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HomeMy WebLinkAbout0036 CAPTAIN BAKER ROAD - Health 3e,/ C'aptlan n,lc�rS ' COMMONWEALTH OF MASSACHUSETTS 12 EXECUTIVE OFFICE OF ENNIRON\1ENTAL-AFFA DEPARTNIE�T OF EN-VIRONNIEN-TAL PROT IOC O \- ��" 0\E WINTER.STREET. BOSTON. NIA 02IOS jUL 1 -.1 Mae a� ' : .. • . ._. . Pit , VN'ILL1AN'F._XILD . TR 0 Governs. _ - . ._. . ... . : ' =rea• ARGEO PAUL CELLUCCl _. _. .. 9 B.STRL•1-E Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions t�i `a(a PART A CERTIFICATION OUT dS Property Address., 3 F5� 1� _ ,�, 10 LI�AZsT00s 'Address of Owner: Date of Inspection: j� jo 1G`4j / Y�n1�I5 (If different) _ .. Name of Inspector: H, o 1 am a DEP ap roved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) Company Name:A-/ a 414-I'e Eir rr'r f-7 r &" P Mailing Address: Rep &nx C_3;f H 11-v 2C4_51 Telephone Number. r$'G 2t;2 CL 4 2— /4 ?_o CERTIFICATIO% STATEMENT 1 certifi that I have personally inspected the sewage disposal system at this address and that the information reported below is true. accurate and complete as o-the time of inspec°so The inspect.ori was performed based on my training and experience in the proper function and maintenance o;on-site sewaee disposa; systems. The sN-stem: Pastes Concmonaii% Passes tieecs Furthe- Evaluation Ev the Local Approving Authonn Fa Inspector's Signat Date: Svs.e^ Insnecw, shal' submit a cop\.• of this inspection rep or to the Approving ^uthorin within them (30) days of completing this inspection. If the s\-stem is a share' s\-stem o• has a desjgn flow of 10,000 gx or greater, the inspecor and the system owner shall submit the repo-, tc the appropriate reelonal office of the Deranment of Environmenta: Protection. The orig,na! should be sent to the system owner and copies t-ri; to the bu\,•e, if applicable• and the approving authority. INSPECTIO%SUMMARY: Check A, B, C, or D: Al SYSTEM PASSES: 1 have not found any information which indicates that the system vioiates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluates are indicated below. _ COMMENTS: 7 lvv�J�, Div. .y�7 .. ` BI 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 cr repair, as approved by the Board of Health, will pass. Indicate yes, no. or not determined (Y, N, or NDi. Describe basis of determination in all instances. If'not determined', explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; Or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. trev:a•d 04/2S!97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` 1 '& ` PART A ^r 5 CERTIFICATION (continued) r Prope 4rty __�.Owner: ._ 6ate of Inspection: B-J,SYSTEM C0hD'RIONALLYj'PAS5E5 tcontinj,!�d- f� -- Se yar"ge backup or breakout or high static water level obser. ved in the distribution box is due to broken or obstructed Ip ppeels)'or due to a broken. settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: :. broken pipes) 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 pipets!.:The system will pass inspection if twith approval of the Board of Health): - - broken pipets) are replacer obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require funhe• evaluation by the Board of Health in order to de!ermine 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 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or prnti is within 50 fee, of a surface water _ Cesspool or priv-y is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM 15 FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less char. 100 fee! but 50 feet or more from a private water supply well, uniess a we!I water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) _.OTHER 71 (revised 04/25/7') Page 2 of 10 SU3SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D) SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: 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. Yes No 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 tl-e distribution boa above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspcol is less than 6" below invert or available volume is less than 112 day flow. Required pumping mcre than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Anv port.on of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Am 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 pricy is within a Zone I of a public well. And ponior. of a cesspool or privy is within 50 feet of a private water supply well Am• portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water suppiv well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No 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 11 of a public water supply well) The owner or operator of any such systen 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 04/25/97) Page 3 of 10 F p ,• 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 60 N U Owner: 6A(�-(�j Date of Inspection:, ( Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. — None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facilih or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. — The site v`as inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material o: construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: g — The facility owner land occupants, if different from owners were provided with information on the proper