HomeMy WebLinkAbout0016 SETH GOODSPEED'S WAY - Health 16 Seth Goodspeed's Way
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94 TOWN OF.BARNSTABLE
L CATION 7AL -51) (2imaS P5�S SEWAGE #a0oS J
VILLAGE it ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. ._)'V J yMfS -1 7 8 a®a'49
SEPTIC TANK CAPACITY CEO® H-/O
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER �a R0411541 -
PERMIT DATE: t7 COMPLIANCE DATE: a 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) Feet
Furnished by
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A �ch�r8E.P5.
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1 - yf `6 "�
v 33
No. O 5 ; ;• Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Migpogal *p5tem Con5truction Permit
Application for a Permit to Construct( )Repair(%)Upgrade(()Abandon( ) O Complete System K Individual Components
Location Address or Lot No. 1 to sEri4 Goo AuPGC-D WAt`I Owner's Name,Address and Tel.No.
05re/ZV/[,LGi r11.4s5 j:tL_L ARcFI%5A•LD
Assessor's Map/Parcel I (o S E•T H G-Da D.S(SEE D W-4 y
M t q& P 053 0.'r2 2✓I LLE 4 r"A-S S
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.So 5--Ll 2$'3 3 t-1 q
-7 IAA f2�E R. Rtj 1Na t✓Ra rv� I Nc
` 7 - OSr�2✓(LL 4Ss'
Type of Building:
Dwelling No.of Bedrooms Lot Size 0.3$Ac sue- Garbage Grinder(Nc�
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 31 gallons per day. Calculated daily flow 330 gallons.
Plan Date •SU t_Y t S, •Z 00 H Number of sheets 1 Revision Date
Title 5/tE- PLA4V - S95T-hL S'►S'TEM R.LPi4((L
Size of Septic Tank EX ISM 1-5_D0 GAL • Type of S.A.S. 1'22)(2S' LE,gr-91 y, (-A4M f3ER
Description of Soil C'-3A LAcvN- LoAlK -0- , -3 to-10 %fDAR%c VE L'1 S H 13Rw WIED SANG
1W4Rw,16-E to"- re" P1t_t- I2 "-24 " )/t12IsH (3RNfAED9AKt) I0YIZS/ --t3--
2Y'= 120 L . -/&L'ISN- BRp.'10ED. SAND I 4R Wq—C—
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 issu this Bo of e r _
Signe Date 1 ( 1
Application Approved by Date
Application Disapproved for the following reasons
Permit No. BO J Date Issued /e
---------------------------------------
06
Fee
1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pphratton, for Mi5pomi *pztem Con5trurttott Vermtt
Application for a Permit to Construct( )Repair(,%)Upgrade X)Abandon( ) ❑Complete System X Individual Components
Location Address or Lot No.I to s E r H Goo D s f3a c-n Owner's Name,Address and Tel.No.
Q51E21/ILLC, r'1A55 alL-t, ARC0%j3AL_D
Assessor's Map/Parcel 1 l0 5 ET 1-I Gov.DS PPE D W19 Y
1y& P06 ✓1�t
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No�50 5--H 2. 3 3 1-1 4
SULt-%VAN EI VC,IIVLz_C=RIPVG- INC
-7 1"A R%L E RZ R.D
7 - (1 1 RV1L Lk )/)5S
pe of Building:
Dwelling No.of Bedrooms Lot Size O.3 F Ac iq-ft Garbage Grinder(1`Ir)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3% gallons per day. Calculated daily flow 3 3 C) gallons.
Plan Date --XU L y 1 6 , -Z o.6._N Number of sheets 1 Revision Date I I l l 1,/0 5-
Title -5 17 E PL,4 N - 5 E PT%C- .5'I STC M Rl_ Pig I R_
Ei Size of Septic Tank Ex 1's7. 1 SGO GA I.. - Type of S.A.S.1-L X 2 5' 1-6xibryce C nlvi(3C-
R
Description of Soil r)-3" L_Aivtl- LOAM -0- , 3"- 10''DA ZIC V8L 1 5 H BQ. , MED S AN
1c)VR 'L411 -'E- I 0"- 1 1" rl-ILL 17 "- ,I ' 1/E0 s P R0ty MI=o 5P.Kt7 10 YfZ S"�8--B- �
-2-L(,= ,2U'1 r-4 1/6L'1:514 BR►j D. SAND 10 14 R (o/C-1—c-- T
Nature of Repairs or Alterations(Answet 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 dab' this Bo d o ealth.
Signe ,. It Date
Application Approved by \ Date' /1 M. ) 6`-
Application Disapproved for the following reasons
Permit No. -'4 00 Date Issued 11 110
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certiftrate of QComphance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded
Abandoned( )by
at 1 L, S F T!a t^>r,n f7S f>l F- 1.I A y (Vs-TA P U I 1 I r-T rY1AS S has been constructed in accordance
with the profis ons of-Title 5 and the for Disposal System Construction Permit No.'�,Q 5 5 dated
Installers Designers t_1 YI E E(2iA,;C- 1 NG-
Y
The issuance of this permit shall not be construed as a guarantee that the tem wIll function}as designed.
Date 11 /1 ?!,) Inspector
. No. �� �-JC\C�-----_------------®---------Fee 00 -
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
ligogar *pgtem Cou5truaton Vermtt
Permission is hereby granted to Construct( )Repair( )Upgrade(�)Abandon( )
System located at 1 t� 1 E-rH <e',00 n 5,EC-:E D W Ayf,s tt 17 VI, I I jt-1 ,N/j4 SS .
