HomeMy WebLinkAbout0023 ABLE WAY - Health 23 Able Way
Marstons Mills P
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15 White Moss Drive
Marstons Mills
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TOWN OF BARNSTABLE
-LOCATION k— 141A y SEWAGE #
VILLAGE A-WtOT-ej iy Allt 11 ,3 ASSESSOR'S MAP & LOT(ZAUI Z-
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY /G6
LEACHING FACILITY: (type) t?-Px>x non bars (size) 3"S00 GR,
NO. OF BEDROOMS —V
BUILDER O OWNE 1JRn Pow,,J&
PERMITDATE: 8 liq /97 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility lU 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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COMMONWEALTH OF MASSACHUSETTS
a a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
b Y
t DEPARTMENT OF ENVIRONMEN ALFrj#
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MAR 2 6 2002
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
_ J
Property Address: 23 Able Way Marston Mills . ,
Owner's Name: Dan Donnelly MAP • ®�'�
Owner's Address: 900 Lumbert mill Road 3�
Date of Inspection: 3/4/02 PARCEL
Name of Inspector: (please print)Timothy Lovell
LOT �
Company Name: Accurate Inspections
Mailing Address:550 Willow Street
Hyannis Ma
Telephone Number: 508-771-3700
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:3/4/02
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 23 Able Way Marston Mills
Owner: Dun Donnelly
Date of Inspection: 3/4/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
gX 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:
There is no signs of hydraulic failure
B. System Conditionally Passes:
_N/A One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
_N/A The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
N/A Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if
(with approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
N/A_ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system
will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 23 Able Way Marston Mills
Owner: Dan Donnelly
Date of Inspection: 3/4/02
C. Farther Evaluation is Required by the Board of Health:
_N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_n/a_ Cesspool or privy is within 50 feet of a surface water
_n/a Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_n/a_ 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.
_n/a_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_n/a_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
n/a_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
i
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 23 Able Way Marston Mills
Owner: Dan Donnelly
Date of Inspection: 3/4/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_x Backup of sewage into facility or system component due to 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'/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
_x_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ _x_ Any portion of 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 1 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. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large 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•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone H 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.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 23 Able Way Marston Mills
Owner: Dan Donnelly
Date of Inspection: 3/4/02
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
_x 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?
x Have large volumes of water been introduced to the system recently or as part of this inspection?
x _ 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?
_x_ _ Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CNM 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 23 Able Way Marston Mills
Owner: Dan Donnelly
Date of Inspection: 3/4/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_3_ Number of bedrooms(actual):_3_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330
Number of current residents: 3
Does residence have a garbage grinder(yes or no):_no_
Is laundry on a separate sewage system(yes or no):_no_ [if yes separate inspection required]
Laundry system inspected(yes or no):_n/a_
Seasonal use: (yes or no):_no
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):_no_
Last date of occupancy:_Current
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Owner
Was system pumped as part of the inspection(yes or no):_no_
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_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)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
New System installed 1997 permitt pulled 8/14/97
Were sewage odors detected when arriving at the site(yes or no): _no
e y
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Able Way Marston Mills
Owner: Dan Donnelly
Date of Inspection: 3/4102
BUILDING SEWER(locate on site plan)
Depth below grade: 2'
Materials of construction:_cast iron _x 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_x (locate on site plan)
Depth below grade:_1.5'
Material of construction:_x_concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 1000 gal tank
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle:_45"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle:_1'
Distance from bottom of scum to bottom of outlet tee or bale: 15"
How were dimensions determined: Field Measurments
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tank looks in good shape no signs of tank leaking levels are fine
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal -fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Able Way Marston Mills
Owner:Dan Donnelly
Date of Inspection: 3/4/02
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:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:—x (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_0"_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
Distribution box levels are fine and box is level
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
I -
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Able Way Marston Mills
Owner: Dan Donnelly
Date of Inspection: 3/4/02
SOIL ABSORPTION SYSTEM(SAS):_x_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
_x_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:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
Leaching chambers are dry and no signs of hydraulic Failure
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
I
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Able Way Marston Malls
Owner: Daw Donnelly
Date of Inspection: 3/4/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supph enters the building.