maintenance of —[ Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. — Determined in the field of any of.the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) (revised 04/25/97) Page 4 of 10 • n 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / �, ',� SYSTEM INFORMATION Properh Address: 3(o �PT N 6 Owner: 6jrlk Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design ilo,% .p.d.,bedroorr. ror S.A.S Number of bedrooms 03 Number o'current residents d5 ` Garbage g,. der (yes or no, &--� Laundry co-•^ected to system (yes or no° Seasonal use ryes or no-. tl� Water meter readings. if ava fable (last rwo '.2; year usage tgpd): ti Sump Pump Ives or na Las date o**occupancy rAagQVJj COMMERCI411NDUSTRIAL: Type of establishmen: Design fio.. aahonsida. Grease trap present Ives or no Industrial \taste Holding Tani; present. -ves or no Non-sanitan v.aste discnargec to the T•t!e 7 Sysiem ives or no \later meter readings. if a.ailabie Las:pate o: c, OTHER: Describe Last pate of occucanc. GENERAL INFORMATION PUMPING RECORDS and source of tniormatior. System pumpec as par, of tnspec,jon: ;yes or no. N If ves, volume pumped ¢allons li Reason for purnping TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Prn)• Shared system (yes or no) (if yes, attach previous inspection records, if any) VA Technology etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: -- :'�*C?uc Sewage odors detected when arriving at the site. (yes or no) (revised 04/25/971 Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertyddress: 3� FAUX Owner: 6 kT1 * Date of Vito BUILDING SEWER: (Locate on site plan) Depth below grade. Material of construction: _cast iron _40 PVC _other (explain! Distance from private water supply well or suction Ii Diameter Comments: (condition of joints, venting, evidence of leakage. etc.) SEPTIC TANK: S (locate on site pl ail .Depth below grade � ' Material of construction: concre:e _meta _Fibergiass _,Polyethylene _othertexplain If tans. is meta:, Iis: age _ is age cor-amec b\ Cen:fca:e of Compiiance _(les�no Dimensions Sludge depth 3 _ (f Distance from top o t sludee to bottom of outie: tee o• ba";e �3t . ` Scum thickness Distance from top of scum to top V outlet tee or ba^ie it Distance from bonom of scu-n to bo-on o, outie: to e• bare 1� Nov• dimensions %ere determined Comments trecommendation for pumping. condition i iniet and outlet tees or baffles, depth of liquid level in rel ion to out( t i vert, str ural integrity, evidence of leakage. e:c.) 111 �� � Y GREASE TRAP:' (locate on site plan: Depth below grade. Material of construction. _concrete _metal Fiberglass _Polyethylene —Other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle. Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping Comments: (recommendation for pumping, condition of i!ilet and outlet tees or baffles, depth of liquid level in relation to outlet invert,.structural ;ntegrity, evidence of leakage, etc.; (re,•-irad 01/25:9,) Page 6 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertm Address:3C Cqe r N OM ner. �1 :5 Date of Inspection: TIGHT OR HOLDING TANK: -Tank must be pumped prior to, or at time, of inspection: (locate on site plan, Depth below grade. Material of construction _concrete _petal _Fiberglass _Polyethylene _other(explain) Dimensions. Capacm•: gallons Desir floe galions-da. Alarm level A;arm in s%orking order_ Yes, _ No Date of previous pumping Comments (condition of role! tee. condition o- a!a,r. and floa, switches. etc.) DISTRIBUTION BOX: S ;locate on site p-an Dept� o! liciuid lee aciove out,e: erne^ Comments incite r leve! and d!s^'b,;- is eoua' evidence of solids tarn- r, e��dence d leakage m rout f box, etc.) PUMP CHAMBER: (locate on site plan. Pumps in working order: (Yes or No, Alarms in working order (ties or No Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 04/25/97) pig• 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ' Property Address: 3� caet Owner: Date of Inspection: I� SOIL ABSORPTION SYSTEM (SAS): t�,5 (locate on site_plan, rf possible, exca%a ,on not required, but may be approximated by non-intrusive methods If not determined to be present, explain. Type: leaching pits. number_kl4KIt, leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fieids, number, d,mensio.n.s overflow cesspool, number Alternative system Name of Tecnroiog,, Comments. inote con itio� of so,i. ssgns of hydraulic failure, leve of pondin . condition of vegetation, etc.) c s Ak— . 1 CESSPOOLS: Mj (locate on site plan Number and configura:.or. Depth-top of liquid to inlet inver, Depth of solids lave, Depth of scum layer. Dimensions of cesspool Materials of construction Indication of ground\,`ate- inflow (cesspool must tie pumper as par, of mspectionl 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 hvdraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION tcontinuedi Proper% Address: % CStnj Owner: �IVT--o Date of Inspection: (�( SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1� Ao Z. •a 0 i tz.vla.