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction`must be completed within three years of date of this rml .
Date:_ 1\ 1 I�I Approve ---
J
1 Town of Barnstable.
of r Regulatory Services
. .
Thomas F. Geiier,Director
. .■utii$r4s�a. = .. .
Public Health Division
ED. . Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: 1�6U 2e6S
Designer: —%r_Z JU A.W Installer: C�A�'►�'vn�d �- D�r►m���
Address: Sid a-W Q weo Ekic'.. �&L C Address: Z, t9G D 5 T�-i�-�A 2o/
-?�P��t2�J Oa�r l� C',�!►l tPr+U��l�, rng• 0�3-L �
On /& Ah"Jf was issued a permit to install.a
'(date) (installer)
septic system at tG J �� � based on a design drawn by
�s�.S�c.�.��►� (address) �I
dated �+�+�-s � 17A lilt( 6S
(designer)
_ I certify that-the septic'system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes(i.e.
greater than 10' lateral relocation of the SAS or any vertical.relocation of any component
of the septic system)but in accordance with State & Local Regulations..Plan revision or
certified as-built by designer to follow.
NOF
PETER
eSULUVI
r's Signature) O.2911M
CML
(Designer's Signature) (Affix Desigzrer's Stamp Here)
Lip—
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION-
THANK YOU.
Q:Health/Septic/Desiper Certification Form
:SEWAGE INSPECTIONS DK 'tLLLAI-D4
rd,
TION.
. dt LOT
ASSESSORS MAP
VI1.LAGE
•INSPBCTOR
SEPTIC TANK CAPACrrf
LT (size)
LEACIVO'FACILM: (ryPe)
NO:OF BEDRO
OMS
BUILDER OR OWNER
OWNER MAILING ADDRESS
F0,
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DATE 6.125104 ———
. 16 Seth nods eed Rd.- RECEIVED
PROPERTY ADDRESS. h q
0.6te2v.i.e.ee, Ra., JUL 0 2 2004
TOWN OF BARNSTABLE
02655 HEALTH DEPT.
On the above date, the septic system at the above address was
Inspected.
This system consists of the following:
1. 1500 ga.eeon Zept.ic tank A�
2. 1-di st z iPut.ion e ox. INSPECTION
'®IV
3. 1- 1000 gaeeon eeach /2,it.
Based on inspection, 1 certify the following conditions:_.:.:..:
4. 7h.iz .i-6 a t.it.ee rive use/2t.ic system (78 cod.e)
5.t The zeptic . zyztem .iz .in hyd1tau.e.ic �a-i;eu2ei,
6.,R new ,.eeach.ing a2ea needs .to ge init ;eiecl
7. i umped zy.3tem at rime o� .inzpect.ion.-
SIGNATURE
Name:— /32uce (1dcaee.i-6tea -————
Company: ,Tna a�ep .PT —.&—Son, Inc.
Address:— P- -o--Bax-6-6-——————————
r'�farVfIIe MA n2632-9066
P h o ne:---1�4$)-—u5._333.a--------- '
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR
WARRANTY
JOSEPH P. MACOMBER & SON, INC.
Tanks:Cesspools-Leachftelds
Pumped & Installed
Town Sewer Connections
P.O. Box 66 Centerville, MA 02632-0066
775-3338 775-6412
0
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AQN COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONUIENTAL AFFAIRS
DEPARTMENT OFNVIRQN1ViENTAL pR OTR CTION
TITLE 5
OFFICIAL INSPECTION FORM-.NO.T:FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART-A
CERTIFICATION
Property Addressfj 6 Seth giood,312eed i2d, r
0.6t J�Uv , IVn
Owner's Name: �-ii P Aa r h P.n 0.]
Owner's Address: Sam v
Date of Inspection: A/,?S i a
Name of Inspector:(please print) :i3 ;,ea_ mn r a.s.:4 e2
Company Name: ., 2: p.. acomie2: & .SAn Inc.
Mailing Address: Rox 66
Zenteay.7 e, 4.sb. 02632
--K-F Telephone Number: 5 0 8-7 7 _3 3 3 8
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(316 CMR &000). Tice system:
Passes t
Conditionally Passes
Needs Further Evaluation by the Local Approving;Authority
Fails .
Inspector's Signature: Dater
The system inspector shall submit a copy of this inspection report-to the.Approving Authority.(Board of Health or
DEP)within 30 days of completing this inspection.If the system:is..a,shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional•office of the
DEP.The original should be sent tolhe 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 inspectiotrand 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. '
Tz,.,,., rn s»nnn nave 1
Page 2 of I 1
OFFICIAL INSPECTION:FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FOR1%I
PART A
CERTIFICATION(continued)
Property Address: 16 Seth jro od s12eed Rd.
n/S.t:P2L.1J. .QP P�Na.
Owner:2iQP 44rA ;PaPrj
Date of Inspection:
Inspection Summary: Check AB CD or.E✓ALWAYS°completeall of Section:D
A. System Passes: NO
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:
�fb8 48f2�66—�L �tBrxt in in hgalnritii n
Onnrbing ninon noodA In go ,inA*1a.R4af/ SD/R.tir }nnk iz jinn.-
B. System Conditionally Passes:
_ One or more system components ai 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.
e . 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 Certificote of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
NO 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):
Pik broken.pipe(s)are replaced
obstruction is removed
distribution,box is leveled or replaced
ND explain:
NO 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
I ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART A
CERTIFICATION(continued)
Property Address: 16 Seth riood.312e.ed Rd.
