Loading...
HomeMy WebLinkAbout0478 FLINT STREET - Health r 478 '-int Street Marstons Mills A= 101,022 i -not'Marstons M C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewa ge Disposal System Form -Not for Voluntary Assessments 478 Flint St. Marston Mills, MA 15 Property Address — Ashley Webber W Owner Owners Name information is required for every Marston Mills ✓ MA 02648 page. City/Town 1-23-17 j State Zip Code Date of Inspection W .i Inspection results must be submitted on this form. Inspection forms may not be altered in any .A 07 way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms # ' oZ 1 on the computer, D use only the tab 1. Inspector: key to move your cursor-do not Darrell Stone use the return key. Name of Inspector Cape Cod Septic Inspection r6 Company Name P.O. Box 1466 Company Address Harwich MA 02645 6- own 508-240-2500 State Zip Code Telephone Number SI4995License 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: ® Pas es Conditionally Pas ❑ Fails ❑ N ds u her Ev luation by oc proving Authority 1-27-17 Inspe tors 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. t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1 i �0 �(s Commonwealth of Massachusetts = Title 5 Official ns ect�on v � p Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner Owner's Name information is .required for every Marston Mills MA 02648 1-23-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below_ Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-3/13 True 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 2 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.4 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner informationi is owner's Name required for every Marston Mills MA 02648 1-23-17 page. City,- own 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 Eva luation 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. I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form I` Subsurface Sewage Disposal System Form-Not for Voluntary ° tary Assessments 478 Flint St. Mar- ston Mills MA Property Address Ashley Webber Owner Owners Name information is required for every Marston Mills MA 02648 1-23-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate ate nitrogen 1s equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 III Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal g p I System Form Not for Voluntary Assessments 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner Owner's Name information is required for every Marston Mills MA 02648 1-23-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection . Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner Owner's Name information is required for every Marston Mills MA 02648 1-23-17 page. Cltyrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ` ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)1 D. System Information Residential Flow Conditions: Number of bedrooms(design)* n/a 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner Owner's Name information is required for every Marston Mills MA 02648 1-23-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: 3 bedroom residential dwelling Number of current residents: 3 Does residence have a garbage grinder? . ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information'in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft_, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 478 Flint St. Marston Mills, MA 7Ai sye` Property Address Ashley Webber Owner Owners Name information is required for every Marston Mills MA 02648 1-23-17 page. cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Unknown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner Owners Name information is required for every Marston Mills MA 02648 page. 1-23-17 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: Pit P2 1993, unknown tank and pit P1 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 10"+/- 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.): Apparent good condition Septic Tank(locate on site plan): Depth below grade: 4" feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallon . Sludge depth: 7'1 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form - W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 478 Flint St_ Marston Mills, MA Property Address Ashley Webber Owner Owner's Name information is Marston Mills required for every MA 02648 1-23-17 page. Clty/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 25" Scum thickness 1/2" 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 16" How were dimensions determined? Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Normal liquid level No sign of leakage Sch 40 outlet tee Recommended next maintenance pumping within 1.5 year Recommended maintenance pumping every 2-3 years Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner Owner's Name information is required for every Marston Mills MA 02648 1-23-17 page. City/Town State ZipCode 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of:onstruction: ❑concrete ❑ metal ❑fiberglass 9 El polyethylene El 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•3n 3 Tide 5 Official inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner Owner's Name information is Marston Mills required for every MA 02648 1-23-17 page. Cityrrown State Zip Code Date of Inspection D. system Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): Grade to box 17" OK condition 2 outlets Normal liquid level No sign of leakage No scum No sign of failure 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form;Not for Voluntary Assessments 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner Owner's Name information is required for every Marston Mills MA 02648 page. City/Town 1-23-17 