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HomeMy WebLinkAbout0105 CAMMETT ROAD - Health 105 Cammett Awe Marstons Mills F/R 4 I i I I� ' Commonwealth of Massachusetts 7 Wo Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments rti7 105 Cammett rd Property Address ity; Doug Bean Owner Owner's Name information is ✓ ryi required for every Marstons Mills ma 02648 _ 7/28/15 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: 5/J ��77 -� 149-3 9 key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain ae Company Name 8 Johns ath Company Address etwn S_Yarmouth MA __ _ 02664 City/Town State Zip Code 508-364-9587 _ S113522 _ Telephone Number License Number 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 In ector's 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 future under the same or different conditions of use. U3 t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Pag If Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I �•,M 105 Cammett rd Property Address DougBean Owner Ownr's Name — - information is Marstons Mills _ _ ma 02648_. 7/28/15 required for 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: ® 1 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: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of two 500 gallon leach chambers. no signs of failure present at time of inspection. 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•3113 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 a 105 Cammett rd Property Address Doug Bean Owner Owner's Name information is required for every Marstons Mills ma _02648 7/28/15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 15ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 L_ Commonwealth of Massachusetts W Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I M a' 105 Cammett rd Property Address Doug Bean Owner Owner's Name ------ - information is required for every Marstons Mills ma 02648 7/28/15 a e. City/Town --- P 9State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if an pp � Y) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence f e o ammonia nitrogen and nitrate nitrogen p is equal 9 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 1/2 day flow 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Cammett rd Property Address Doug Bean Owner Owner's Name information is required for every Marstons Mills ma 02648 7/28/15 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. El E Any portion of cesspool or privy is within 100 feet of a surface water supply or tributaryto a surface water . t 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 15,000 gpd.. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section 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•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Cammett rd _ Property Address - ----- Doug Bean Owner Owner's Name - --- ---- ----- -- -- information is required for every Marstons Mills ma 02648 7/28/15 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? E ❑ 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 t51ns•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Cammett rd Property Address Doug Bean Owner Owner's Name information is required for every Marstons Mills ma 02648 7/28/15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of two 500 gallon leach chambers. no signs of failure present at time of inspection. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available last 2 ears usage d 163 GPD 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date Commerciallindustrial 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: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts _ , _ r Title 5 Official Inspection Form _ _ - _ = o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments A 105 Cammett rd Property Address -- Doug Bean Owner Owners Name information is required for every Marstons Mills ma 02648 7/28/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date -- Other(describe below): General Information Pumping Records: I Source of information: Home owner Pumped in 2011 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? - Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form i= S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Cammett rd Property Address Doug Bean Owner Owner's Name information is Marstons Mills ma 02648 7/28/15 required for 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: 13 years Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented throught the roof. Septic Tank (locate on site plan): Depth below grade: 1 ft feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon If tank is metal, list age: years I Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gallon 3" Sludge depth: -- t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Cammett rd Property Address Doug Bean Owner Owner's Name information is required for every Marstons Mills ma 02648 7/28/15 page. City/Town 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42 Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: NA 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: r Date 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M a 105 Cammett rd Property Address Doug Bean Owner Owner's Name information is required for every Marstons Mills ma 02648 7/28/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction.- El 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•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Cammett rd Property Address Doug Bean Owner Owner's Name information is required for every Marstons Mills ma 02648 7/28/15 page. City/Town 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 At normal level 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 is level and at normal level with no signs of carry over or decay. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located explain why: P y t5ins•3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts ,U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments l 105 Cammett rd Property Address Doug Bean Owner Owner's Name information is required for every Marstons Mills ma 02648 7/28/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2 500 Gallon ❑ 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.): No signs of carry over 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 ❑ No 15ins•3113 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 °^M- 105 Cammett rd Property Address Doug Bean Owner Owner's Name information is Marstons Mills ma 02648 7/28/15 required for every page. City/Town 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.): No signs of ponding or hydraulic failure. 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.): t51ns•3/13 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 105 Cammett rd Property Address Doug Bean Owner Owner's Name information is required for every Marstons Mills ma 02648 7/28/15 page. City/Town 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 105 Cammett rd Property Address Doug Bean Owner Owner's Name -- information is required for every Marstons Mills ma 02648 7/28/15 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: 12+ ft feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plains 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: Test hole data on plan dated 10/25/02 NGE at 120" Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 105 Cammett rd _ Property Address Doug Bean Owner Owner's Name information is required for every Marstons Mills ma 02648 7/28/15 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 9 � V MC, TANK CAPAC R OR OWNER � qq� f"I ��,��1�"DATE:. 1 ._....:CoMFLIAN DATE; 5eratation Dinance Between the: t 41justed Groundwater Table to the'Bottorn of Leaching Facility --, Birivate Water Supply Well and Leaching Facility (If any wells exist F t on site or within 200 fret of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I 1 p 1 _ I t How i � � . Agile e -, 71 . 4 , s — 1 '39 V -3 6 4? . r COMMONWEALTH OF MASSACHUSETTS d EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION M t I y�� � 5V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A „I! CERTIFICATION Property Address: JM Cammett Road ., Marstons Mills MA 02648 "l Owner's Name: Todd A.Gibson Owner's Address: Same C; czj Date of Inspection: September 2,2005 Job tt 05-250 j Name of Inspector: PATRICK M.O'CONNELL ' Company Name: SEPTIC INSPECTION SERVICES CO. r MailingAddress. 189 CAMMETT ROAD .� MARSTONS MILLS MA 02648 Telephone Number: 508-428-1779 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 DF.�Oeoittll approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: `� .� OF Passes 2� Conditionally Passes P Needs Further Evaluation by the Local Approving Authority `O: M. Fails w Inspector's Signature: — k Date: September 2,2 ,q�FS�NSPE�� ( j iirunt um�� 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: Leaching system shows no visible evidence of saturation or backup.Tank is not in need of pumping at this time. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 105 Cammett Road Marstons Mills MA 02648 Owner: Todd A.Gibson Date of Inspection: September 2,2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Tit1a f 1ncnortinn F—A/1 snnnn 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 105 Cammett Road Marstons Mills MA 02648 Owner: Todd A.Gibson Date of Inspection: September 2,2005 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system.has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of 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: Title G Incnartinn Anrm All siInnn 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 105 Cammett Road Marstons Mills MA 02648 Owner: Todd A.Gibson Date of Inspection: September 2,2005 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 %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 I of a public well. X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well. _X_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [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 forma _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—1WPA)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. Tifla C InenArfinn Rnrm 4/1 v100n 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 105 Cammett Road Marstons Mills MA 02648 Owner: Todd A.Gibson Date of Inspection: September 2,2005 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks`? _X_ _ 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) _X_ _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS, located on site? _X _ 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? _X _ 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 _X_ _ Existing information. For example,a plan at the Board of Health. X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] Title C Tncnantinn T7nrm 6/1 annnn 5 Page 6 of 11 OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 105 Cammett Road Marstons Mills MA 02648 Owner: Todd A. Gibson Date of Inspection: September 2,2005 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:2 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): Seasonal use: (yes or no): No Water meter readings, if available(last 2 years usage(gpd)): 2003—46,000 gal.2004—56,000 gal. Sump pump(yes or no): No Last date of occupancy: Currently Occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/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: Tank pumped three years ago. 