Owner:. ; a a 4,7r h;0.,Pd
Date of Inspection: 6,12 5 L
C. Further Evaluation is Required by the Board of Health:
n1 Conditions.exist which require further.evaluation-by.the.Board-of Healthdri 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_tbe�environment:
Cesspool or privy is within 50 feet oft.surface 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-4hat 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.ofa
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 SO feet of a private water.supply well.
QThe 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 rytew2bieA
"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.
3. Other:
3.
Page 4 of 11
OFFICIAL INSPECTION FORM NOT.:FOR::IVOL ARY.ASSESSMENTS
SUBS>EJItFA E.SEWAGE.-DISPOSAL,SYSTEM INSPECTION FORM
PART::A
CERT)EFICATTQN. (continued)
Property Address: 96 Seth Good.612eed Pd.
U.s.t e2vi,e_Pe. Ma-.
Owner: l.i.e e 4 chip aid
Date of Inspection: 6/75/ 4'
D. System Failure.Criteria applicable to all systems:. '
You must indicate"yes":or"no"to.each:of the:followingfor all inspections:
Yes No
. _ Backup of sewage•,into facility or system component due-..-to.overlo aded:or clogged SAS.or cesspool
.�Discharge.or>ponding.of effluent.to the surface•b f the:.ground.or;surt`ace:waters due to an.o.terloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due-to,aa overloaded or clogged SAS or
cesspool L?-49aO i_ Liquid depth inveeMml s less than.6"below invert or.available-whime is less than'%.day flow
/' -Required pumping more-than times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
r 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
watersupPly.
Any portion of•a-cesspool-or.privy is within ea-Zone.1.of apublie: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.5.0 feet from a private water
supply well with no acceptable water quality analysis,[This system:passes:if the;vell water,analysis, `
performed at a DEP certified laboratory,.for coliform bacteria and volatile organic compounds
indicates:.that the.well is.free from pollution•fr..om:th&t:facility:and.thg preseacaof.Ammonia
nitrogen and nitrate nitrogen is equal to okless than 5.ppm,provided that no other failure criteria
are triggered-.A copy ofthe analysis•must be attached.-to.-this for.q.] .
(Yes/No)The system falls.I h$ve determined that ane or.:more of the.:above..failurcx6teiia exist as
described in 310 CMR 15.303,'therefore the,system.fails.The system owner.should.contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system:must serve.a>faeility with-a,design flow of.10,19.0-god-to I5�000.
god-.
You must indicate either"yes"or"no"to.each of the following:
(The following criteria apply to large systems mi .addition to the criteria above)
yes no
the-system is within 400 feet pf,,a surface drinking water supply
_ /the system is within 200 feet of a utar ,to a surrface drinking water supply
the system is located in a nitrogen sensitive area:( W ion Area-1WPA)ora mapped
ed t
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
f
Page 5of11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 16 Seih 0ood6/2eed /?d,.
Owner: c Alach.igald
Date of Inspection: 6/2 5• 4
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
_ 4z 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 syste#n•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
v _ 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-&baffles or tees,material 6f 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 I 1
OFFICIAL INSPECTION:FORM`—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE AGE DISPOSA-L-SYSTEM:-1NSFECTION FORM �
PART C
SYSTEM.INFORMATION
Property Address: 16 Seth Good,3/2eed Rd.
O,s.teay.i-P.ee, Na.
Owner: 2.i ei 42ch.i aid
Date of Inspection: 6/2 5/0 4
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): y Number of.bedrooms(actual): :
DESIGN flow based on 310 C1VI1�15.263(for example: 110 gpd x#of bedrooms):�_= 5 5 0 t_e D
Number of current residents: ..r2
Doesresidence have a garbage grinder(yes or no):I�
Is laundry on a separate sewage.system(yes or no):. [if yes separate inspe.ctipn required]
Laundry system inspected yes or no):1 ,Ogg,
Seasonal use:(yes or no):_ o,o�
JO
Water meter readings,if available(last 2 years usage(gpd))- A-00 15 1,141,o 00
Sump pump(yes.or no):
Last date of occupancy:7 .
COMMERCIALbUSTRIAL
Type of estab hmont:
Desr.gn flow ",;$d on 310 CMR 15.203): d
Basis.of design flow.(seats/persons/sgR,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):PD—
Non-sanitary waste discharged to the Title 5 system-(yes or no):
Water.meter readings,if available: AID
Last date of occupancy/use: —
OTHER(describe):.
GENERAL INFORMATION
Pumping Records
Source of information: ",D� yc'Adnp do
Was system pumped as part of the inspection(yes or no):t
If yes,volume pumped:@6gQLgallons--How was quanti pumped determined?
Reason for.pumping:Loq ekfV
TYPE OF SYSTEM
✓Septic tank,distribution box,soil absorption system .