M
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 23 Able Way Marston Mills
Owner: Dan Donnelly
Date of Inspection: 3/4/02
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_14_feet
Please indicate(check)all methods used to determine the high ground water elevation:
_x Obtained from system design plans on record-If checked,date of design plan reviewed:_1997
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
According to repair as built the water table is 14' no signs of water
Page:. 1:
CLOT W' A •i E. OF ANAL- Y"'
Ramble County Health:Laboratory
Report Prepared;'For: Report Dated: 03/14/2002 .
Coldwell'BankerReal-Estate; Order Number:. G0213637`
Carol McCullougli
2957 Falmouth Road'
Osterville, MA, 02655
Laboratory ID#: 02:1 637=01 Description:. Water-Drmldng;Water
Sample#: 13637 Samulin¢Location::. 23 Able Way, Marstons Mills Collected:, 03/07t2002=
Collected'by: Carol-McCue Received:' 03/07/2002'.
Routine
TTEK RESULT UNITS MCL Method# Tested
LAB:ICLab
Nitrates 0.5 mg/L 10 EPA 300.0 03/08/2002
LAB.--Metals
Copper 0:6 mg/L 1.3 SM 3111B 03/07/2002
Iron <0:1' mg/L 0.3 SM 3111B 03/07/2002
mg
Sodium:, 7.0... _.. � ._
20... ., .,. SM3111B.., .. ... ...._.._03%08/2002..._.... ..;_.. '
LAB:Microbiology
T,otal'Coliforul Absent P/A Absent. P/A 03/07/2002
LAB:Physical Chemistry
Conductance: 88. umohs/cm EPA 120.1 03/07/2002
pH. 5.9- pH-units EPA 150.1 03/07/2002,
Note: Water sample meets the.recommended.limits for-drinking water of all above tested.parameters.
Approved By: c�..-
(Lab Director)
3I/sl�z-
Superior Court-House;..PO.Boz..427,, Barnstable,- MA 02630 Ph: 508-375-6605'
TOWN OF BARNSTABLE p
LOCATION SEWAGE # / �• a+�
VILLAGE MILL ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. .
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 3 61t, Cam`"6'
NO. OF BEDROOMS 3
BUILDER OR OWNER �� ST�ILfc
PERMTTDATE: ���: COMPLIANCE DATE: TZ
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
�g
j No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(pprfcatfon for Digpoml bpgtem Con.5truction Vertu
Application for a Permit to Construct( )Repair(1/)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. V RN6 bvl?fif Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 2
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
ocv TW1W C./R MtV5VA1.f
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow _270 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 Alterations(Answer when applicable) 2 3 c A6605 4`)Q
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 a Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued is d ealth.
Signed Date
Application Approved by Date �(r ,Z
Application Disapproved for the following reasons
Permit No. 7 Date Issued �{—�'
13
L,/ 5 a Fee°
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
0[ppYication for Diopaar 6pelem Con.5truction Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) D Complete System El Individual Components
Location Address or Lot No. �3 19S,6 IA1196f Owner's Name,Address and Tel.No. b
Assessor's Map/Parcel O r 2
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
a0 atrtal C44Z #,3r6f,.f
Rpuw y 4dv-q! m
Type of Building:
Dwelling No.of Bedrooms -� Lot Size sq.ft. Garbage Grinder( )
Other Type of Building .5 No. of Persons Showers( ) Cafeteria( )
Other Fixtures 1
Design Flow //0 `l gallons per day. Calculated daily flow er gallons.
Plan Date Number of sheets Revision Date
Title
' Size of Septic Tank / pp �TyDpee of S.A.S.
Description of Soil Q ! `L Td �-2 0/& V01ZL
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
tr
Agreement:
t 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 Ae En ironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued is d ealth. p
Signed Date O��'��
Application Approved by Date ? —i L1 ?7
Application Disapproved lor-the following reasons
Permit No. 7 e), ) Date Issued W-R7
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired GNrl Upgraded( )
Abandoned( )by JQ, jw . A N*
at k fil has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 7- y2.5--dated
Installer Designer
The issuance of this permit shall not bber cons e�jas a guarantee that the system will function as designed.