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: Compliance date: 10/30/02 Were sewage odors detected when arriving at the site(yes or no): No Tit1. C 1ncnartinn Fnr 4/1;/Innn 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 Cammett Road Marstons Mills MA 02648 Owner: Todd A.Gibson Date of Inspection: September 2,2005 BUILDING SEWER: XX (locate on site plan) Depth below grade: 1' 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: XX (locate on site plan) Depth below grade: V 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:8.5' long x 5.2'wide—1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 2" 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: 12" How were dimensions determined: STICK WITH HINGE FLAP. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tees are intact and clear,liquid level at bottom of outlet invert Recommend pumping tank every three to five years to properly maintain system. GREASE TRAP: No (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.): Title G fncnartinn P^—Arl vinnn 7 Page 8 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 Cammett Road Marstons Mills MA 02648 Owner: Todd A.Gibson Date of Inspection: September 2,2005 TIGHT or HOLDING TANK: No (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: XX (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.): No solids or high stains present. Box set level with equal flow to both outlets PUMP CHAMBER: No (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.): Titlo C 1ncnortinn Rnrm till;nnnn 8 Page 9 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 Cammett Road Marstons Mills MA 02648 Owner: Todd A.Gibson Date of Inspection: September 2,2005 SOIL ABSORPTION SYSTEM(SAS): XX(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number: Two 500 gal drywells. 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.): Chambers have no evidence of backup,probed stone around structures and found stone clean and CESSPOOLS: No (cesspool must be pumped as part of inspection) (locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: No (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.): T41.G Tncnantinn T? r, 411 ci')nnn 9 r ' 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: 105 Cammett Road Marstons Mills MA 02648 Owner: Todd A.Gibson Date of Inspection: September 2,2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Cammett Road Water Service Driveway #105 22 31 60 53 71 60 T41. i fnanPrtinn Pnrm 4/1 a1')nnn 10 Page 11 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 105 Cammett Road Marstons Mills MA 02648 Owner: Todd A.Gibson Date of Inspection: September 2,2005 SITE EXAM Slope None Surface water None Check cellar Dry Shallow wells None Estimated depth to ground water: More than 30 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) _X_Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water below el.35 and topo map shows property above el.70. Tihla G inonanhinn 17nrm Ail ciinnn 11 ' x . Health Complaints 11-May-05 Time: 1:26:00 AM Date: 4/29/2005 Complaint Number: 18062 Referred To: DALE SAAD Taken By: JOAN AGOSTINELLI Complaint Type: STABLE io Article X Detail: UNSANITARY CONDITIONS v Business Name: Number: 105 Street: CAMMETT ROAD Village: MARSTONS MILLS 'Assessors Map_Parcel: - Complaint Description: Is there suppose to have certain containers to store the manure? Does it need to be on site. What would'be the time to depose of it. There is a odor which is offensive. Concerns about the flies. Actions Taken/Results: 5/2/05 Checked area and manure problem was cleaned. WiWkeep an eye on the problem---� 6/10%5`Received another Lat,this1ime. laint=on.thisaparcelSpoke,to complainant' hey will.now complain as:soon as they note blem and not,waiL No problemior .this site 4 Investigation Date: Investigation Time: vi 1 TOWN OF BARNSTABLE L, kTION 01-In K� SEWAGE # 5„ VII:1 AGE M-IM115 ASSESSOR'S MAP& LOT 07S D II" £R'S NAME&PHONE NO. 'ff SEPTIC TANK CAPACITY /0C.0 LEACHING FACILITY: (type) e-:) (size) _ I NO. OF BEDROOMS 3 BUELDER OR�R—� i' SoV PERMITDATE: DATE: GI �2 ®S Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet \Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i I c 3i -. 7l -- TOWN OF BARNSTABLE \TION IBC; 5�' C, ,0 dy-e tt 1) SEWAGE #aA�,1 -5"06 VII.LAGS 114,4 0010w.-s t 3 L L 4 ASSESSOR'S MAP & W02 4offq? INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �2 5F oo /12-121,1,(size) R `�X�� X 1- NO.OF BEDROOMS -3 BUILDER OR OWNER XL �vr PERMIT DATE: 10.21 COMPLIANCE DATE: v Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by H -� oz;' 3 610 . N . Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: VYe PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Mto goal *pgtem Construction Permit JApplication for a Permit to Construct(���Repatr( )Upgrade( )Abandon( ) O Complete System O Individual Components Location Address or Lot No. C I"IaTl &D Owner's Name,Address and Tel.No. `S,1 A—Assessor's Map/Parcel 7 ?4,w c e-L K`��� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. P.4ri v,-E E,1rt.0L, -7-3On. ) .4vE INASOi� 54 -D ajolfl J-*,s yz - �Oo t�ST 5"4ti-9 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 3 1 O gallons per day. Calculated daily flow gallons. Plan Date Ito Number of sheets Revision Date Title Size of Septic Tank / 0,00 Type of S.A.S. oZ �l Od 4e;,4Gf.®r,-. Description of Soil 4 e? Sof ti� Nature of Repairs or Alterations(Answer when applicable) 7,4 L C `l O `t a L C o, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board Health. Signed 112 Date 107 -O Application Approved by Date Application Disapproved or the following reasons Permit No. Date Issued a:•.'^fC,+rl.ar ''` O � '�' 'F •w�.»eey� ��-. � � ✓ - Fee ^ THE COMMONWEALTWOF MASSACHUSETTS Entered in compute: s Yes HEALTH DIVISION - WN OF BARNSTABLE MASSACHUSETTS PUBLIC HEAL �O� ., --� 01pprication for Migpugal *pgtem Congtruction Permit, Application for a Permit to Construct(°Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. I 0 e ft ti'1 e TT /Z 1) Owner's Name,Address and Tel.No. p Cis ivr Assessor's Map/Parcel. V r A,w e e L r y,q os eA^Aq eTi *1 rj Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. PA�1O.. E C.rC.o(r,C7�On. Dq�.E IkASOr�- y s 5.4,-D w-rckA yz -Q7oo taste Type of Building: i Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures F Design Flow 3 .7 og gallons per day. Calculated daily flow gallons. Plan Date /O - g 2 Number of sheets Revision Date Title Size of Septic Tank / 0DfJ Type of S.A.S. of Sao G,4t cy.. 7.�w�CLs Description of Soil en 5,*,--n Nature of Repairs or Alterations(Answer when applicable) F-37A L t 02 + y D �cr! o� I 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 BoarjA Health. Signed �G /J Date� �'o�l Application Approved by ✓ j Date r Application Disapproved for the following reasons t a Permit No. v r Date Issued -----------------------------/ V/------- `T' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance ` / THIS IS TO CE. Y,that the On- ite Swage Disposal Syste Constructed( )Repaired (X )Upgraded( ) Abandoned( -by � x ►A� -s' / ` at �� ffi�-a � t I �tj has constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ted Installer Designer The issuance of this permit hall no c,Onstrued as a guarantee that the sy tem will function as designed✓ Date r -. 0 L/ Inspector /�a / ''r ✓ V fi r � f�lM'/// ! l, / 1 — ———————————————.—.————————N.AnZ_ - - - Fee — i i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 1wigpo0al 6pgtem Congtruction Permit Permission is hereby granted to Construct Ree am- �U .grade l ,Aband System located at�. / /f'., �/ 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: Co ction m It b�completed within three years of the date of tP7,��,�ev 't Date: �� Approved by `�' TOWN OF BARNSTABLE LOCATION 142 ' C 4 ,0 Owe °- itt SEWAGE #21�*at .S06 VILLAGE ZU4 441 -s 41.1 l G s ASSESSOR'S MAP & LO INSTALLER'S NAME&PHONE NO. Pal SEPTIC TANK CAPACITY j . LEACHING FACILITY: (type) �2 Do ��L ��/��+*Yet (size) a2 NO.OF BEDROOMS 3 BUILDER 09 OWNER XL 1v • PERMITDATE: COMPLIANCE DATE: v jSeparation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet j Private Water Supply Well and Leaching Facility (If any wells exist 1 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 f�-f I- t Z - 2113 49.9 057 t d ✓ US Postal Service Receipt for Certified Ma e� No Insurance Coverage Provided. Do not ysv for Intemabonal Mail S e reverse Sent Str fKber Post Office,State,&ZIP Code Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee uO Return Receipt Showing to Whom&Date Delivered Q Return Receipt Showing to Whom, Q Date,&Addressee's Address CM TOTAL Postage&Fees Is M Postmark or Date Q co a Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service m window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the QQ) return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the O O addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. �`6L 6. Save this receipt and present it if you make an inquiry. t o2595-97-B-ot 45 rf a oFtt+et Town of Barnstable Department of Health, Safety, and Environmental Services sARNSCABM i MASS.i639• Public Health Division 9qj `0� P.O. Box 534, Hyannis MA 02601 Office: 508-862-4644 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Pub]ic Health March 26, 1999 Justine Klein 105 Cammett Road Marstons Mills, MA 02648 NOTICE TO ABATE VIOLATIONS THE TOWN OF BARNSTABLE BOARD OF HEALTH NUISANCE STABLE REGULATION,PART X PARAGRAPH 7 The property owned by you located at 105 Cammett Road, Marstons Mills, was inspected on March 22, 1999, by Jerome Dunning, Health Inspector for the Town of Barnstable, because of a complaint. The following violations of the Board of Health stable regulations were observed: Paragraph 7: Manure piled approximately six feet high and sixty (60) feet along the property line. You are directed to correct this violation within ten (10) days of receipt of this notice by removing the manure from your property. You may request a hearing if written petition requesting same is received by the Board of Health within seven(7) days after the date order is received. However, this violation must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. You are also subject to non criminal