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HomeMy WebLinkAbout0044 ABLE WAY - Health 44 Able Way Marstons Mills p A = 046 123 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 44 Able Way Property Address Maureen McCloskey Owner Owners Name information is required for every Marstons Mills Ma 02648 1/16/2012 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return key. Name of Inspector Capewide Enterprises Company Name Z77 r.� 153 Commercial St. Company Address Mashpee Ma. ""' ,�02649 Q1 c Cityrrown State tZip Code 1 508-477-8877 SI 4522 Telephone Number License Number 3 B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1/16/2012 Inspectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the fu ture under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewa Disposal System-Page 1 of 17 Commonwealth of Massachusetts L v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not)'is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G 0 y`e M , 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): El broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering.vegetated wetland or a salt marsh t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system.has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow l5ins•11,10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,••'°y 44 Able Way . Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons.Mills. Ma 02648 1/16/2012 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: 2010= 30000 total = 82 gpd 2011 = 58,000 total = 159 gpd Sump pump? ❑ Yes ® No Last date of occupancy: unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Able Way M Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for um in : P P 9 Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: stsyem repaired 6/1/2000 per town records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank (locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 511 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 3.5' � Scum thickness 21' Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years as maintenance. Water level was ok, tank was not leaking and was structurally sound. Outlet baffle was intact and in good condition. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M 44 Able Way Property Address Maureen McCloskey, Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumpingrecommendations, inlet and outlet tee or baffle condition structural integrity, g y, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day .Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Oil 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.): Box was functioning as intended. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 °❑ 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 facility was.dry with no signs of past hydraulic overloading, vegetation was normal. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'GSM ,•''y 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privyto n i I((locate o site n :p a ) Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, ilevel of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ye 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for every Marstons Mills Ma 02648 1/16/2012 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately /'r DES Al � / , 0 o ° A-3 /DS t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water. ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: Groundwater elevation was established by accessing Town of Barnstable groundwater contour maps Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 J Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 44 Able Way Property Address Maureen McCloskey Owner Owner's Name information is required for Marstons Mills Ma 02648 1/16/2012 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE # 0 O � VILLAGE ✓�/r I�S ASSESSOR'S MAP & LOT i INSTALLER'S NAME&PHONE NO. i�`-,f 6 v 7 S �/ % I, SEPTIC TANK CAPACITY LEACHING FACILITY: (type) o�L ' S'�} L. �. (size) /02-vZs- I' NO.OF BEDROOMS 3 BUILDER OR OWNER i PERMITDATE- �s3 � COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwatee able and Bottom of Leaching Facility Feet Private Water Supply Well andLeaching Facility (If any wells exist on site or within 200 fef leaching facility) Feet Edge of Wetland and aching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i' / 0 OWN OF BARNSTABLE LOCATION SEWAGE # ,!ILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. _ SEPTIC TANK CAPACITY r NO SUBSURFACE SEWAGE DISPOSAL SYSTEM W SPE PART C BU SYSTEM INFORMATION(continued)_ i PEI 'roperty Address44 Able Way, Marstons Mills _ )caner: Jim V o z e l la Sep Date of Inspection: L •f.-�/ Mx !t PriN SKETCH OF SEWAGE DISPOSAL SYSTEM: t include ties to at least two permanent reference landmarks or benchmarks ! E locate all wells within 100' (Locate where.public water supply comes into housel,t ,` Furnished by -- -- I W ' L 4d TOWN OF BARNSTABLE �� LOCATION l �� �1:� �� y SEWAGE # 0 — VII.LAGE + !