Date — �. �f ` / Inspector
---------------------------------------
No. 2 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwiopozar *pgtem Construction Permit
Permission is hereby granted to Construct_( )Repair Upgrade( )Abandon( )
System located at
A
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 this permit.
Date: _ �, ` / Approved by ,. +�
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r NOTICE: This Forth is to be used for the Repair of Failed • , •r �
SeI)tic Systems Only
• � C SKETCH
AND
APPL ICATION FOR A DISPOSAL
CCK 1'tt'ICATION O
%VUITKS (,UNS1ItU(.1lUN
I E 101
I'I' �VI'I'IIUU'I' llESIGNEll PLANS
hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at /.� meets all of the
� � . ,�•�
following criteria:
There are no wetlands within 300 feet or the proposed septic system
There are no private wells within I5o feet of the proposed septic system
The observed groundwater table is 14 feel or greater below the bottom of the leaching faculty
There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
SIGNED: DATE:
LICENSED SEPTIC SYS INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Allach a sketch plan of the proposed system. Also if the licensed Installer posesses a certified plot plan,
this plan should be submitted).
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BORTOLOTTI CONSTRUCTION,INC. A
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648
508-771-9399 508-428-8926 FAX: 508428-9399
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: (9
Date of Inspection: 7/7 Inspe or's Name:
Ownees Nand Address: A lot / J
CERTIFICATION STATE ENT•
I certify that I have;personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection.The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal systems. The System:
Passes
Con ' ' nally Passes.
Further Ev tion B the Local Aproving Authority
Fails ;
Inspector's Signature: Date:��/��7 ,
The System,Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(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.
INSPECTION SLiMMARY!
A)SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in,310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If
"not determined",.explain why not.
The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup 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):
-1 -
N PECTION FOR
M
iJ,, ,.SUBSURFACE,SEWAGE DISPOSAL SYSTEM I S V. PART A
,o-
`' CERTIFICATION (continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
ed pipe(s).
r obs
tructed four times a year due to broken o p Pe( )•
The System required pumping more than y
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: yn
Conditions exist which require further evaluation by The Board of Health in order to determine ,F,.
,,.the system,is failing to protect the public health,safety and the environment: s
1),,SYSTEM W,ILL PASS.UNLESS BOARD OF HEALTH DETERMINES,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 a surface water : .
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER t
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER-THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT
The,system has a septic tank and soil absorption system and is within 100 Feet to a surface
water ply or tributary to a surface water supply.
The-system has a septic tank and soil absorption system and is with a Zone I of a public
water.supply.well.
The system has a septic.tank and soil absorption system and is within 50 Feet of a private;,
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
4
Feet or more from a private water supply well,unless a well water analysis for coliform O
bacteria and volatile organic compounds indicates that the well is free.from pollution from
f.;;.. the,facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below.,The Board of Health;;
shouldbe contacted to determine what will be necessary to correct the failure.
logged SAS
Backup of sewage into facility or system component due to an overloaded or c
or cesspool.
Dischar a or nding of efluent to the surface of the ground or surface waters due to an
i.
g Po
cesspool.
overloaded or clogged SAS or
le invert due to an overloaded or cl
S. q
og-
i ton box above outlet
Static liquid level
in the distribution
ged,SAS or cesspool: u
Liquid.depth in cesspool is less than 6"below invert or available volume is less than 1/2
day flow.: . Y'
Required pumping more than 4 times in the last year NOT due'to clogged or obstructed
pipe(s). Number of times pumped
-2-
D
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
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 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. 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.
E)LARGE SYSTEM FAILS: £:f
The following criteria apply to a large system in addition to the criteria above: .
The design flow of a system is 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:
The system is within 400 Feet of a surface drinkingmater 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 apublic water supplymell. .
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
f.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
✓Pumping information was requested of the owner,occupant,and Board of Health.
_None of the system components have been pumped for atleast 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.
✓As-built plans have been obtained and examined. Note if they are not available with N/A.
✓The facility or dwelling was inspected for signs of sewage back-up.
✓The system does not receive non-sanitary or industrial waste flow. '. {
__ZMe site was inspected for signs of breakout.
_ `AII system components,excluding the Soil Absorption System, have been located on site.
