------------- --•-----------•-------------------•-----------•-----•-•--------.... Street as shown on the applicatio for Disposal Works Construction Permit N,p .'_____ Dated.......................................... Board of Health DATE:.. -- `�--. __..._.: FORM 1255 A. M. SULKIN, INC., BOSTON - TOWN OF BARNSTABLE — UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION OWNER AND INSTALLER INFORMATION ADDRESS:. -- r� �f �� �' Ji' MAP NO. � V! PARCEL, NO. '✓� :t�— �^ / /rc ' . , J,VILLAGE .!`>'�r ,sl7: Gr.G' OWNER NAME: .....- INSTALLATION DATE: B.Y: ADDRESS: ! ._ CERT. NO. ' TANK I .'IkNFORMAT I.,ON LOCATION OF TANK: " �1 U �� TYPE < r AGE' 7 ✓., 4 FUEL/CHEMICAL ..,;. 'TESTING"CERTIFICATION-• C J PASS C ] FAIL DATE LEAK—DETEGTION 'C'/7}'C-HE CK IF N/A TYPE/BRAND ZONE OF CONTRIBUTION C '`7. YES C NO DATE TO BE REMOVED FIRE DEPT. PERMIT ISSUED C: ] YES C ] NO ; DATE CUNSERVATION C 7 CHECK IF N/A DATE t 'a BOARD OF HEALTH TAG NO. C 3E ]C ]C ] DATE 1 PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD L� �