= 04'25!97) T.y. I of 10 ' i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 1!, SYSTEM INFORMATION (continued) Propertti Address 34 C-PqTN �R � Owner: Wts_ Date of Inspecuon:6 1� `r1co Depth to Groundwater �r Aeet Please indicate all the methods used to determine High.Groundwater Elevation: Obtained irom Design Plans on record Observation o;Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Cneck %.rth Iota' Bsarc o' neaar Chec�. F:titA Macs Checl, pumping recorcg Check Iota' e%ca%a:o•s ins:alle's �[ t_se ''-5'.._ Da Describe in �c.,• o,.- �o_ es:ac;-shec the '-;g`• Crouncwate• Eie.•ation (Must be com;:ie'ec elo lr.vC.•d 0�.':S '9- D.q. 10 of 10 s t TOWN OF BARNSTABLE LOCA'fl(�N 3� ��Zti �a4 SEWAGE # VILLAGE ASSESSOR'S MAP& LOT i2bWas_ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPAC= 1 LEACHING FACILITY: (type) oD 1\ (size) l eldG 41A. NO.OF BEDROOMS BUILDER OR OWNE � S SATE: y� COMPLIANCE DATE: Separation Distance Between the: l Maximum Adjusted Groundwater Table and Bottom of Leaching Facility + 30 Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) IN I Feet Edge of Wetland and Leaching Facility(If any wetlands exist <J l� . Feet within 300 feet of leaching facility) o,,� Furnished by z . IbZ- s' 03- ' 1A \p Ik�'.o I \. %Sj owl-0 l \ 1 ) 1 . E■ 235 Great Western Road P.O. Box i044 Telephone(508)398-83i i South Dennis, MA 02660 Fax (508)398-3063 PROFESSIONAL CIVIL ENGINEER,SOIL EVALUATOR,SEPTIC INSPECTOR SEP I IC;SYSTEM DESIGNS,COASTAL Ili BUILIDING DESIGNS February 26,2002 Chuck Delcourt 36 Capt. Baker Road Marstons Mills, MA 02648 RE: 36 Capt. Baker Road,Marstons Mills,MA CRS File# 1-136 Dear Mr. Delcourt: In response to your request,I am providing the following calculations relative to the referenced site. The capacity of the 6 x 8 leaching pit that was called for in the original design was calculated as follows: Bottom it r 2 = a(4)2 x 1 gallsf = 50 g.p.d. Sidewall 271 r(h) = 2 a 4'(6)x 2.5 gal/sf = 377 g.p.d. TOTAL CAPACITY = 427 G.P.D. Since 427 g.p.d.exceeds 330 g.p.d.minimum required for a 3 bedroom dwelling, in my opinion,the system originally had a 3 bedroom design capacity. If you have any questions, please give me,a call. OF Sincerely, CRAIG � L/C SHORT y� � t -a Craig R. ort, P.E. p No. 27483 �4 Enc. Invoice for research&dal\eufations OAtE PRIME i/312019 > > / - k 7L'IHLIE ID)IEIL00�ILLIL�Z T RIEs5ILIDIEAr�CIE -�6 (CA PT IBB)AUK EIR RID.. r 1AKARSTOA Z67MILILIL65. 1 VIA r Ln N 1 O N W I FRONT/51PE AND REAR 5ET5ACK5:30'/15' LOT AREA: 20,037 5.f. GROUND COVER RATIO:15% �j �/ •j o EXISTING GROUND COVER:+/1039 5.f. i' W N PRO1205ED NEW GROUND COVER:357 5.f. I w j N b G TOTAL GROUND COVER: 1,396 5.f. I • I °` '•W ALLOWABLE GROUND COVER:3,005 5.f. o eD • W W S� I � � 1 _ � 1 51TE PLAN o SCALE: 1" = 15' . ® as W m c� - EXISTING BUILDING FOOTPRINT CAI T. BAKER ROAD A oire I'WN1E /'ul/:019 VD _ e� 13 9 IR ------- A5-BUILT a a o MASTER BATHROOM DECK t--------t PA710 °C 1111111�11 �1111111' 4'-51/4"_ I I 1 b �I CLO5. HER 1115 00 POWDER!� ® I O b w 1111 I LL IIII�I I IINN�NHNN� I Ell4p — --' io�N C< - --- O LAUNDRY LL N LIVING- i _ I O, I II PANTRY 'O 9 CL05 , II I: -_WALL 13'-11n' _ OVEN MASTE 4 I b R BEDROOM � KITCHEN � JJ ac L.---------------------------- ------- - FIRST FLOOR PLAN NOT FOR CONSTRUCTION I Commonwealth of Massachusetts 03 Title 5 Official Inspection Form J. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Captain Baker Road j Property Address Charles Delcourt Owner Owner's Name information is required for every Marstons Mills MA _ 02648 September 28, 2018 page. Cdyfrown — State Zip Code Date of Inspection il D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: i ® hand-sketch in the area below ❑ drawing attached separately i i I } � I i 7 / J J J `v, I t5insp.doc-rev.712612018 I Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page I16 of 18 I i Commonwealth of Massachusetts cop",( -- �l? Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;; (<; 4 36 Ca twin Baker Road r..t Property Address Charles Delcourt Owner Owner's Name -- - information is X. required for every Marstons Mills MA 02648 September 28, 2018 page. CitylTown State Zip Code Date of Inspection iN — 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 A. Inspector Information 5 filling out forms p 4 fs3 (, I on the computer, use only the tab Patrick T. Sullivan _ key to move your Name of Inspector - cursor-do not Ready Rooter Excvating use the return key. Company Name -- - - Box 89 Co Company Address Forestdale MA _ 02644 City/Town State Zip Code 508-509-0802 _ S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15 340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the pi oper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails October 3, 2018 Inspector's Signature��- Date The system inspector shall submit a copy of this inspection report to the Approving A&ority (Board of Health or DEP) within 30 days of completing this inspection. If the system has a desi n flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and co les sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Pag 1 of 18 Commonwealth of Massachusetts ;-Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Of 36 Captain Baker Road Property Address Charles Delcourt Owner Owner's Name information is Marstons Mills MA 02648 September 28, 2 018 required for every _ page. CitylTown State Zip Code Date of Inspection C. Inspection Summary Inspection Simmary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have nct found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhib is substantial infiltration or exfiltration or tank failure is imminent. Systerr 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 ❑/N (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pag 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Captain Baker Road Property Address Charles Delcourt Owner Owner's Name information is required for every Marstons Mills _ MA 02648 September 28, 2018 page. CityTTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Heal h approval if pumps/alarms are repaired. ❑ Observation of sewage backup or brea /out or high static water level in the distribut on box due to broken or obstructed pipe(s) or due�o a broken, settled or uneven distribution box. System will pass inspection if(with approval of oard of Health): ❑ broken pipe(s) are repla d ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remov ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is veled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructs 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 1 ❑ Y ❑ N ❑ ND (Explain below): i' 3) Further Evaluation is Required by,/the Board of Health: ❑ Conditions exist which require/further evaluation by the Board of Health in order to c etermine if the system is failing to protect public health, safety or the environment. a. System will pass u nI ss Board of Health determines in accordance with 31 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7126f2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Pag 3 of 18 Commonwealth of Massachusetts 1p Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Captain Baker Road Property Address Charles Delcourt Owner Owner's Name information is Marstons Mills required for every MA 02648 September 28, 2018 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if ar�y) determines that the system is functioning in a manner that protects the publi 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 privat( water supply well. % ❑ The system has a septic tank a /d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply ell". Method used to determine distan e: #" 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 hat no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pag1 4 of 18 Commonwealth of Massachusetts i Title 5 Official Inspection Form "r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Captain Baker Road Property Address Charles Delcourt Owner Owner's Name information is Marstons Mills MA 02648 September 28, 2018 required for every __— p page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) I Yes No I ❑ 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 'h day flow ❑ Required pumping more than 4 times in the last year NOT due to logged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground wafter elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality E nalysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and th presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd ❑ ® The system fails. I have determined that one or more of the abo a failure criteria exist as described in 310 CMR 15.303, therefore the syste fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes'or"no"to each of the following, in addition to the questions in Section CA. � Yes No ❑ ❑ the system is withi400 feet of a surfac e ce dunking water supply f ❑ ❑ the system is within 200 feet of a tributary to a surface drinking wE ter supply the s stem:is located in a nitrogen sensitive ❑ ❑ y g area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/2612018 - Title 5 Official Inspection form:Subsurface Sewage Disposal System•Pag 5 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form P Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Captain Bake, Road Property Address Charles_Delcourt _ Owner Owner's Name information is Marstons Mills MA 02648 September 28, 2018 required for every _ page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a si nificant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Sectior CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Boarld of Health ❑ ® Were any of the system components pumped out in the previous �o weeks? ❑ ® Has the system received normal flows in the previous two week period? El ® Have large volumes of water been introduced to the system recent) or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they ere 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 constru tion, 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 tile site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Fag 16 of 18 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form i — i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Captain Baker Road Property Address Charles Delcourt Owner Owner's Name information is required for every Marstons Mills _ MA 02648 Se tember 28, 2 018 page. City/Town _ State Zip Code Date of Inspection D. System Information - 1. Residential Flow Conditions: Number of bedrooms 3 3 (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD Description.- Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to.- Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2016=203 GPD' 2017= 19 GPD" Detail: High water use in summer months due to irrigation. Property has had year round weeks d use over last couple of years. Sump pump? ❑ Yes ® No Last date of occupancy: We akends Dat t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 7 of 18 Commonwealth of Massachusetts I�p Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Captain Baker Road Property Address Charles Delcourt Owner Owner's Name information is required for every Marstons Mills MA 02648 September 28, 2018 page. City/Town State Zip Code Date of Inspection I D. System Information (cont.) 2. Commercial/lindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): , Gallons per day(gpd) Basis of design flow (seats/persons/sq,ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? / ❑ Yes ❑ No If ,es discharges Z — Y 9 - Industrial waste holding tan resent? ❑ Yes El No Non-sanitary waste discha ged to the Title 5 system? ❑ Yes ❑ No Water meter readings, iivailable: Last date of occupancy/use: IDate Other(describe below): 3. Pumping Records: Source of information: Ready Rooter records: Pumped March 2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: 15insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsuiface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts ;o Title 5 Official Inspection Form Its Subsurface Sewage Disposal System Form -Not or Voluntary Assessments 36 Certain Baker Road Property Address Charles Delcourt Owner Owner's Name information is required for every Marstons Mills MA 02648 September 28, 201 8 page. 6dt fffown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if ny) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: System installed 06/06/1998. Certificate of Compliance on file at Health Dew Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): Depth below grade: 2 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.): t5insp.doc-rev.7/26G2016 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 f 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 36 Captain Baker Road Property Address Charles Delcourt Owner Owner's Name information is required for every _Marstons Mills _ MA 02648 September 28, �01 8 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan).- Depth below grade: 1 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: 8.5' x 4.5' x 5' 100 _qallons Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness `1 — Distance from top of scum to top of outlet tee or baffle 101, _ Distance from bottom of scum to bottom of outlet tee or baffle 14 How were dimensions determined? Dip tube and 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.): Inlet PVC tee and outlet concrete baffle in place. Liquid level at outlet invert. Risers bring inlet and middle covers within 6" of grade. Recommend maintenance pumping every two years. t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts ,r Title 5 Official Inspection Form I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,(7 36 Captain Baker Road Property Address Charles Delcourt Owner Owner's Name information is required for every _Marstons Mills MA 02648 September 28, 2018 page. City/Town State Zip Code Date of Inspection 1 D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ;r ❑ concrete ❑ metal El/fiberglass ❑ polyethylene ❑ o her(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle i' Distance from bottom of scum/to bottom of outlet tee or baffle --I l Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, struct ral integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I i 8. Tight or Holding Tank (tank must be pumpYd at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal / ❑ fiberglass ❑ polyethylene ❑ over(explain): Dimensions: Capacity: � gallons Design Flow: _ gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Ili Title 5 Official Inspection Form — i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Captain Baker Road Property Address Charles Delcourt Owner Owner's Name information is required for every Marstons Mills MA 02648 September 28, 2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: `// - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and fl oat switches, etc.): *Attach copy cf current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): One inlet, one outlet. No solids carryover. No high water staining over outlet invert. I I i tSinsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pagel12 of 16 III � i I <14N� Commonwealth of Massachusetts p Title 5 Official Inspection Form i I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Captain Baker Road Property Address Charles Delcourt Owner Owner's Name information is required for every _Marstons Mills _ MA 02648 September 28, M 8 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i 10. Pump Chamber(locate on site plan): Pumps in working order: � j ❑ Yes ❑ No* Alarms in working order: / ❑ Yes ❑ No" I Comments (note condition of pump ch ber, condition of pumps and appurtenances, 1 c.): — I 1 — I I If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: P Y I i I Type: ® Teaching pits number: 1-6'x6' w/2' stone. ❑ leaching chambers number: ❑ leaching galleries number: — ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: - ❑ innovative/alternative system Type/name of technology- Title•rev,7L26/2018 Title 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page 13 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Captain Baker Road Property Address Charles Delc_ ourt � Owner Owner's Name information is Marstons Mills MA 02648 September 28, 2018 required for every — p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cant.