G :
_ The septic tank manholes were uncovered,opened,and the interior of the septic tank was in
spected for"condition of bales 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
existing information or approximated by non-intrusive methods.
-3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,
FLOW CONDITIONS
i i "I
Design Flow: 3 U gallons Number of Bedrooms: Number of Current Residents: S
Garbage Grin ed r:A� Laundry Connected To System:f AQ Seasonal Use:
Water Meter Readings;if available: �l
Last Date'of Occupancy.4'Q
COMMERCTALIINDUSZRIALX-Ia v
Typed Establishment: -
Design Flow: "''!' gallonslday "Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-SanitaryVaste Discharged To The Title V System:
Water'Meter'Readings, If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information (✓(1
System Pumped as part of inspection:_ If yes;volu a pumped: gallons
Reason for pumping:
TYPE OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous.inspection rec ds, if any)
-L ZOther(explain) n2� OAd
_
ROXIMATE AGE of all componen s,date installed(if known)and source of information:
S ge odors detected when arriving at*the site: `
-4-
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth; elow grade: Material of Construction: V--concrete metal FRP Other
(explain) —
Dimisions: SkLo Ir. S Sludge Depth: Scum Thickness: 5ii
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation tooutlet invert,structural integ 'ty,evidence of le age,etc. ;o,•a
.GREASE TRAP:
D 'Below,Giade: Material of Construction: concrete metal FRP_Other
Dimensions: Scum'Thickness: ,
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and.outlet tees or baffles,depth of liquid
levehin relation4o outlet invert,structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK:,
Depth Below Grade: Material of Construction: concrete metal FRP_Other(explain)
Dimensions: Capacity: gallons Design Flow: aallons/day
Alarm Level: '
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
7
Y
DISTRIBUTION BOX:
Depth'of liquid level above outlet invert:
Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into
or out of box,etc.)
PUMP CHAMBER: y
Pump is in working or er•
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
f SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive 14.F
methods) If not determined to be present,explain:
i lr
4r Aeaching.pits,number: Leaching chambers, number: Leaching galleries,number:
Leaching,trenches, number,length:
Leaching fields,number,dimensions: '
Overflow,cesspool,number:
Comments: (note condition of soil, signs f hydrauli Failure level of ponding,co lion of vegetation,;
etc.) r:
Number and configuration: Depth-top of liquid to inlet invert:
Depth of solids layer: s Depth of scum layer: Dimensions of Cesspool:
Materials of construction: Indication of groundwater:
Inflow.(cesspool must be pumped as part of inspection) .
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, ''
etc.) lY !.
� )
PRIVY: N6 P
Materials of construction: Dimensions:
Depth of Solids:-
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,-
etc.)
y�
tl,
-G-
t
'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION (conlitmed)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or bencl►marks.
Locate all wells within 100 Feet. f CP t$
i
(�S
DEPTH TO GROUNDWATER:
Depth to groundwater: Feet
Method of Determination or Approximation:
-7-
f
TOWN OF BARNSTABLE
LOCATION SEWAG A
VILLAGE d / /I'�i'l4ZneQt .f.IA ASSESSOR' MAP& LOT
�l ISiQS'NAME&PHONE NO.
SEPTIC TANK CAPACITY ODU04 Aj1
LEACHING FACILITY: (type) �/� (size)
NO.OF BEDROOMS
BUILDER OR O R
PERMTTDATE: 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
D1
r
o ' �
11 TOWN OF BARNSTABLE p►
LOCATION �C3 //�l3CC Li�/�" SEWAGE # / • y s
VILLAG ASSES
S
OR'S MAP & LOTQ}
INSTALLER'S NAME&PHONE NO. A. Y9
SEPTIC TANK CAPACITY 1- 0C
LEACHING FACILITY: (type) 6)7� 1 )
NO;OF.BEDROOMS 7�j
BUILDER OR OWNER
PERMTTDATE: / -=LI COMPLIANCE DATE: " �
Separation Distance Between the:
Maximurn 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
Famished by
5
Q9 1
/
TROY WILLIAMS '
SEPTIC INSPECTIONS ;�G
Certified *MA Department of Environmental Protection �I. ��� (508) 760-1819
40 Old Bass River Road ��
South Dennis,MA 02660 V, L96' "
Commonweafth of Massachusetts �O
Executive Office of Environmental Affairs
Department of
Environmental Protection
WNliam F.Weld Trudy Cote
Gowe mw gory
Argeo Paul Celluccl David B.Struhs
LL Gawn w t.onvrAwjorwr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
1 CERTIFICATION
Property Address: a,3 /I �� GJO`y M�s La.,r A ;l(S Address of Owner. �✓l y H^ ` �c"�f'f /r�S .