�s ASSESSOR'S MAP &L'OTQ Ials INSTALLER'S NAME&PHONE NO. �"n� 7 �' / SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS -3 J BUILDER OR OWNER �C� PERMITDATE: S—J COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwate�Table and Bottom of Leaching Facility Feet Private Water Supply Well �Le, hi Facility (If any wells exist on site or within 200 fe�f leaching facility) Feet Edge of Wetland and Poaching Facility(If any wetlands exist within 300 feet leaching facility) Feet Furnished by �. � �� �� �a r� � � .�. ,� -- �� � �-.-__ I No. ' 7.2��T Fee $50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE MASSACHUSETTS 01pplication for MigooaY &pgtem Con.5truction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 44 Able Way, Marstons Mills Jim Vozella Assessor's Ma /Parcel 200 McCorkle Rd., Hershey, PA 0703 Installer's Nam A ress,and Tel. o. Designer's Name,Address and Tel.No. Wm. E. tot inson eptic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil S and. Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting of a D-box and. 2 concrtte leach chambers with stone a around.. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this ar Healt Signed �� Date � Application Approved by Date Application Disapproved for the following reasons Permit No. a'Aa Date Issued �� , - No. �Q�tSA, s°V Ra Fee $50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �' ' • Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ricati tt'�for iq ooar .5tem Construction ermit4 Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 44 Able Way, Marstons Mills Jim Vozella Assessor's Ma /Parcel 2- 200 McCorkle Rd., Hershey, PA 0703 ti taller' am Ad�r�ss,and Tel. Designer's Name,Address and Tel.No. 1 m. 0% Son peptic Service P 0 Box 1089,- Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand 4 Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consisting of a D-box and. 2 concrete leach chambers with stone all aroun .. r,.. Date last inspected: .. Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this 13,oar4X Healt Signed � Date 3 O---0—u Application Approved by —Dater0 Application Disapproved for the following reasons Permit No.eykm a ;�! Date Issued QC THE COMMONWEALTH OF MASSACHUSETTS Vozella BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( ) Abandoned( )by Wm. E. Robinson Septic Service at 44 Able Way, Marstons Mills has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction - dated-. _- Installer lolm. R. Robinson S r. Designer The issuance of this permi sh 11 not be construed as a guarantee that the m will fu cti9 as de e Date Inspector T' % - 0� --------------------------------------- No. Fee �PS0 V/ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Vozella igogal by,5tem Construction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) Systemlocatedat 44 Able Way, Marstons Mills 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:Consstr-uccttiioon must be completed within three years of the date of thi rmit. Date: Approved r NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERmn(WITHOUT DESIGNED PLANS) I, William E. R ob in o on.s�eby certify that the application for disposal works construction permit signed by the dated S-3 G—e-10 , concerning the property located at 44 Ari P w2;& naarC+„nsDills meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. e soil is classified as CLASS l and the percolation rate is less than or equal to:5 minutes per inch. ere are no wetlands within 100 feet of the proposed septic system — Y;n lere are no private:wells within 150 feet of the proposed septic system ere is no increase in flow and/or change in use proposed rJr7�ere are no variances requested or needed. e bottom of the proposed leaching facility will Wt be located less than five feet above the mwdmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor od when applicable( If the S.A.S.will be Iocated with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation _ +the MAX High G.W. Adjustment. DIFFERENCE.BETWEEN A and B b d SIGNED : �./ i G' � — DATE: [Sketch proposed plan of system on backl. y:health folder cen _L j/ J , ��r� l�� xs}.� 1� F \., �1�\. \.^ ���`� /Z o (AJv'�f WNo.------ --- --------- Fee------ ---- BOARD OF HEALTH TOWN OF BARNSTABLE Zipp[uat ion-*rVell Con5trurtionAermit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair (v)an individual Well at: Location — Address Assessors Map and Parcel Y Y fs f b,.c ,�.a//s ------------------ ------ --------------------- Owner Address ---------------- Installer — Driller Address Type of Building Dwelling --------------------------------------------- Other - Type of Building------------------------------- No. of Persons------------------------------------------ Type of Well-q`_�v�- ---- -- --------- Capacity--- - - ---—----- - --— Purpose of Well-®O'R`RS Y�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 CertificatV of ompliance has been issued by the Board of Health. D^ Signed uw _ - — -- --- - ------ — v Q date Application Approved By -a- -- -- date Application Disapproved for the following reasons:-------------------- ---- ---------------- - - ---------- - ------------------ - ------ ---------- ----- date Permit No P . 