citations of$40.00 for the first violation and $15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. PER ORDER OF THE BOARD OF HEALTH �mas A. McKean Director of Public Health klein/q/wp/order/Is M od�a vv °t 4El IV�A b y� NOTICE TO ABATE VIOLATIONS OF-'05 E"INKIR "" "" cam A TLC Q A � Di ION A&D THE TOWN OF BARNSTABLE BOARD OF HEALTH NMSANCE The property owned by you located at I D S was inspected on _ Q 1997, by Health Inspector for the Town of Barnstabfd, be use of a complaint. The following violations of the N � -� +�^ � lattaxrrthe anit _--Co�_ : ere-observe 9 1 a (PA ,wd `7 finch-e SI-x4n You are directed to correct violations within of receipt of this notice. �-) e6�e.. /L,Y, ,e- �-- � � � You may request a hearing if written petition requesting same is received by the Board of Health within seven(7) days after the date order is received. However, this violation must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $500. Each separate day's failure to comply with an order shall constitute a separate violation. You are also subject to non criminal citations of$40.00 for the first violation and $15.00 for each additional violation. Tickets will be issued daily until the violations are corrected. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean Director of Public Health �, 4 � � ,'� �• -�: Y' �' i.. :A i. .. ern~, � �1����, rti � � "�i�. �j � �, ti, Y .7 � r,,� � �� `i-{ '[4 � �• f Justine Klein 105 Cammett Rd Marston Mills MA 02648 (508) 420-9846 March 10, 1999 Mr.Edward Barry Health Inspector Town of Barnstable Health Division 367 Main St Hyannis,MA 02601 RE: shavings pile on boundary complaint of 12/98;3/99 Dear Mr.Barry, I am writing to inform the Town and yourself of complaints of one of my neighbors,Mr.Giorgio LoBue, regarding a pile of primarily wood shavings that I have erected on my property within 15 feet of the shared boundary with Mr. LoBue. This pile, as I explained when I was visited by you in late December of 1998, was erected to protect my horses from the harassment of barking and loose dogs residing on Mr.LoBue and his neighbors property,Mr. LoBue continues to harass me about this pile and I am enclosing a copy of my letter to him for your records. This pile has hardly any horse manure in it,and is designed for the manure to settle at the bottom of the pile on my property where it is spread to encourage the growth of vegetation and removed bi-annually by neighbors with gardens as fertilizer. I would welcome any suggestions the Town might have to cease this constant harassment of myself and my livestock. Sincerely, Justine Klein T~ n t '.-41 Justine Klein 105 Cammett Rd Marstons Mills MA 02648 March 9, 1999 Giorgio LoBue 55 Papyrus Way Marston Mills MA 02648 Mr.LoBue, This correspondence addresses your"dislike" of the shavings pile located within 15 feet of our shared boundary between my agricultural land and your home. This 4ft pile consists primarily of shavings, being 80% wood shavings and 20% horse manure. It is located in this site due to the constant harassment of my livestock by barking&/or loose dogs residing at your and your immediate neighbors' properties. I am not going to move it, but will keep it within 5 feet in height and seed portions of it in spring (1/2 is already seeded with grass facing your property). If you so wish,you may erect a stockade fence or other solid fencing as a noise/visual barrier on the boundary line, and I will cease to pile the shavings on that boundary.This is the last time I will address this issue with you. My animals have the right to enjoy their time outside on my property without the incessant noise and regular invasion by neighborhood dogs and I am certainly not going to pay thousands of dollars to erect a solid wood fence to correct a problem caused by the irresponsibility and lack of consideration of abutters to my premises. Due to your argumentative tone and language, I think it best not to have Daniella over until you have resolved this situation in a more neighborly manner. Sincerely, Justine Klein cc:Board of Health MJM,esq. Commonwealth of Massachusetts Executive Office of Environmental Affairs .c� department of APR EwEO Environmental Protection 8 1996 Wililam F.Weld ' dI9� oo•.e,aTrudyQ��C..�,oyyx��,e�; ArG I Celluccl LL oovemor David_'�SVYhs �CoMr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 105 Cam r\eft RD. r na.< '.j rv)���S. M-A Property Address: Address of Owner. Date of Inspection: rf161`f tIn -a(9, %9 9 40 (If different) Name of Inspector. C Mr k�vJ \4 eake'C S Company Name,Address and Telephone Number. C _<_V S 7T t\e. �I s cp+: C_ S y s�cw� s Zwi . ) � e. . I3D r-1 0\4hpeC,.mG.. o -A (.4q CERTIFICATION STATEMENT Sob- 41"7 — a $-2,5 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 maiatenaace of on-site sewage disposal systems. The system: J `asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails n Inspector's Signature: � -u , _ Date: M0..v��'y�, ^(o� (Cj q (o • The System Inspector shall submit a copy of this inspection report tothe 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: 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 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 a 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 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292-S500 A iJ Pnnted on Recycled Paper it SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 n s (A^rr �t �� Pt1-'1`�(S-�p►3 M;,'S meL, Owner. �?