_Lp Single cesspool
Overflow cesspool
t Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
1 Innovative/Alternative_technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
ti Tight tank *—Attach a.copy of the DEP.approval
Other(describe): `�►
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at.the site(yes or no):_
6
Pap 7ofII
I ► .ARY ASSESSMENTS
OFFICI-L I RK-rNOT FOR VOLUNT
O SILCTION FORM. EWAGF57ACE S
PART C "
SYSTEM-INFORIv ATI4N(;onttnued)
t?ropcKy Address: 16 Se.tt h i!�Q o 4 yn-ed Rd.
o.waer: i p 0 A n nf� n O d
Dstt of Ia ipcctloA,:
Btl3LDIPfG sEwER(1-ocstvon site plan)
Depth t,64w We. AJW
Materialso co�struci on;�,,,,,cawt front „ 40 PVC
,r,,.othtf(aatplain)r
Disutlkec fr rt�private wttcr 1upply watt or sv.etlon:line:
eor�n►cnts(pn conddtton oG Joints,vcntlttt,cvldcAaa qC Ic >+;e,a.tc.}:
Sye.tem ih vented .thorough the houze venth.-
SEPTIC TAKYW ,(locate on sits plui)
Dgth.bcaow grade: Xt,__
►,t�tcriil.of consovction: eoncrcte,,,,,metal,,_,ftbcrglass, polytthylette.
othtrcfcxpattirt� ,
If cx+�ic is mewl fist so;_.. (s agrcottf'umc.. by a Carxificatc ot'Compl.tutec(yes or no):,,,�(attuch a copy of
ccrtift¢ate;j. �. ' er
Dimomlons: 9- 1p S^8
Sludge depth:
Dis.tltncc from tc of s-Wop.to-bonoRt o Duffel tee or baffle:
Scum thickness:
D'astanee irons tap of scurtr to.to.p of ot#tltt tee or baffle;,�-K-�e..P- -
D.is.w &om.bottom of KUM to bottom of outic ice or bafflc:
H.ow w.�rc di:mcnslons dcternsincd:
C.o-trtritcnts.(on.purrtpin.g r.ecommtndi~t�trns, aet and qua.ct ace or bkfflc.condi.tion,structural integrity,liquid levels
as rclitad.toovtk.t invert,avi:danea of.tcaXaga.,etc* tank
n ace. a an
j,, zt4uc.tuRaUy A'und and .shawz np;,�5 g!L4, P 'leakage.
GREASE TRAP: 8blocato on site plank �' r
Depth b:clow 1P10:
Material of co�nsvvction:�,, coneretc l�,mFtal fl�,fibcrgla3sl'1 polyethyl�na g,,othar
(explatA. .
Dimcn;.tans,ld::...
Scum thki ftcss:J1 b, .-1
Distanec b om top of scum to t.op of outlet(ee yr baffle: .�
pIstanec from bottom of scum to bottom of outlet tee or baffle:
Date of tut purnp1A.gi,Y ,;r,,,,,
Cotrtm.eM3(.on.pumping rctommarlda0_ons.,.inlet and outlet tee or baffle condition, structural integrity,liquid levels .
as related to auki innn.evidence of:leaka:ga,etc.):
I
Page 8 of 11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 Seth Good,312eed Rd.-
-U'3-L eavi
Owner: Iiii 42ch Prl r"�
Date of Inspection: 6/2 5/n 4
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: conerete(metal fiberglass .,polyethylene other(explain):
Dimensions: Y\4�
Capacity:_!a j gallons
Design Flow: "e. gallons/day ,
Alarm present yes or no):JjL_
Alarm level: > Alarm in working order(yes.or no):
Date of last pumping:�a
Comments(condition of alarm and float switches,etc.):
T.igh.t o2 ho2d.L/Lp_i((6k t na Anni .
DISTRIBUTION BOX: (if present must be opened)(locate on'site plan)
Depth of liquid level above outlet invert:.
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):•-Aa _
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
r
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 Seth Good,312eed Rd.
0A;t go a i_h Poa hla.
Owner:.'6QP 44ablaaPd
Date of Inspection: 6.125 Lam.
A.
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
1- 1000 cr2.; /22eca,3.t Leaching, 12i.t hacked in 1P" ztoner
If SAS not located explain why:
tanofor/ ,coo Qngv 10
Type
leaching pits,number:
AA leaching chambers,number:
(V,3 leachigg galleries,number:
IW leaching trenches,number,Ingdth:
leaching fields,number,dime sion :
.�overflow cesspool,number: _.
innovative/alternative system Type/name of technology:_liho- qWC C 7$ C0cb-
Comments(note-condition of soil,signs af-hydraulic failure,level of ponding,damp soil,conditi n of vegetation,
etc.):
f gamy ,snarl 1.0 med"ium sand. Theae ate z.i•ynz o� hydaaaiie /a.iivae
.i e -So.i e.6 ate dam12.
Vegetation .iz noamae.-A new Zeaeh.ing a2ea needs .to ge .instaUe r
CESSPOOLS:la-(cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert: V19.
Depth of solids layer: .t\,0. `
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.):
644�26��-�b o n.nf nnyAy_n-L.
PRIVY: locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:e%,
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): -
glil j i6 R0.f�Q4o60nf_
i
9
r
Page 10 of 11
OFFICIAL INSPECTION FORM--NOT FQR VOLUNTA1t'Y:ASSESSMENTS
SURSURFA:CESEWAGE DISPOSAL SYSTEM`.INSPECTION FORRM
PART C!
SYSTEM INF-ORMATLON(continued)'
PropergAddres&6 16 Se.th Goodspeed . Rd.,
Owner: L- 2c i. ¢ed
Date of Inspection: 6/2 5/a 4
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.
�[o
10
.Page 1.1 of I I
OFFICI.A.L INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .`.
SYSTEM INFORMATION (continued):
Property Address: 16 Seth good s/2eed Rd.
UzzFzv7-ffP_, u.
Owner: I.iii Aach.igaid
Date of lnspectioo: 6125/04
i •
SITE EXAM
Slope .