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit had no standing liquid with damp base at time of inspection. Light high water staining 3+' below invert. Clean stone visible in sidewall. No sign of past hydraulic failure. � i i I I I 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth-top of liquid to inlet invert Depth of solids layer Depth of scum layer i' Dimensions of cesspool / Materials of construction - Indication of groundwater inflow ❑ Yes ❑ No Comments (note conditi o f soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l/ - I 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Captain Baker Road Property Address i Charles Delcourt Owner Owner's Name information is required for every Marstons Mills MA 02648 September 28, 2018 page. 6'Wrown State Zip Code Date of Inspection -_ I D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids . Comments (note condition of soil, signs f hydraulic failure, level of ponding, condition of vegetation, etc.): / — _ I I i - i I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 i i Commonwealth of Massachusetts IF Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Captain Baker Road Property Address Charles Delcourt Owner Owner's Name information is i required for every Marstons Mills MA _ 02648 September 28, 2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately F_ I A % / i �4 i VS ti j 15insp.dnc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Paget6 of 18 i I � Commonwealth of Massachusetts Ilo Title 5 Official Inspection Form I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 36 Captain Baker_ Road Property Address Charles Delcourt Owner Owner's Name information is required for every Marstons Mills page. City/Town MA 02648 September 28 2018 - State Zip-Code Date of Inspection D. System Information (cont.) I 15. Site Exam: ❑ Check Slope i I ❑ Surface water i ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: '5 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: 1995 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) i ❑ Checked with local Board of Health -explain: j I, ❑ Checked with local excavators, installers -(attach documentation) ! I ® Accessed USGS database-explain: f _maps.mass is.state.ma.us/oliver.php I I You must describe how you established the high ground water elevation: Test hole to 12' found no ground water in 1995. Base of leach pit 8' below grade. Accessed local ground water contours and topo maPPin . No high round water in area of system. I I i I i Before filing this Inspection Report, please see Report Completeness Checklist on!,next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 r i Commonwealth of Massachusetts Ip Title 5 Official Inspection Form /.� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l 36 Captain Baker Road L Property Address - Charles Delcourt I Owner Owner's Name information is I required for every Marstons Mills MA 02648 September 28, 12018 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. i i ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked i ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed i ® D. System Information.- For 8: Tight/Holding Tank—Pumping contract attached I I For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached ! For 15: Explanation of estimated depth to high groundwater included I I i 1 i i I i i i5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 iI I No. Fee P2;;_� COMMONWEALTH OF MASSACHUSETTS Entered in com titer:PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 4plitation for Mispo8al *pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System N41ndividual Components Location Address or Lot No. Zr., C,.�Ct:,d.����,�—� Owner's Name,Address,and Tel.No. °�'�a,n�-cam�+.V`��\\� �• ln.�ra.r\�� ���C O ei-�.,+�i Assessor's Map/Parcel p F Installer's Name,Address,and Tel.No. dog�7Z' �� ,�" Designer's Name,Address,and Tel.No. Type of Building: ? Dwelling No.of Bedrooms J Lot Size Est S s4 . Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank \ ����--�;V e Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) M@, � � � � �e__ Ga c 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 Certificate of Compliance has been issued by this Board of Health. S' d 4 0 Date t' Application Approved by Date Application Disapproved by Date for the following reasons Permit No. Date Issued /187 No. I Fee / J THE COMMONWEALTH OF MASSACHUSETTS Entered in comAter: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplicatlon for ]Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ©#Iirdi vidual Components Location Address or Lot No. Owner's Name,Address,and Tel.N�;?a2C. Assessor's Map/Parcel Q ,mot r, �c� _o Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms _7Z__-) Lot Size �-�T c,s,£t. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date N. Title Size of Septic Tank ,�c�- ��tsX� Jest Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)J�cam t YN ,Date last inspected: , 4, 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 Certificate of Compliance has been issued by this Board of Health. Date 6 r Application Approved by �'/f. n l���? IA .i /i Date I Application Disapproved by v / i r Y Date v for the following reasons Permit No. Date Issued - - -7 - -- - - - - - - - - -- - - - - - ------------------._ K THE COMMONWEALTH OF MASSACHUSETTS (� BARNSTABLE,MASSACHUSETTS Certificate of Compliances THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed O Repaired( ) Upgraded( ) Abandoned( )bY2 -J— �.kc^. e ^� at_Z C'„a �4�-y�� `t;]���_r--- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. e Zted Installer ,� ��'��----- �1,.� Designer #bedrooms Approved design flow gpd The issuance of this permit shallot be construed as a guarantee that the system ill functio as<desia ed. Date 1�s5)n 9 Inspector- _— - =-------------------- - ------- - ----- ----_- ------------------------------------------------=------- ------------- No. Fee / Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Voposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must a co m= e ed ithin three years of the date of this permit. Date Approved by / TOWN OFBARNSTABLE ,`��{ LOCATION SEWAGE# VILLAGE M,& ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY LEACHING FACILITY.(type) (size) NO.OF BEDROOMS. OWNER lh�► r C�f'�.? PERMIT.DATE: COMPLIANCE DATE: ($ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility T 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 F`. 3 So. r-eJ, c` a��`1 I 4 3� 33 rso 9' I L01CAT10N 1,� �5� �\�C , �� SEWAGEr PERMIT NO. �\ LO T � VILLAGE INSTA LLER'S NAME & ADDRESS R � CFt<Ti L� A-( B U It D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �. •-T III 1 f � I � �� ZI al 1 ., 1 " '�"�mot/ �I No. ....OQ Fps...... . .....U. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... ........... .----OF......................................................................................... Appliratiuu -fur 13hipuuttl Workii Tattfitrurtion Prrunit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: / . , ��— 14 Z2�!.keA�; ..Z .....Al- .. y� /' Location• dress /,� Lot N .!lzST C�. ..... .t....... - ....------- ......4i- /-J _-!S.4?! .A57 -GR!�S7'.. /ham dT/y "�•�f er ddress Installer, B t Address Q Type of Building Size Lot----------------------------Sq. feet U Dwelling—.No. of Bedrooms--.-_-_ Expansion Attic Garbage Grinder `4 Other—Type of Building ............................ No. of persons---------------------------- Showers — Cafeteria 04 Other fixtures ...................................................... W Design Flow............... !?..........................gallons per person per day. Total daily flow............. ................gallons. WSeptic "Tank—Liquid capacityJaOO__gallons Length.. ----- Diameter--.............. Depth..--_-._..._- x Disposal Trench—No. .................... Width---------------------- Total Length.................... Total leaching area..............------sq. ft. � Seepage Pit No.-___-_- ______-_.. iameter......k.......... Depth below inlet..?.'. _.__.__ Total leaching area...A? ----sq. ft. z Other Distribution box ( i Dosing tank ( ) � � /--2 �w 7-7 a Percolation Test Results Performed bY------------------------------------------------------------ ------------ Date........................................ Test Pit No. 1................minutes per inch Depth of "Test Pit.................... Depth to ground water----.__.:--------------- w Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-------------------- O Description of Soil D--.3 ? ,�n ,r� � s r ®/t_ x `�®�......-/. �2�. ......�... e9�'!i® .. ------•......A✓ L- --------- ------------_------------- V W ------------------------------------ ......----------------------------------------------------------------------------------------------------------------------------------------------------------- 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 unders. ned further agrees not to place the system in operation until a Certificate of Compliance has been ' su e rd of health. Signed------ ------------------------------------ .......de2)) 7 Date Application Approved By.......... -... /(----------------------------------------••--- Date Application Disapproved for the following reasons------------------•--•-•••------------------------•.....-------•-••-•------•-•••-•----....--.................... -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Date Permit No.---..`j�`> y Issued. 77 - --------------------------- Date - - - --- ------------------------------------------------------------------------------------------------------ No.......................... FwK............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......... ... _ ..................OF....................................I.........................................I......... Appliratfou -fur Ui,ipoottl Workii Towitrurtion V- utft Application is hereby made for a Permit to Construct_( ) or Repair ( ) an Individual Sewage Disposal System stem at: t f --- �/ LLBr -- T � + W /z;r;�/ /.• �/i�vaLocation c ion- No s //e'T` / -t ',& r — / a i✓7 _- . -•-•-•--••-••••=•-------------•••-------. •...._..._•--••- a • ^er. ddress •-----•------•-------•-------------•-•------••-----•-•......•-----•--•--•-••-----•---•-----•-••--- ---•....