Date of Inspection: 6 A-2, /y 6 (If different)
Name of lnspectorl--7—,�6� 7G
Company Name,Address d Telephone Number.
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:
�L Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
InapectoL's9ignature• Date--
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 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.
INSPECTION SUMMARY:
Check A,B,C,or D:
AI SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
BI SYSTEM CONDITIONALLY PASSES: A,114
One or more system components need to be replaced or repaired. The system,upon completion 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 determined",explain why not)
The septic tank is metal,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 ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Add., o23 b fe-
Owner.
Date of Inspection:
III SYSTEM CONDITIONALLY PASSES (continued)
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
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
CI 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 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 a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and 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.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: Q-7 1-9 fv/ti
Owner. G /�T
Date of Inspection: 4 //2/ 6
D] SYSTEM FAILS: /v
I have determined that the system violates one or more of the following failure criteria as defined 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.
— Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
— Liquid depth in cesspool is less than 6"below invert or available volume is less than 1N day flow.
— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(a).
Number of times pumped
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 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. 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 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:
— 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 lI of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: oL 3 l L
Owner.
Date of Inspection:
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
VL1`�-Gbh -I— �{wwlt,S
None of the system components have been pumped for at least two weeks and the system has been
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
_I/Ae built plane have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
ZThe system does not receive non-sanitary or industrial waste flow
V The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
ZThe 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.
V The size and location of the Soil Absorption System on the site has been determined based on existing information or
/prozimated by non-intrusive methods.
✓/The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property address: 2 3 /9 6 I
Owner. / T
Date of Inspection:
RESIDENTIAL: FLOW CONDITIONS
Design flow:.3 J� gallons
Number of bedrooms:_3
Number of current residents: d
Garbage grinder(yes or no):_A/0
Laundry connected to system(yes or no):_jvr S -
Seasonal use(yea or no):—A/�
Water meter readings, if available: /'J.
Last date of occupancy:J&c,a �- c��jo.o Y �.�e L k S
COMMERCIAL/INDUSTRIAIL
Type of establishment:
Design flow:-----_gallona/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Xj
System pumped as part of inspection. (yes or no)
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM �I
Septic tank/di +oa.baadsoil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE f all components, date installed(if known) and �— / //source.f information: _�h 3 ?t^ �� y a
Sewage odors detected when arriving at the site: (yes or no) �(0
(revised 11/03/95)
b
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (oontinued)
Property Address: 23
Owner. G A T
Date of Inspection:
SEPTIC TANK
(locate on site plan)
Depth below grade: l � _
Material of construction: �ncrete_metal_FRP_other(ezp]ain)
Dimensions:_ 5 k 9 Y s; �oOU qa/lo N
Sludge depth:,_
Distance from top of sludge to bottom of outlet tee or baffle: ._L/
Scum thickness: .5 '
Distance from top of scum to top of outlet tee or baffle:
/.
Distance from bottom of scum to bottom of outlet tee or baffler
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.) tcj c,
Jo in w+ U '� C u.r[.✓ A e. o� .sa O T' 6✓ 4— �—
v S O L c. L V aA a r
rc
GREASE TRAP:/
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal_FRP_other(ezplain)
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:
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.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddress: C�J
Owner.
Date of Inspection:6 T
TIGHT OR HOLDING TANK
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_FRP—other(explain) -
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX✓J/,j
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of so}ide carryover, evi ence ofQ leakage into or out of box, etc.) �0
PUMP CHAMBERI�/L�
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
a SYSTEM INFORMATION(continued)
Property Addrem �J ".9
Owner.
T
Date of Inspection: G R
SOIL ABSORPTION SYSTEM (W):
(locate on site plan, if pws11e;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
leaching pits, number: r/YG
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, signs of hydraulic failure, level of n �^
" � ding, condition of vegetation,etc.)