�4e,�- Q: ro.•L�\ — 1Mty - Date of Inspection: B)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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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. Z) SYSTEM WILLFAIL 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. 9) OTHER (revised 11/63/95) z 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: D5 e4rv.v.c ��. �0.t-gloves rn;��S. 1MCl. Owner. + � Date of Inspection: Mare..D) SYSTEM FAILS: �b , O96 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 L2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number o°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 ooliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)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 II 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 Addrem' 09 C��..,-� `�D. �Ar`5'1'O� W1\6 Owner. `.�nl aG� Q yv.l.t.1 � Date of Inspection: %M Check if the folio ve been done: Pumping information waa requested of the owner,occupant, and Board of Health. Zone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ZAsuilt plans have been obtained and examined.. Note if they are not available with N/A. ZThe facility or dwelling was inspected for signs of sewage back-up. ?The L m does not receive non-sanitary or industrial waste flow l< The7swas inspected for signs of breakout. ?wc.1,.Ltw� ZA11 system components,excluding the Soil Absorption System,have been located on the site. V/The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of ba8les or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum. ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. �e 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: OS G.CLMvVI�1e-'lt Owner. L o hf1 e Date of Inspection: FLOW CONDITIONS RESMENTIAI: Design flow:Asf callons"r Qe't.0.4 'Qev- Number of bedrooms: Number of current residents: Garbage grinder(yes or no):_Mp Laundry connected to system(yes or no)— C ,, Seasonal use(yes or no):�Q ' q q — S� , o o o '� 19 i Q`/ — `(o O Q Water meter readings, if available: Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:___galions/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: ` S tdt eYt,r ��QW System pumped as part of inspection: (yes or no) P.S If yes,volume pumped: ons Reason for pumping. t'mGt an .5 S a�e TYPE O$BYSTEM _Ig!fj 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) Other(explain) APPROXIMATE AGE of all components, date installed(if known)and source of information: -'Z./fea"b Sewage odors detected when arriving at the site: (yes or no)NA (revised 11/03/95) b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: IDS C.Awn mr-TV RCS , rvnarSShca Vv.,;,,S . (Y1Q..• Owner. L°"a. Q- Date of Inspection: v�r�arc.4• , a� , i q 9 � . SEPTIC TANK:_ (locate on site plan) Depth below grader / Material of construction:_oone:rte(/ metal_FRP_other(ezplain) Dimensions: t to POD D►v S. N K, Sludge depth:_Ej _ i Distance from top of shidge to bottom of outlet tee or baffle:�� Scum thickness: 9 ,, • Distance from top of scum to top of outlet tee or baille: Distance from bottom of scum to bottom of outlet tee or baffie: 3'' Comments: (recommendation for pumping,condition of inlet and outlet tees or baffies,de h of liquid level in relation to outlet invert,structural integrity, evidence of 1 ,etc.) t: A , r't"" G G# M VV 44761 W D v •W S. Taw U, wa 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) Property Address: 1Y1� ��ry , ty1� Owner. Date of Inspection: TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction:_concrete_metal_M_other(e:plain) Dimensions: Capacity gallons Design flow: eallons/day Alarm level: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) I DISTRIBUTION BOX: (locate on site plan) 1 Depth of liquid level above outlet invert: LC' L° O k Comments: (note if level and distribution,* equal, evidence of solids carryover, evidence of leakame into or out of boo,etc.) Wa a PUMP CHAMBER: (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 r 4, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: o,s mow. • e Owner. L l rA a m Q, Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number., leaching chambers,number._ leaching galleries,number. leaching trenches,number,length:�_ leaching fields, number,dimensions: overflow cesspool,number: Comments: (note condition of so signs of h ulic failure, level of ponding,condition of vegetation,etc,) A�a j r'{ '4 'e r' .- CESSPOOLS:_ a (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: (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.) (revised 11/o3/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ,aS GArw rr,e.' Owner. L,.p aA Q i ►.�.e, •� — hneNa� Date of Inspection: "",r,\, , a.b , t Ot 4 b SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent referenoes landmarks or benchmarks locate all wells within 100' Yb" a" DEPTH TO GROUNDWATER Depth to Vvjndwater-4k+feet method of determination or approximation: W �rJ ran Q (revised 11/03/95) 9 TOWN OF BARNSTABLE LOCATION VILLAGE ASSESSOR'S MAP lSZ LOT INSTALLER'S NAME & PHONE NO. e-VI S�127 SEPTIC TANK CAPACITY U-r-O f0 LEACHING FACILITY:(type) P rze-. -(size)-- NO. OF BEDROOMS PRIVATE WELL 0C&3LIC BUILDER OR OWNER a t ,4NN_ Q,�atn DATE PERMIT ISSUED:_ �-`1 ell DATE COMPLIANCE ISSUED: VARIANCE. GRANTED: Yes -- No 4 e-r �° r TOWN OF BARNSTABLE I OS C r LOCATION _ SEWAGE VILLAGE i ✓/ //S ASSESSOR'S MAP & LOT ,Qj INSTALLER'S NAME PHONE NO.P � �� SEPTIC TANK CAPACITY I aQ z" LEACHING FACILITY:(type) _ _(size) _ NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER-t'��I�C. BUILDER OR OWNER , �Sp (L ZII 1Le 1 5 DATE PERMIT ISSUED:_"7-01 = DATE COMPLIANCE ISSUED ��1 -5`0 6Y Qr•to'f VARIANCE GRANTED: Yes —.