Surface water
Check cellar
Shallow we.lis
Estimated depth to ground "cater feet
Pleasc indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record•If checked,date Qf'deslgn plan reviewed:
_Observed site(abutting property/obscrvation•hole within ISO feet of SAS)
Checked with local Board of Heald-explain:
T Checked with local excavators, installers. (attach documenwtiori)
_Accessed USGS database-explain:
You.must describe how you established the high ground water elevation:
U,6ed:gahe2ty9Nieee11 mode.P 12116194 G2ouad watea_g9ove .sap
��3ed:�SC/S:Upii522UCZi� -ol] len�0 I]��ifn Z,na 9992
Llbed:CISGS:ZachnJr_rJ PuZ4ofnn 97_nnn9 239rdi .9
�
g2ound 61a4ga, nf pat__ Znniln4 999�
Leaching
Pit 'ect
T4 .
Groundwater. Fect Below Bottom of Pitf High Groundwater Adjustment 1.8 ft per Frimpter Method
r nerc(ore,.the vertical,separation distance between the bonom
of thc.lcaching pit and the adjusted groundwater table is
ll
I
`.,•rrnrv.—nl•r's'r'-rl— rnr mr•nm1 R-*'rt+�lt rs*Trl-.�4rarrr�rr**'AT lrlrnv/TR'RRY RTS TerPs".^tr�m�..:..r�•.,l
TOWN OF Barnstable BOARD OF 11EAtT11
SUHHUACE SEWAGE oisr'OSAL SYSTEM INSPECTION FORM - PART D•- CERTIFICATION
�r„trn.tf„*.rn.f•rf:lrr+w•.++rrr•r-•�• .�..•
\...t..l.T••,-•,:1^T.11.•.^•"1T\.�1",11-n:,Ti TI{R nIT1f T1T11 T�:•1."Ilrl'1,SY„R1R1� ��
-TIPC OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 16 Seth Goods/teed Rd.�
ASSESSORS MAP , D�QCK AND PARCEL # '0
OWNER' s NAME 7iei Alzchig a.P,rrl
, ..
PART D - CEIiTIF1CA7'ION
NAME OF INSPECTOR BliaCe l�aca2$�.stea
COMPANY NAME Joseph P. Macomber' &tbn Inc
COMPANY ADDRESS Box 66 Centerville Mass 02632
Street TOVn or c1Ly State E I P
COMPANY TEUEPHONE ( 508 ) 775-33-38 FAX ( 508 ) 790-1-578
q
CFR'rI ('ICAT°ION. STATEMENT
I certify that I •, have personally inspected the sewage ' disposa`1 system nt
this nddress 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 :
System .PASSED
The inspection which I have conducted has not found any information
which indicates that th.e system fails to adequately protect public
health or- 'the. environment as defined i:n 310 CMR 16 . 303 , Any . failtlre
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form ,
System FAILED*
The inspection which I have conaaoted. h.as found that the system fails to
protect the j)ublic health and the environment in accordance with Title
5 , 1.10 CMR 1513Q3 , and as specifically noted on PART C FAILURE
CRITERIA of this inspection. form.,
Inspector Signature . Date .,, � -
d:
T�T.�.��'7�'.T��.... ��..�T"�'L�.Ci ice• .. .
one copy of this gprcification must be provided to the OWNER, the BUYER
-'( where applicable] and the BOARD OF )IEALTII,
* If the inspection FAILED , the 'owner or operator shall upgra;do ' the vyetem-
within one year of the dote of the inspection, unless allowed or required
otherwise as provided in 3.10 CHR 15 ,'3.051
partd , doc
V-;�
No. Avrafi� �_ ,_F Feed
THE COMMONWEALTH OF MASSACHUSETTS. Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for Digo0ar bpztem Conztruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ,&0 $�`�� soj_j'A '41A Owner's Name,Address and Tel No. T
Assessor'sMap/Pazcel �6 e'g63 4� 7U��"y S S iIL
Installer's Name,Addres ,and Tel.No Designer's Name,Address and Tel.No.
C. A1 Y. i �Mj
3►5 &J 4 �T u'ZS �0 6d6�I�
Type of Building:
Dwelling No.of Bedrooms?- Lot Size sq.ft. Garbage Grinder( )
Other 'lope 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 or Al erations(Answer w enpppl' able) Md 91 :5 2 G Wv
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of th&ore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environ ental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is d by Bo of th.
Signed I Date 3 a
Application Approved b Dat
Application Disapproved for the following reasons
Permit No. G'r Date Issued
Entered in computer: /
THE-COMMONWEALTH OF MASSACHUSETTS
PUBLIC,HEALTH DIVISION.-TOWN OF BARNSTABLE., MASSACHUSETTS
Wy
0[ppYicatiott for10igo0a16potem Congmruction Permit
t R Appl icatti.on for1 a Pemu[to Construct Abandon , m lRe ar pgrae( ) aSY,s m O Individual Components
i Location Addressor Lot 1! C106 �d �(�A O er's d sand Te.Nor'P
Assessor's,Map/Parcel _•~ 46�6/7U�SL-s'
. k
Installer's Name,Address,and Tel. ,S�{ of Designer's Name,Address and Tel.No.
1 i fi � Es � �pktir'��
.4A 6 �
Type of Building:
Dwelling No.of Bedrooms .,r/ Lot Size sq.ft. Garbage Grinder( )
Other TI pe 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.
t Description of Soil.
Nature ofRQpairs or Al rations(Answer w en appli able) M®U. ^r A/v k
Date last inspected: '
Agreement: fr "~
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 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been i s ed by s Board of Health.