... a ✓-s— r c -1-
V k G"c�,,. ... G .1 L s G✓ J c.�.l
CESSX0LS:
(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(cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: A(/9
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 11/03/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
a SYSTEM INFORMATION (continued)
Property Address:
Owner: G T
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks v� ,
locate all wells within 100' 6S
�b
3 �
D
loco"
4
DEPTH TO GROUNDWATER
W�
Depth to groundwater: feet — adjusted high groundwater level
method of determination or approximation: A Cp 4C 5. o
9
TOWN OF BARNSTABLE QC�
LOC.1?bN ��/ �— SEWAGE # �6
VILLAGE A, ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) 6X G e2 S��►.
NO.OF BEDROOMS
BUILDER OR OWNER PERMIT DATE: LI oZ S/ / 7L,
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 leachi facili
//ty) Feet
j
Furnished by /r�"' �`.�` b— 2 2 L
rJ
. . -�
_ �,.
1��
/ �� / ��
O
��
/ ✓�
Sq)
-a11A- Get L44z—lCr
4o-C
10
l000
30
�� y
FM1
NO—f ..44...............
-7---- 6
THE'COMMONWEALTH OF MASSACHUSETTS
`, BOARD OF HEALTH
7&��AV.....--.oF...... .� lt.A__4, s�'X_4�_......--- - -------------------
Appliratioaa -for M_qpniitt1 Works Tuatitrurtion Vrrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
/���Location-Address or Lot No. W
"" �-.f(��' 4�!! �5_... -J'^' ""'^ ✓C- .-C`.413°'- d_Z!" 7 x.....--•-------
Ow Address
W
Installer Address
QType of Building Size Lot-----------------------------Sq. feet
Dwelling—"No. of Bedrooms------- ..............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of ersons---------------------------- Showers Cafeteria
a YP g P ( )
a --
Other fixtures -----------------'----•-•------ -- .,.;.
W Design Flow---------------------- ---------------gallons per person per day. Total daily flow...-.-...... --------------------------
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 iqlet.......--........... Total leaching area........._...-----sq. ft.
z Other Distribution box ( ) Dosing tank ( ) O i= PC041--
a Percolation Test Results Performed by-------------------------------------------------------------------------- Date------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.....--.------------ Depth to ground water....-,. ----------
Test Pit No. Z----------------minutes per inch Depth of Test Pit..----------.--.---. Depth to ground water..........-------..._...
f l.4 �-------------- ....................................................
1AVV
Descri Description of Soil ----- ...............................---- -��"r` !-------------------------------------------
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'off'Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b n issued by the board of health
Signed ----- -------------------------- -•••--:---•-----•----'-
_ D1'e
_
Application Approved BY - ' . ..Z. - / .
D
Application Disapproved for the following reasons:................................. -------••--.............................---'---"----.....------------••...
---.-----•----------------------•------•-----•---------------------------------------•-••----------------....------------------------•------•-------------•----...---------------------------------------
Date
PermitNo......................................................... Issued........................................................
Date
Fmc
No.
_/J($f
} THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7-0 (A,,,, 1 :1 !S I?.l�/I.. ..............................
, ppliration -for R,gpooa1 Workii Tanstrurtioo Vrrotit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
Location-Add ss or Lot No.
-----------------------------------
ow Address
WNs, ... ...... ................... ..................................................................................................
aOL •••-
Installer Address
Q Type of Building . Size Lot............................Sq. feet
Dwelling o. of Bedrooms------03___-------------------------------Expansion Attic ( ) Garbage Grinder ( )
PLI Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ----------- -----
Q ------------------------------------
i
w Design Flow..................... __-_____-_____.gallons per person per day. Total daily flow............ _.................
P4 Septic Tank—Liquid capacity_-_____--_gallons Length................ Width---------------- Diameter_:_-----_--_____ Depth._.._.___-------
xDisposal Trench—No..................... Width.................... Total Length-------------------- Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below i et___________.________ Total leaching Brea. _:___-_ _________sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) 0/a FC441-o
a Percolation Test Results Performed by__________________________________________________________________________ Date-----------------------------------------
Test Pit No. 1----------------minutes per inch Depth of "Pest Pit.................... Depth to ground water..--_,j�',ui _
lz, Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water__-__________________...