—No----- —,— rf I C.-e- 0 40L, No.............--_ F�a:: ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / ........OF......... L— Applira#ion for Uhipmal Works Tonstrnrtinn runtit Application is hereby made for a Permit to Construct (A) or Repair ( ) an Individual Sewage Disposal System at: -- .. - ------------------------------------------- . or t \o w - .......------------- ------------- ---------------- - ..... .11 O e .� A ddres .......... .. _... ................... --•---............................ let Address Type of Buildin Size Lot....3. f _ q. feet U Dwelling NO. of Bedrooms___________________________________________Expansion Attic ( ) Garbage Grinder (LpldJ Other—T e of Building No. of persons............................ Showers G4 YP g ------------------••------•• P ( ) — Cafeteria ( ) Q' Other fixtures ............................ W Design Flow.�...�.-..................5.5...........gallons per person per da�. Total daily flow-_-_-..-----.__�1._.3.�.............gallons. 1� Septic Tank-Liquid capacity.1022gallons Length. !'(0.'. Width.*_--i6?"Diameter---------------- Depth...5......:q. Disposal Trench—No..................... Width................. Total Length.................... Total leaching area..:.................sq. ft. 3 Seepage Pit No........../........ Diameter........1_a. . Depth below inlet..... Total leaching area..../g.%...sq. ft. Z Other Distribution box Dosing tank '—' Percolation Test Results Performed by..;E�j�..(�. ___2 Ggl Date..... minutes per inch Depth of Test Pit......_ Test Pit No. 1__---.�._._ p p �_._...____ Depth to ground water.... (z, Test Pit No. 2................minutes per inch Depth of Test Pit....... ... Depth to ground water_.__/Ul%!� ---....- ...... .. --------••-- . . -----•------•-•------•--•......................................................... ODescr tnof Soil..... 4 �i x UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------•----------------------------------•----------------------------------------.....----•-------------------------------------------------•----------------------------------------------....------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with '--� the provisions of :'L/'1 1 of the State Sanitary Code—The undersigned further agrees not toplace he system in operation until a Certificate of Compliance has been iss by the oar o- e N u,, t Signed--------- -- --= --------------- _ Date Application Approved By................................. -- -------`� . . ---•--._--- ------1(2- IaL e Date Application Disapproved for the following reasons:--•--•--•-----•-•-----•-•-•---------------•-----•-•------••----•-•-•-----•----•-•----•---------•-----........... ---------------•-----------...---•-----•--....-----•-----••-----------.----- •--------.-----•-------•--------------•-..--- ----------------------------------------------------- �( Date PermitNo.... �.- ----•------. Issued------------------------------------------------------- Ditc- No.........t ---•- .. Fps.... THE COMMONWEALTH OF MASSACHUSETTS i I BOARD OF . HEALTH ApplirFatiun for %sponal Works (> omi rurtiun Vanfit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: t �•1 ..._.. .. o .. . � 5�.... ..Z" __. �o.------------------------------------------ /n ss or ---------------------------•• ' •-....••--•••. --•---...•--•--•----....-------.........._...--•----••••........._..-•------•-•- Owner Address W Installer Address UType of Building Size Lot_..,3_ q, feet Dwelling--XNO. of Bedrooms.............,.......................Expansion Attic ( ) Garbage Grinder (4V47 pa-1 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) al Other fixtures ..:......................... . W Design Flow..........................S..,5_..._..._..gallons per person per day. Total daily flow............... __ ............gallons. WSeptic Tank-4/Liquid capacity.1 allons Length-_�".(V_ titi: idth__**.--ZO- Diameter_______________• Depth....5:4--.-. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area............________sq. ft. Seepage Pit No----------/-------- Diameter.........`--------- Depth below iniet.....5s.(�P.7- Total leaching area.... ...sq. ft. Z Other Distribution box ( &-r Dosing tank Percolation Test Results Performed Date...... a Test Pit No. 1...:rZ....mmutes per inch Depth of Test Pit......./._ ___. Depth to ground water-----W_/11.01L% (i Test Pit No. 2................minutes per inch Depth of Test Pit........L .. Depth to ground water-_-_-- ►� ' f .... O z �1.'." C.� �11/L..� `' �l '! 'escrtn Soil__.__. //...7....... x •U ...... _.----- ---------. --•-.✓te ----•---- � 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 Ti T p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. NO J Signed-------------------•--..._..........._...------••------.....-•••....-•---�..... ................................ Application Approved B z_.____ _ -�— Date Date Application Disapproved for the following reasons:-----•.....................•-•-------------------------------------------------••-------------------...•-------- .................................. --•---•---.