Signe i ! r ?� Date d1. /tea
Application Approved b„� Dam01 6—
e`
Application Disapproved for the following reasons
Permit No. 4°40 Date Issued.-� .� --1T
-
-_...� g -- � •�--x--- - - ,..� 77,77
THE COMMONWEALTH
. H OF MASSACHUSETTS .-,• • Y y ,-
BARNSTABLE, MASSACHUSETTS ,
certificate of Compliance
THIS IS TO CERTIFY,that the 0}1�1 site Sewage Disposal System Constructed(' )Repaired( )Upgraded( )
Abandoned( )by C� aiG- I31 Silo
at CT� S� W A V Of�`�r�ul J/F has been constructed in accordance
with the PTYP
ns of Title d the for Dispos4System Construction Permit. 2 v I""' ed-- '�'.- �- f Z
Installer !nA i j ` Designer
The issuance o this permit shall not be construed as a guarantee that the syste• will,function as d si ned.
Date Inspector A
r� '
------ -- --
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
laiopooal Op Oe oConotruction Permit
Permission is hereb'y,granted to Con truct( Repair O Upgrade( ) ando� ( )
System located at le Rwo 5 Ned W.4 y OS C k y/�/d,
. i
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions. .
Provided:Construction must be completed within three years of the date of td 4!�=7 it. /
Dater '" Approved ly
y
TOWN OF BARNSTABLE �L
LOCATION 10 �� �� � � SEWAGE # � `���3
VILLAGE �S��Rt>i�� RA ASSESSOR'S MAP & L,OT'
INSTALLER'S NAME& PHONE NO.
SEPTIC TANK CAPACITY i-T
LEACHING FACILITY: (type) �- e Pi i (size)
NO. OF BEDROOMS
BUILDER OR OWNER CK�1G
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
Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility (If any wetlands exist Feet
within 300 feet of leaching faci 'ty)
Furnished by
�5�—; GAGA&F
P�r
A = 3(-
e - y3'
3 7'
E:; S�? '4.
�= 70
q41
- COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad
DEPARTMENT OF ENVIRONMENTAL PROTECTION .. DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
t . (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: 16 SETH GOODSPEED WAY OSTERVILLE MAP 146 PAR 053(21
�!
0
Name of Owner CESARINI fid
Address of Owner: SAME
Date of Inspection: 10/1199
Name of Inspector:(Please Print)JOHN GRACI
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) cS
Company Name: n/a
Mailing Address: n/a
Telephone Number: n/a
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 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 Further Evajuation 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:1014/99 -
The System Inspector shalliubmita copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 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 THE SYSTEM EVERY ONE YEAR TO PROLONG THE SYSTEM'S USEFULL
LIFE.
revised 9/2/98 Page 1 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) "
Property Address: 16 SETH GOODSPEED WAY OSTERVILLE MAP 146 PAR 063 L 20 L
Owner: CESARINI
Date of Inspection:10/1/99
INSPECTION SUMMARY: Check A, B, C, or D: i
A. SYSTEM PASSES: T
_ I 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: F.
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.
Wa 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. 4
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,. p "-
_ distribution box is levelled or replaced'
nta 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
y
-
,N
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 16 SETH GOODSPEED WAY OSTERVILLE MAP 146 PAR 053 L 20
Owner: CESARINI
Date of Inspection:10/1/99
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: t
_ 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 16.303(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 watersupply 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 9698 y Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART A
CERTIFICATION(continued) .
Property Address: 16 SETH GOODSPEED WAY OSTERVILLE MAP 146 PAR 063 L 20 °
Owner: CESARINI
Date of Inspection:1011/99
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 nla.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation
X An portion of a cesspool or privy is within 100 feet of a surface water.supply I or tributary to a surface water,supply. ,
Y P P P �N PP Y ry
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. r
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 public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 1.5 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: 16 SETH GOODSPEED WAY OSTERVILLE MAP 146 PAR 053 L 20
Owner: CESARINI
Date of Inspection:10/1/99
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 Heilth.
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: 16 SETH GOODSPEED WAY OSTERVILLE MAP 146 PAR 063 L.20,,
Owner: CESARINI
Date of Inspection:10/1/99
FLOW CONDITIONS +
RESIDENTIAL;
Design flow:-M g.p.d./bedroom
Number of bedrooms(design): 3 Number of bedrooms(actual):3
Total DESIGN flow: $$Q
Number of current residents:2 ,
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NO If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):DLO
Water meter readings,if available(last two year's usage(gpd): IILa
Sump Pump(yes or no): NO
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL
Type of establishment: nLa
Design flow: nLa gpd(Based on 15.203)
Basis of design flow: n/H
Grease trap present:(yes or no):JLt2
Industrial Waste Holding Tank present:(yes or no): &Q
Non-sanitary waste discharged to the Title 5 system:(yes or no):N4'
Water meter readings.if available:nLa '
Last date of occupancy: nLa
OTHER: (Describe)
S'
Wa
Last date of occupancy: nLa M
GENERAL INFORMATION
PUMPING RECORDS and source of information:
THE SYSTEM HAS NOT BEEN PUMPED IN THE LAST YEAR
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped nLa, gallons
Reason for pumping: nta
3 Y
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: Wit
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1976 PERMIT#314
Sewage odors.detected when arriving at the site:(yes or no): MQ
revised 9/2/98 Page 6 of 11 r'
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 SETH GOODSPEED WAY OSTERVILLE MAP 146 PAR 053 L 20
Owner: CESARINI
Date of Inspection:10/1/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: V 6..
Material of construction:_ cast iron _40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: n(H
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 1
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
n/a
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ .
Dimensions: L 8'6"H 5'7"W 4'10" xy
Sludge depth: „
Distance from top of sludge to bottom of outlet tee or baffle: ar
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:,1L"
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.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND THEN EVERY ONE YEAR.
GREASE TRAP:
(locate on site plan) „
r.
Depth below grade: '
Material of construction:_concrete, metal Fiberglass _ Polyethylene_other(explain)
Ills - n
Dimensions: nLa
.Scum thickness: IlLd
Distance from top of scum to top of outlet tee or baffle:-a&
Distance from bottom of scum to bottom of outlet tee or baffle IVA
Date of last pumping: nla A.
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.) ,
Wa it
revised 9/2198 Page 7 of 11 t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 SETH GOODSPEED WAY OSTERVILLE MAP 146 PAR 063 L 20
Owner: CESARINI 4
Date of Inspection:10/1/99
z
TIGHT OR HOLDING TANK: NQ (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
4 <.
Dimensions: nLa
Capacity: nta gallons
Design flow: nLa gallons/day
Alarm present: Mil
Alarm level:jiLa- Alarm in working order:Yes—No—: NQ
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]/a
PUMP CHAMBER: NQ
(locate on site plan)
Pumps in working order:(Yes or No): NO
Alarms in working order('Yes or No): No
Comments: s
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLa ti ,
t
revised 9/2/98 Page 8 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM,
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 SETH GOODSPEED WAY OSTERVILLE MAP 146 PAR 053 L 20
Owner: CESARINI
Date of Inspection:1011/99
SOIL ABSORPTION SYSTEM(SAS): X -
(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 GALLON LEACH PIT
leaching chambers,number: jiLa
leaching galleries,number: _nLa
leaching trenches,number,length: nLa
leaching fields,number,dimensions: Wit
overflow cesspool,number: Wa
,
Alternative system: n1a r {,
Name of Technology; jiLa
Comments: ;
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,`etc.)
THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY THE PIT HAS I'OF LEACHING LEFT AT THE TIME OF THE
INSPECTION.HAD S
CESSPOOLS:
(locate on site plan)
Number and configuration: Wa _
Depth-top of liquid to inlet invert: Wa z
Depth of solids layer: nta
Depth of scum layer. nta
Dimensions of cesspool: nta
Materials of construction: nLa
Indication of groundwater: nta inflow(cesspool must be pumped as part of inspection)n(a
4 t
Comments:
(note condition of soil,signs of hydraulic failure,level of'ponding,condition of vegetation,etc.) , -
Wa
PRIVY: _
(locate on site plan)
Materials of construction:nta Dimensions:nL
Depth of solids: nla
Comments: .
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc:)
nta
revised 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 SETH GOODSPEED WAY OSTERVILLE MAP 146 PAR 063 L 20
Owner: CESARINI
Date of Inspection:10/1199
SKETCH OF SEWAGE DISPOSAL SYSTEM: s "
include ties to at least two permanent reference landmarks or benchmarks
p
locate all wells within 100'(Locate where public water supply comes into house)
n/a
0c,
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 16 SETH GOODSPEED WAY OSTERVILLE MAP 146 PAR 063 L 20
Owner: CESARINI
Date of Inspection:10/1/99
NRCS Report name: Wa a
Soil Type: Wa
Typical depth to groundwater: nla
USGS Date website visited: Wa ,
Observation Wells checked: NO
Groundwater depth:Shallow _ Moderate _ Deep
, - e ,. °* ,fit:' .,.. • -
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 LL
_ 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 �z
_ Checked local excavators,installers a `,t, s
X Used USGS Data
Describe how you established the High Groundwater Elevation:(Must be completed)
USGS MAPS AND CHARTS
revised 912/98 Page 11 of 11
LOCQTIO 5EWW: E PE MIT UO.
1I�ISTQLLER�S IJ E ADDRESS - -
BUILDER 'S Q /1,7 Q,DDRESS e
Dl.'►TE PERKA T ISSUED
DATE COMPLI &DICE ISSUED
N r
i Ia
I; Sa n Sv3 k/
7119 Mary
�,MO
1-1 C;? GOO/ Wtv l 1�
i
. ..k �b TOWN OF BARNSTABLE E�
Ln%r;TlClly`/®J el -y.2o ��I1 C�oc�M7J �F�Y7 �y SEWAGE #
VTLL-AGE OS'lXR01 LL& f %A n ASSESSOR'S MAP & ItOT,1 r0
INSTALLER'S NAME& PHONE NO. a 1 L L A'M P i
SEPTIC TANK CAPACITY /S®® 6;9Z #-12
LEACHING FACILITY: (type) I-SQ64 (size)
NO. OF BEDROOMS J
BUILDER OR OWNER �/�f(,
PERMITDATE: g 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
�PHr
:�- 37`
E=; S:-2'
f� �S7'
Ir:OC&-TIOt� ' t +vj SEWo,(:�E PERMIT MO.
' VILLAGE
IMST&L ER 5 W E 4,D0RESrS
BUILDER 'S Q &"' L\,DoRE SS
DNTE PERMIT
D ATE COMPLI & aCE ISSUED : — — —
231
No......................... Fay/ ............._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD� HEA T
�Appliration -fur Uiipuiitt1 Works Tatuitrurtion Vrrmtit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
SYstTP at
.-- � . •--
DR o •Address or e.;RN
...... ....... .......--........ -- . ..........
- ............ ....................... .. ....................... .........
Own Address
Q
nsta ler Address -
Type of Building Size Lot.../IOC D_':�'..Sq. feet
V Dwelling—No. of Bedrooms --
Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ___________________-------- No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
Q, Other fixtures --------------------------------------- - - .