--'--------------•------ --•- ---••--•------------------------•---
D Description of Soil--- Q............................................ -----•--- ------=...-= ................. fi .............
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
r
the provisions of Article XI of the State Sanitary;Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b.y n issued by the board of health.
Signed •-- •-- •-•--• 14-1 l ! . =
Application Approved B ...........
ate G
PP PP Y-----;- �' v`v` - / D��
Date
Application Disapproved for the following reasons:................................. ------------------------------------
----------------------------------------------------
Date
PermitNo. - .......................... Issued........................................................
Date
;THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... ...........OF.....A#�p
Qrrtifiratr of T&MVIlatta
TH O'CERTIF That%n6ivilual Sewage Disposal System constructed ( or Repaired ( )
by •-- ••--------'-----".L-----
... f Installer p
- --------------------------------------------------------------------------------
has been installed in accordance witlf the provisions of Article Xj o The State Sanitary Code ps descr ed in the
application for Disposal Works Construction Permit No-_____`_:___._ _ __�____________ dated._. .'��....7.�'/.......
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 0,07 HEALTH
-�<
No.....Uf.._ FEE.....Zd--... ....
Bi.rio ork� ( fir ii_�44
rani#
Permission is ereby granted•- • --- ��,,,--•••• - ------------•................
to Construc ( or Rep an I div•dual_ Seag - osal Sat No' � --- - ---- --- ------ ----•-------
l""�'
Street y
as shown on the application for Disposal Work Construction er it.N _ ____ ated.... _._ ( __---
:z
- --= -----=----
a Boar o 'Health
DATE......../
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
BARNSTABLE COUNTY HEALTH DEPARTMENT
BARNSTABLE, MASS. 02630
TELHPHONES
362-2511
Ext. 331
Date: April 18, 1974
To: Wincy Corporation
235 Arrowhead Drive
Hyannis, MA 02601
On the basis of a sanitary survey and a laboratory examination on
the sample of water taken from a . . . . . We;L.1, . . . . . . . . . . .located on
the premises of. . . .Wincp Corporation . . , . . , . , . . . , , , , ,located at
f-;
9 f,n$�h�oi,§treet, Marstons'Mills. . . . . .on, , , gpril, 15,, X9.7.4 . . .
(place) (Date)
this suppler is approved for domestic purposes at the time the examination
was made.
If you wish further information regarding this supply, please
contact us at the County Court House, Barnstable, Massachusetts
(Tel: 362-2511 Ext. 331), and we will be glad to assist you in any
way possible.
d
Si-
ge�n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Public Health Sanitarian
Coliform - 0
cc: Board of Health in Barnstable
Mayflower Well Drillers, Inc.
I
t.
AS SHOWN IN PLAN BOOK 273 PAGE 22 A5 LOT 21 BARNSTABLE REGISTRY
OF DEEDS
Gli5 N 550 19' 30 " E ,99-
scti 276.98'
m
s96°,1 OO<
lo� WELL
U,CC z Y N e� N o
w Q d� N 'd
s
R=50Q00' Z
A=37.73' ,0
G8 Fo � 151 '
GB IF S 57° 32 ' 58" W
L 96'g _
A B L E WAY E4 9 g e
I CERTIFY THAT THIS PLAN SHOWS
THE ACTUAL LOCATION OF THE
STRUCTURE ON THE LAND AND
THAT IT CONFORMS WITH THE
A
OF THE TOWN PLAN OF LAND
i 1N
I
2�'14 OF BARNSTABLE MASS.
CWN>EL➢ BY
RANk
CONERY W I N DC Y CORP.
No. 6573 No. 6232
�'..^ FRANK CONERY HYANNIS, MASS,
REGISTERED F-NQNEER 61 6AND rbUR's(K QR
f! R
0 A i N
L E � �N S U R�
/ � Z i /7 i SCALE 9 IN w 401 .