19 ,7 — q- --- Issued--- - - ----- ---— --- date BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired (°I by------ ��- Gttn�nt f/ - - ---------------------------- �/ Installer at— — ��f G�i C$ GJ�r—t—_ /N a ec -----_-------— has been installed in accordance with the provisions of the Town of Barnstable Boa Health Private Well Protection Regulation as described in the application for Well Construction Permit No. - ---- -Dated---THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- - - Inspector----------------- ------ - No.------ ---'--------- _ Fee------ -------------- BOARD OF."HEALTH i.; TOWN OF BARNSTABLE a. Applicat on fibrVell Cootruct ion Permit ' Application is hereby made for a permit to Construct (' ), Alter ( ), or Repair (v )an individual Well at: G 13 �i YY--- --- a}]Locahon <Address Assessors Map and Parcel M. i Owner ----- ---- ---------- --,----- -Address -- I - --- - nsta ller — Driller Address Type of Building Dwelling----------------------------------- ----- Other - Type of Building --- No. of Persons---------___-------------_-__— _______ t� . Type of Well 00 Purpose of Well_-- i`------------------- Agreement: " The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The i Town of Barnstable Board of-Health Private Well Protection Regulation — The undersigned further agrees not to place the well in.operation until a Certificat of ompliance has been issued by the Board of Health. Signed - — - - — — ---- ------ I. date Application Approved By, -- date Application Disapproved for the-following reasons:—=--=---------- -=---__ —�_ date Permit No. ---- Issued-- l-— - —--- ---— — - ate , 'a#r+r.}ePa rr!e4sd.R.e.,•.w:....*•sn..x.as.'�<1s1:34.!�e•ei!'e4i�iarlam'il.�'V�ei.Rn:R.'.R.6Ra.Rsel.Rarti.iisi.nieaNadR�:eiY+aaOaaila6ssleew:PS!Pa�T:.Ra�Ndri�«feel:.ail:Ilo�N!reuxr�kslmso2�i5!s7&esl�Asa4b4:'!i.9:rec9. BOARD OF HEALTH ' TOWN OF BARNSTABLE ' f Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired by - --------------------------------------=--------- ----- Installer r y�/ c�/31• w� i,,,a,c�� s ,t,,, l k has been installed in accordance with the provisions of the Town of Barnstable Boa ��Ve Private Well Protection Regulation as described in the application for Well Construction Permit No.0 Dated THE 15SUANCE OF THIS CERTIFICATE:SHALL NOT BE CONSTRUED AS A GUARANTEE THAT.THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- —- — Inspector---------- ---— --- ---- a i^an.-ST+�ass�aTi".aR!•et.ifiOaRiV..IYi}s8t-.<�..wif'I..e Ta 66Rr4�TC fYA'�£8E-R9..l�an b?�dRSSeLla.11tet.-'aPSS.?+^!^.uld•t39it!ILTi�dsf.,}Ra!qY'i"G°�i'�.}d^'.^iaO.d?aRy�?Q�+4�?C4a}O?G?Y�'is!'�'aRraa+�:)� E BOARD OF HEALTH TOWN- OF BARNSTABLE Well Construction permit No. — --- Fee— - -- Permission is hereby granted &4 to Construct ( ), Alter ( ), or Repair ( `(an Individual Well at: c I 7 .. ' No. GvG ----- — ----------------------- treet as shown on t plicat'o for a Well Construction Permit J No. ---__ Dated— ------------- ----_�`2 --£------- � J � —— — — -— ------ ----- -- Board of ealt� DATE-- __ LOCATION AL 5EWo,C,E PERMIT UO. fL 1 - f VILLAGE IWST&L ER 5 ► &ME ADDRESS BUILDER' 1.1 &V AE ADDRESS M."TE PERNAIT ISSUED D ATE COMPLI &, 4CE ISSUED : — — — i c �' ✓� '_ �j`�' 7,��' ,,t 2/ 7' � I __ — f No..`.:........SS Fizx./ ........ .......- THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH .-..----.--.OF....... ...A Y12........................................................... Appliration -fur Bhivagal Worko Tutu trnrtion Permit Application is herebymade for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: i' .......N--�----k...E........... .. .....--•--• ------------------- --------------/P.T.....1,9........................................................-•--.... Location• Q ess r Lot N a. v r -----------------------••............._............ ................ .. .LZ own AAd/d�ess ....... _ .......................................... Installer Address Q Type of Building Size Lot..-?@f_P_9t_t._....Sq. feet Dwelling—No. of Bedrooms______________� -------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------------------------------ w Design Flow.......s.©............................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter---------------- Depth_---___.__..--- x Disposal Trench—No-____________________ Width...._.__..._._._.... Total Length------------------.. Total leaching area--------------------sq. ft. Seepage Pit No_____________________ Diameter 060--lZR Depth below inlet_. Total leaching area-------.----------scl. ft. Z Other Distribution box ( ) Dosing tank ( ) " 64,0^ /f C� - /A Y—7J` aPercolation Test Results Performed by---------------- ......................................................... Date------------------------------------.-.. .a Test Pit No. 1................minutes per inch Depth of Test Pit-................... Depth to ground water...____-____-__.__-_--.- L� Test Pit No. 2................minutes per inch Depth of Test Pit.________-_--_-__. Depth to ground water--._..___-__._____--.... �2 {E -- ---------------------....---.......... x Description of Soil rv--- - -- ----- -�` i... -- .._w_ ..-_. `m' e -= U ------------ - � 1 - �/ 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 XI*of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by th� of health. Sign - ........................................ 