------------------- .................... ----------------------------------- Installer Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms-------- -Expansion Attic Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) Other fixtures _______________________________ _ _ W Design Flow............. _________________________gallons per person per day. Total daily flow..----------ZG j?____...._._.....---_.gallons. Septic 1'cutk—Liquid capacity 10 __gallons Length_. _.__ __. . Diameter---------------- Depth---------- ._.... xDisposal Trench—No_ ____________________ Width....._.------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........Z--------- Diameter______ ___________ Depth below inlet-- ... Total leachingarea.... SZ....sq. ft. Z Other Distribution box ( ('� Dosing tank ( ) aPercolation Test Results Performed by---------------- .................................................... ... Date---------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ f., Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-__-....._-._--..--_-._. --------•---------------•-------- .................. ................................................................................................... O Description of Soil---- =� /�......jc:_1,r7„<< u-�N riL-----------------------•-------- �C'/' �GI r i._......i F sf"� A, - --•-----•------------•-•-------.----•-•--•------------------- W -------------------------------------------•-•--•-------------•--•--•-•--•--•---------•-----------------------••---- -------------------------•---------•-------------------- --------------- --------- UNature of Repairs or Alterations—Answer when applicable----------------------------------------------------------------------------._._.__.----------- ------------------------------------------------------------------------------------------------------ .. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been.is�sued by the board of health. Signed �- . --------------------------------------- •--••------• ..... rDate ApplicationApproved By-----------`-------------------------------------------------------------------------------------- --------------------- ----------------- Date Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......J.. ..OF........ .............................................................. TI.rrtifirate of f1.1kompliatta THIS IS TO CERTIFY, Tha�� e .Ind'vtdu�.,Sewage Disposal System constructed ( ) or Repaired ( ) � J r Installer at......................................... ----------------------- ------ has been installed in accordance with the provisions of Article NI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.----_�`_--�- �____________________ dated__.-__l.::..:_-_-_-____.--.---_--____---__-••- THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ''z 7 Inspector C 1-------------------•---•------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �r ......................OF J E.....:.� .... No......'/ ' ----- FEE------ --------------- Binpoottl ork,o ClIougtrurtio$t rrmft Permission is hereby granted________ _ _ "-:_L.----------- / to Construct ( �) or Repair ( ) an Individual Sewage Disposal System atNo. = ----------- ................................................-------.....------ ----------------- Il- ' Street as shown on the application for Disposal Works Construction Permit No..?................ Dated---- ----------------/._........ ..........................................-............................................................ _ Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS /0 5' I i ! 0 �7 �--i-. oP 53 0 O �!N \ rp•�lu�f \ O -/Ile- coy 07 CRAIG �'yG �x��r1 S/O RAYMOND o SHORT No. 27483 el E`cc,OHAI ENS' /z-5 v o C E R T I FIE D PLOT P L A N L O C A T 1 0 N= /1 j►�q es 7O,c%S /YJ/GG S. /1JA.SS . ,olj oF�oS E v .9'-o 0 l/v�- s,3o ' /d!/ 3, / 971c �)'/S7E^/cG .4 of Th//s OATC S C A L E DATE_ REFERENCE: .Cj T Z7 oc?S -SNaw'� a,� ,� .��.r '�y/�►.i0`4--A,e45)- .4'o `/�G ,E�co2n� t� /qT B.n,2✓sr-�vC3�C ,eE�/ST,e� �✓ 4 O EGGS /A./ ,UL�q ✓/��k- Z ,o�G 0 A T E I HEREBY CERTIFY THAT THE BUILDING R G. LAND SURV OR SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT -CONFORM TO THE o c ���t� �ssy�y ZONING AY - LAWS OF THE TOWN OF �IgQNS'TAt3�-� INH E N C 0 N S T R U C T E 0 . JOSEPH M. G� MONAHAN,.JR. H 13660 Q S ASSOCIATES, INC . ��CISTV- REGISTERED ENGIISEERS Q LAND SURVEYORS CIp,® §u�v�,'� MID -CAPE OFFICE BUILDING - 1 265 ROUTE 28 (` 76-/o SOUTH YARM O UTH, MASS. 02664 i 6 IE TnT � ,Xoo � _ r m .. .:.:. ...- ._ 070 T 7-01,• - N N N � mD > D 79 � N o � o Em r v � - _ z z a 71 A O 70 ":FF n 0 !j N e Z fi N t a T1 N 73 O O D � z - x � - m cn El z E� G N 3 Nil D m> O Z r i o o N z m � THE 1�1E1L�C�l[d[l(�'l[' 1[�]E�1[1D>]E1��lE FIRST FLOOR PLAN REVISIONS: 3s�_ a 111TON ROTUR)6 0500 ITE3 f: 3 onm rcigL wJnuaril� DATE: 03/15/2019 � t 31G Captain Backer head[. 5GALE:1M'=1'o° is z[ (����u 1�iC�G��C—,G����,pC�G�'��[�`i�f c :FM- z m o - D p Z m �a m.a D m o � D m m D i . Enu�p1 lJ� •• _ I I I U3 x o 0 o -° 'I z ' aw m N. O I � � I I ZO m = 1 Z m Q m o ' o I � _ I . I - M Wp • r O O 7U P � r Z - - D O A Z THE lD�]E1L�C�O�I[][l[�'][' RESIDENCE SECOND FLOOR PLAN REVISIONS: _ u�ILT0V-�0 UAH ,`a5-SD���aTE3 N sirz DATE: 03/15/2019 �3* PS WHINIERO801L EMU 36) Captain Baker RcC](. 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