•••-•-..---•---•--•-•---•--•- ._. 44�1 7. Date Permit No.---• --......�---•---••----------•--. Issued.............................................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOAR OF HEALTH ....... ) d.......OF 01rrtifiratr of ToutpliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( } by.......................................................................................................................................................... .__1�. � n Install at...._._h(/.;�__----_/........._C.. � ( t_.?__)_______ _ _ t �,; .___ � „ has been installed in accordance with the provisions Sf TITIE 5 of The State Sanitary Code as desc ib in the l �� application for Disposal Works Construction Permit No...-__ ___ - _ _., j_ dated_...__�i._. . ___ ii ,�_ _ ____ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUA ANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS nn!t )) OARD F HE TH No....U..t3..... °t FEE. .... �in�rouatl� orkn �o�t.�#rttr#ion rrani� Permission is hereby granted......In-.1.__� to Construct ( r R )an_IIndividua Sewage Di sal S stedV O- at No..-..I— --,. t -•-• -•••r f' t JI/W �� reet Q as shown on the application for Disposal Works Construction"Per NOV ';04Dated..6__ ___--C?-- --__-_--__ DATE-- /__.L�? _. Board of Health / ... FORM 12'55 HOBBS & WARREN. INC., PUBLISHERS - ASSESSORS MAP: 1 _ TEST HOLE LOGS PARCEL: _ t� FLOOD ZONE: '� U�P�,1 �— — — — SO I L EVALUATOR: - - WITNESS : U`�Ti"' l.tG ✓ �/�_KV� ��'`1 C ? 1Re _ P r . 6 _. __4 - REFERENCE: (N j 1���2��✓ �r ��� ��` 'O � � � �'`�1 DATE: bL'(b►�1 � PERCOLATION RATE: Z PA14 11,., t �_ _ ---- Nay TH- 1 TH-2 tjbV LOCATION MAP `r5 -- - - ' _r- -- ----------- -- -- - -- wb Gr#2W0. W SEPTIC SYSTEM DESIGN FLOW ESTIMATE BEDROOMS AT IO GAL/DAY/BEDROOM - 33b GAL/DAY SEPTIC TANK ?J�JD GAL/DAY x 2 DAYS - GAL USE IttoGALLON SEPTIC TANK L�K"5TI 4 SOIL ABSORPTION SYSTEM Aj -tt�v-.11 c Mew, — ----- ---- — o v , SIDE AREA: Z BOTTOM AREA: 1 X L x 01-741s"23b88 IC SYSTEM SECT I ON /f ,,$) A � p y. 0 VA. 3 IQQQ GAL 1 SEPT I C TAN 4� 0,� SITE AND SEWAGE PLAN LOCAT I ON Ib �MIM ' ipl4D a 41 PREPARED FOR : t'�Ilt?iIM G SCALE DAV I D B . MASON 'Ri5 DATE:Iz 0 DBC ENVIRONMENtAL DESIGNS 1 4 EAST SANDWICH . MA W DA HEA H AGENT � ( 508 ) - 833- 2177 Z ZONE' RF SOIL TEST PIT DA TA.' SETBACKS• FRONT 30 ' SIDE 15' T.P. -1 T.P. -2 REAR 15 ' l GRND. EL EV. 100. 1 GRND. EL EV. 100. 1 G. W. EL EV. G. W. EL EV. Go4m 5 DESIGN CRITERIA 24'I ' DESIGN FL Ok 3 BEDROOM DWEL L INS @ 110 GAL/DA Y PER BEDROOM c-' EQUAL S 330 GAL S PER DA Y. • GLE,U�/ GL6=f76 AJ o co a�e sc C a e rLs c= SEPTIC TANK REQUIRED,• .y INDICA TES PERC. -tCOiu H-1 wt ErJi u 330 GPD X 15OX = 495 GAL . ,► oG w� TEST s a.v Z9 - 0/ A 4 4 zow SEPTIC TANK PROVIDED- 1000 GAL . l ,26 - INDICA TES OBSERVED SIZE OF LEACHING FACILITY REQUIRED.' GROUNDWA TER DESIGN PERC. RA TE = -2 MINUTES/INCH 330 GALLONS PER DA Y OF cucvu�urE� ice,„ 4 SIZE OF LEACHING FACILITY PROVIDED• ROGER 10 ' DIA. X 3. 67 ' DEEP PI T = 193 S. F. PAUL SIDEWALL 115 S.F. X 2. 5 - 288 GPD s MICHIWIEWICZ BOTTOM 78 S. F. X 1. 0 _ 78 GPD No.3042p DA TE* DA TE' TOTAL - 366 GPO CIVIL AUG. 26, 1986 AUG. 26,, 195: TEST BY.' TEST BY.' o DOWN CAPE ENGINEERING DOWN CAPE ENGINEERING / RICHARD R ,. FA P. E. RICHARD R. AIRSANK P. E. / 86 WITNESSED BK WI TNESSED BY.` \ 19A TE PROFESSIqPAL NG ER T MC KEAN T. MC KEAN PERC. RATE' PERC. RATE BREAKOUT CAL CULA TIONS.' LOT 9 � �N of , - 2 IN./IlW . MIN./IN. Pain. yG 5 9 SL OPE X 150 , 34, 094 f S.F. R. y 7 9 6o A No.32448 c 9ECISTE"�� � 2 o 'D4 I rE PROFESSIONAL LA1016URFEYOR 103. 00 101. 50 ACCESS COVERS MUST BE WI THIN 12 OF FINISH GRADE. 99. 50 0 98. 70 MIN. 2" OF .1/8"-1/2 " DIA. ris X 97. 67' WASHED STONE N tS <� r t L MUM _._. - DEPTH W 3/4 1 1/2 DIA. • • p WASHED STONE 1000 GAL . SEPTIC Y. WANK W 94. 00 ' • �, �= 10 ' DIA 0 P 0 - , - INVERT EL EVA TIONS.' Pond,... P # « .o • <9�-�. ° �'� 0. 1 INVERT AT BUILDING 99. 50 _. __.... f ndir► ,�� TES IT # 1 �. INVERT IN/ AT SEPTIC TANK 99. 25 REVISIONS' p _ • ;; 'DL BAR ` �� ELEV. 100. 1 (J�'� 0' 3 INVERT OUT A T SEPTIC TANK 99. 00 NO. DA TE REVISION o 0 INVERT IN/ AT DIST. BOX 98. 87 ' pUND INVERT OUT AT DIST. BOX 98. 70 { ,r a' I ,•.' (o ' -'' ti to B.R•B' $SUME� INVERT IN A'T SEEPAGE PIT 97. 67 p -,.• .`s �,� , �� �� M • # 1°°• ° (A p BOTTOM OF SEEPAGEPIT 94. 00 ! U . / G✓` -(: , �� ice ' �-�ww� Et,EV• mac'/ -5p alr .4• L .� _ 79< Z RQ AD 8- s�o o PUBS ICE • t, .pUND -- 10-- - �- !•. '- :,� ; ' '' �; % '"� C.B•/D�as$UMEDI v o - 1 p p 1�E LAN SHOWING THE DESIGN OF A PROPOSED a �E�• 1°°• 43 ' 9g' 1NE SUBSURFACE SEPTIC DISPOSAL SYSTEM E 1°p6' gg• Z CENT GENERAL NOTES.' �� L OCUS MAP R TO SCALE METr 1. THIS PLAN IS FOR THE DESIGN AN/D LOT 9 CAMMETT TOAD, BARNSTABLE. MA . NOT CAM CONSTRUCTION OF THE SEWAGE DISPOSAL WIpE FACILITY ONL Y. (qo• °° PREPARED FOR 2. ALL CONSTRUCTION METHODS AND M1A TERIAL;S' SHAL L CONFORM TO MASS. D. E. Q. E. TI TL E 5 AND LOCAL BOARD OF HEALTH REGVIL A TIONS'. HOL MA Y HOMES 3. ALL SEPTIC SYSTEM COMPONENTS SUBJECT TO , VEHICLE L OADING (I. E. UNDER DRI VEWA YS, ETC. SCALE. 1 30 DUNE 13, 1988 SHALL BE DESIGNED 70 WITHSTAND H-20 LOADING. 4. ALL SEWER PIPE SHALL BE SCHED&/LE 40 OR L`AGLE SURVEYING AND ENGINEERING, INC. APPROVED EQUAL . ALL DIG SAFE 441 ROUTE 130 G"CONSTRUCTION EFORE STARTING 5. B 1-800-322-4844 FOR LOCATION OF- UNDERGROUND UTIL I TIES. SANDWICH, MA . 02563 (617) 888-055-9 PROJECT NUMBER 88-036