P
q <'
No.— _Y_- - Fee-
BOARD OF HEALTH
TOWN OF BARNSTABLE
Zippritation-*rVell CongtructionVermit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (-jan individual Well at:
— ------- —- ---- — — - - - -- -- ---------------- --------
Locat'on - Address- Assessors Ma---and Parcel
Owner Address
-QA-Se P.�..�e� r,�e lr Ors�1 e -- 3J. ,60�j0� `1A ��—e—�'---_—_--
------------ - ----------------
Installer - Driller _—� Address
Type of Building
Dwelling
Other - Type of Building-------------—------—----------- No. of Persons---------------___:__________—____
Type of Well Capacity----------------------------------------------- - —
Purpose of Well
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed-l - =-s�� ----- --- --- � h3
r
date
Application Approved By----------------- - - ----- ---- ---- — -_ --—_— __—
date
Application Disapproved for the following reasons:-------------------------------------------
-----------------------------------------------------------------------------------------
------------------------- -
date
Permit No.— -- -------- Issued ---- - - --___-—— - -———
date
------ _ _ - - ----- ---- ;-----�
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate ®f Compliance
THIS IS.TO CERTIFY, That the dndividual Well Constructed ( ), Altered ( ), or Repaired
-----------------------------------
' . Installer —
J3 • Q 03 n (,Ocz
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. l -= Dated---------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--- —— --- ---— -- -—- - - Inspector—--------------------------—---------------------------------_--_
BOARD OF HEALTH
TOWN OF BARNSTABLE l
Very Con5tructionVermit
No. 3 -- - Fee-- 5-----------
Permission is hereby granted----- --------- ---------------------------------------------
— ---- —- ———�...��K --
to Construct ( ), Alter
or Repair e- an Individual�Well at:
No. Street r--- — ----- - _—_— ----- —------
as shown on the application for a Well Construction Permit No.— - -- -- - - - -- - ----------------------------- Dated---------j f-_n IF
-i�--------
— —----------------— � —--- — __
Board of Health
DATE ---------- —— --- -- -- ---
No.-,�� _�_ Fee--I
'-` --6-----1-�----
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application-*rMelt Cootruction Permit
Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (-)an individual Well at:
)- --- ---l ------ — —— — — .'"'"--------------------------------------------------P-----------------------------------------------
Location — Address Assessors Ma and Parcel
1v1 r /�c M rl G ! ��). Loa l L/ ti
---------------- -------------------- -------------------------------------------
Owner Address
- - - -- —- --- - -- ----- -- -- -
Installer — Driller Address
Type of Building
Dwelling ��°" c
Other - Type of Building ---- No. of Persons--------------------;-------------------------_---_-
Type of Well /"',v C- : -------------------------------------------- Capacity----------------------------------------
---------------------------------------
Purpose of Well--- -'-rnL 7"c
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to
place the well in operation until a Certificate of Compliance has been issued by the Board of Health.
;
Signed-��=��` *-C` �. ! ------------------ - elf %?---------------
--------------------
date
Application Approved By---- -- ----- - - - - - - ---- --------------------------------
date
Application Disapproved for the following reasons:---------------i-------------------------------------------------------------------------------
-
date
PermitNo. �j- -5-7a - - ----------------- Issued--------------------------------------- --- -----------------------------------
y date
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of Compliance
THIS IS TO CERTIFFY, That tnhe.Individual Well Constructed ( ), Altered ( ), or Repaired ( `)
ll�__ �I1'J Ne I �p I/ R/I 1 I/l
by_AO -- --- ------ --- -- --- -- - -- - -- ---------------------
� �, Installer
at——X.-a //J'o tic�� r`=i—O I a—1 o ,C �I !/1r
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. -4--?3--= Dated---------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--------------------------------------------------------------------------------------- Inspector------------------------------------------------------------------------------
BOARD OF HEALTH
TOWN-OF BARNSTABLE
Ver[ Con5tructionVermit
No. -W 3-=-, g f Fee-- = ----------
X -
Permission is hereby granted - ----------�-t- - -
to Construct ( ), Alter ( ), or Repair O an Individual Well at:
` treet
as shown on the application for a Well{Construction Permit, r�
. I 1_ ZI
-
No.-—- - -— ---- -—- - Dated--------� ------j--
-----------------------------
'�`,� _fig
'Board of Health
DATE------------------------------------------------------------------------------