W Design Flow---------------_j 0_.._.._.__.._._...gallons per person per day. Total daily flow.............. -----------....gallons.
WSeptic Tank—Liquid capacity/ allons Length................ Width_......._.._.. Diameter_--.-_--._-__ Depth-----.-__......
x Disposal Trench—No- ____________________ Wi 1 .................. Tot 11.................... TOtal achqe area--_ .sq. ft.
Seepage Pit No.--�&'Od D' ,._ De w t------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( ) O �"�' 7, M
Percolation Test Results Performed by-------- ------------------------------------------------•---------------- Date........................................
a Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..._-----_--.--.--.----.
f14 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water--..-.---_--.--.--.----.
--------------------- ---------- f ............
G Description of Soil Q �b-1� l� _�... 6 -- --------
--------------------------
-------- -- -
x
W
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
UNature of Repairs or Alterations—Answer when applicable..----------------------------------------------------------------------------------------------
---------------------------•--------.....------..........-----------•----•------=.................................... ------------------------------------------------------------------------------...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I 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 boa of heal h.
Sign ---- -------------------------•--- -- -.. --- -• -•----••-- •-••--•-%-�--1`- ----�-
ate
Application Approved By...... -- l `�'. .... r---------------- ---.7"1Dat
Date
Application Disapproved for the following reasons:...........................................................................................•-------------------
----•-.....•-••-••---•---•••----••--•-------------------------•------------------------•---------------------------•-----------------------•-------•-----•---••-----•-------••--------------------------
Date
PermitNo.............................................------------ Issued........................................................
Date
No.. --•3� ./ i FicE./ 1/ .t/.....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD -,F HEA T
�
O of ........................................................................................
Application -for 43i"oiial Workii Tonftrnrtinn Prrntit
tAp'plication is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
Sys, ate` O /1 � ` `G � "............................. � � _..._.
---- ... : -------------------------------------
ddres.s..o :Address or of IVo.
.-- .._......�.�__..:-•-_-- ------ ''�-- -- ------------ ----------
Own \ Address
Way -�I/�`�-7 ---••- --•-----------••-•----------•--• •-------------•--------- -- -•--•-- -••-----
Ynstat er Address /
Type of Building Size Lot...1OO�/.Sq. feet
U Dwelling—No. of Bedrooms-------............... .............Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- - -
W Design Flow---------------- .................gallons per person per day. Total daily flow-------------- _�f a--------------
WSeptic Tank—Liquid capacitvl?�gallons Length................ Width........... .... Diameter._ Depth._.--__-_---
x Disposal Trench—No- --______________ __ Wid i ------------------ Tota gth.................... Total chi area. ..3_�J-Z--sq. ft.
Seepage Pit NO..__ZO O a Di --- De w ---•• a ------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) d
aPercolation Test Results Performed by-------- ----------------------------------------------------------------- Date------------------------- -------------
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water-_.-_.---.-_._--._----
44 Test Pit No. 2----------------minutes per inch Depth of "lest Pit-------------------- Depth to ground water--.-_.-.---.__-.-_-_-. -
9 ..... ... ---------- -------------- --•---------`---- - 1.............y .._..
Descri tion of Soil "" �� �` = -V
p �`` t , =
V ----------------------------------------------- ----------------••-••--•-••••••-•-•----•---•-------•--.....-•----•-••-••••......•-•-- -------------------------------------------------------------
W
VNature of Repairs or Alterations—Answer when applicable....--------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI 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 Vboaof healSigne __/ ------------------- ip......••••.--- -- ------------- ---------7 1%.
Date
Application Approved By------ ------'-Z' -' .........--,•--------------- ••.
Date
Application Disapproved for the following reasons:--•-••-•---•-•..........................•-----•--------•-------...-•-------.._..................._..._.._.__....
•--•----------------•---•---•-------------------------------•-•---•--...........................-----------------------------------------------------------------------------------------------
Date
PermitNo......................................................... Issued............. -------- .................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEALTH
G` -fi ...O F......:.. '1�1 .........................................................
Uplertif irate of 01.1,11ntpliaurr �-
T g_JS TO CERTIFY at -Re Individual Sewage Disposal System constructed ( ) or Repaired ( )
by.....f e'!- -----------------/ `f-
Install
has been installed in accordance with the provisions of Amil h State ttary Code as described inthe
application for Disposal Works Construction Permit No.z,. `�P_-___.___. dated........
---------71,�.__....._..
THE ISSUANCE OF THIS CERTIRCATE SHALE. NOT BE.CONSTRUED AS A GUARANTEE THAT THE
SYSTEM Wl,kL FUNCTION SATISFACTORY. "" f
DATE_
> --------------••••-• Inspector---------------------- ----I.....................
= ' �r •�
THE COMMONWEALTH OF MASSACHUSETTS
-76 BOARD O5 HEALT
. .......7:�-- .. '� .....OF...... LL.�......................... /�/No.--•-••----•--•--(--.. FEE........................
Bi voiial .nrk_q �=tr fition rrmit
Permission is hereby granted - l jf`' =.. ......................................................................
to Constructat NoA or RepairIndividual Sew age Dispos 1 Syt�erty,
-----.------ - ------------------_ - -•-------------------- ----- --------------------•----
Street _
as shown on the application for Disposal Works Construction Permit N ---------------/,Dated__-2-/G _- ---••.--
- � U1.
DATE-------��,`... ®------------------------------------•----------------------- Board of Health r-
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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