7 i Date Application Approved B ______ _-----.._10 i PP PP Y f r� 7 J Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------- --- - •.....................•••••••....•••....----•---•-•-------------•---•---•••••---------•---••.._......••....----------..........--••--•--•••-----••.._.....••-•------------------------...------•-•-••... Permit No......................................................... Issued..i!-- `' 7ete Date I 0........................... Fz�s .......�..._...._ COMMONWEALTH OF MASSACHUSETTS ' t BtJARD 9F HEALTH Z. '1--- -------- OF ..... ..are"t........_ ............ ............................. Appliratiou -for Uiipoitti Works Tomitrurtion Vaniit Application is hereby made for a Permit to .Construct ( ) or Repair ( ) an Individual Sewage Disposal System.at: -------=-=-= ' ---- ----------- ------------ ----------- Q -------.---------•-------•-••-•---•--•.•-------•-----•----••-•--- Location ress 7 t r Lot N 1 •_________ *__- x•..... . . ...... ............. _•__•_,•____... ^' __ __`_ 'r am----------..' ........... _•__ R•___ Own Ad ess --------- --- - -`"�----•---- •-- �° ''� "'......•.............. ...��� � ._� "_ .................................... Installer Address UType of Building Size Lot.9AI.Ot�_R------Sq. feet Dwelling—No. of Bedrooms--------------P--------------------------Expansion Attic ( ) Garbage Grinder ( ) Other-Type of Building -__-______________________ No. of persons..-_____-_-:_-___-_----_-_-_ 'Showers ( ) — Cafeteria ( ) Q' Other fixtiires -•-----•••-•---•----------------- w Design Flow-------r P............................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. �I Seepage Pit No..................... Diameter/AO.Vk Depth below inlet__ ________ Total leaching area-------...........sq. ft. Z' Other Distribution box ( ) Dosing tank ( )'"� �* .� f A �T �" a Percolation Test Results Performed bY-------------------------------------------------------------------------- Date--------------------------------------- ,� Test Pit No. I................minutes per inch Depth of "Pest Pit.._-___.__________-. Depth to ground water-..--..-..-.---.---.---- f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__.__.--___.-__-___-.... 0'r---- �t --------------------- - f =--- ---` _ _ O Description of Soll_ •� ' ' -�"----- - - .. ..' . � ----- -- w ------------ 01..t� , ,,�- ... -- --` " .------- --- U Nature 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 XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of`Compliance has bee issued b thwztoaq of health. Sig ---•• - ----------------------------------- ................................ ��j,,r Date Application Approved B �,.... ------ ` 'rt''_: .."-.7--- . . .Date Application Disapproved for the following reasons:--- ................. ............................... ................................•----•-••--•-•---------------...-• ------•--•-•-•---•----=---••----------.......---•-•-•--•-...........----•-------•-•--......---•-----------------------•-----•---_---•. Date Permit No......................................................... Issued....L_~_P.r7LQ ---•-- Date THE'.COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......O F... .................................................... AT Qwrttf iratr of f"ontphaurr THIS.AS. TO C, RTI ' . That the I • ual Sewage Disposal System constructed or Repaired ( ) bY--='•., � --- . � •--------•---------•---------•--- -- -- ------------------ ' s' Installer fiFes-= a: Y .................................................. has been installed in accordance with the provision :of._ 'c XI of The State Sanitary Code as described the application for Disposal Works Construction Permit Nce----_._. _ --------- dated_._ .`. -.?.. ................ THE ISSUANCE OF THIS CERTIRCATE SHALL AOT BE CONSTRUED'AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION TISFACTORY. DATE_ � inspector ---------- ------------------------------------------------•-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EALTH ` ..... .... '�:...........OF............:.. .ate No.....�✓ . '"..,,:-FEE.. --------------- �i��o�tt ork�s nou�tr: �tioit �rrotit �-�ryx..,, Permission is reby granted--r--- ............#. to Construct ),or Repair ) n ndivi ual ewage D• sal Sy m "" / �? at No.---- w ------------------------- Stre t �. as shown on the application for Disposal.Works C struction P it No. __. ----- Dated---- .2-_.l�_ _J........ DATE---� -7 ------------------------•------------ FORM 1255 HOSES & WARREN. INC., PUBLISHERS . fi • �.9 S S ,���to 2-7 L)i7 46. L#. /� 0. � re� 7 / G .��/.s 7 c r77 f Gf=ctz�'Hvc 40(>a -- N. i I CERTIFY THAT THIS PLAN SHOWS THE ACTUAL LOCATION OF THE - STRUCTURE ON, THE LAND ANO THAT , IT CONFORMS WITH THE BY-LAWS OF THE TOWN PLAN OF LAND J7•e)Al /4/41. s MASS. OWNED BY �4rttµ OF MApJ � OF MAJJ�C\ FRANK CONERY $ TRENTON ST. HYANNIS. MASS. 02601 FRANK .,1 S- (RANK IS rn REGTERIM ENGINEER !t L.ANO SURVEW-17 v CONFRY ��, �� CONERY y I Q A No. b232�c No. 65'1:{\ � �F 1 SCALE I IN -,?OFT. -Arc c:!S? /J 74- GISTS *n suR0, / \�s10NAl `'