State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ 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.): 2 (6x6') pits with stone P1 Grade to pit 25" Bottom 112" The pit contains 52"of standing water P2 Grade to pit 42" Bottom 112" Cover 5" The pit contains 6"of standing water No sign 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 t5ins•3113 Title 5 Official Inspection forth: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 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner Owner's Name information is req u ired for every Marston Mills MA 02648 1-23-17 page. Citylrown 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.): 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.): t5ins-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 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner Owner's Name information is required for every Marston Mills MA 02648 1-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 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 I � f I I P Z a �Z A B 2(-i U_C 2 3 33 --Y 3p .2 4 3 Z-1 U" 2 t- Z 6 � t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Comm onwealth th of Massachusetts Title 5 Official Inspection Form rn Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner Owner's Name information is required for every Marston Mills MA 02648 1-23-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cone.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >4 feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Plan on file ❑ Checked with local excavators, installers-(attach documentation ® Accessed USGS database-explain: See below You must describe how you established the high ground water elevation: Approximate elevations from USGS maps Property ELV. 85.0 Bottom of SAS ELV. 75.67 GW ELV. 46.0 Adjustment 6.1' SDW-253 Zone B 51.87' December 2016 Separation >4' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments syey',. 478 Flint St. Marston Mills, MA Property Address Ashley Webber Owner information is Owner's Name required for every Marston crownMarston Mills MA 02648 1-23-17 page. C 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 AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION -97�— SEWAGE 9-:7- :POW VILLAGE 44 oW/eej ASSESSOR'S MAP & LOT10/- INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) p/`J ( J (size) ` (/ /d NO:OF BEDROOMS PRIVATE WELL OR '�LiE-WATER BUILDER DATE PERMIT ISSUED: Cp p DATE COMPLIANCE ISSUED' VARIANCE GRANTED: Yes http://issgl2/intranet/propdata/prebuilt.aspx?mappar=101022&seq=1 1/23/2017 QQ TOWN OF BARNSTABLE LOCATION �O CU.1 # c, "VILLAGE jAA, t`��S ASSESSOR'S MAP&PARCEL Il4=X=W'S NAME&PHONE NO`. CA_L_Gdo vt u�t[I 4-08"1-119 n I SEPTIC TANK CAPACITY 'Ji0o LEACHING FACILITY:(type)C_�>i' (size) (�1,(D NO.OF BEDROOMS OWNER OP-�LU4 PERMIT DATE: C0ft==t=E DATE:a,+SP 111� 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 EtA v Front •. \ h h h h h h h h h h h h h h 4 ♦ h h ♦ h r f f f r ! r f f f 4 4 4 4 \ \ \ \ \ ♦ \.\ 4 \ 4 4 4 4 h \ \ f f f f i f f i f f i / J ! / f f f f f \ \ \ \ \ ♦ \ \ \ ♦ ♦ 4 4 4 4 h ♦ \ \ ♦ 4 ! ! ! ! f f f f f f f a f f ! ! f f f f \ 4 h \ ♦ \ \ \ 4 ♦ ♦ \ \ \ \ \ \ h \ k \ - -i ! ! f ! f f ! ! f ! f f f ! J r f f r 3 2 33 33 . 31 29 41 41 >c l Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is Marstons Mills MA 02648 November 4, 2010 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co Company Name 189 Cammett Road Company Address Marstons Mills MA 02648 ,enn, Cityrrown State Zip Code 508.428.1779 SI 12855 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 November 4, 2010 Job# 10-271 Mpector'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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2010 every page. Cityfrown 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: Tank is not in need of pumping at this time, overflow pit had no standing water 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•09108 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 M r 478 Flint Street Property Address Scott Oakley - Owner Owner's Name information is Marstons Mills MA 02648 November 4, 2010 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ 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 l5ins•09108 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments y 478 Flint Street Property Address Scott Oakley - Owner Owner's Name information is Marstons Mills MA 02648 November 4, 2010 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than _day flow t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is Marstons Mills MA 02648 November 4, 2010 required for every page. City(rown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "< 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2010 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is Marstons Mills MA 02648 November 4, 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No September 2010 Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M rf 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Tank pumped every 2-3 years. 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ..'( 478 Flint Street Property Address _Scott Oakley Owner Owner's Name information is Marstons Mills MA 02648 November 4, 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Overflow pit installed in 1993 remainder of system was installed when house was built. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 1' Depth below grade: 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.): Septic Tank(locate on site plan): 6" Depth below grade: 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 8.5' long x 5.2'wide- 1000 gal. Dimensions: 3" Sludge depth: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2010 every page. Cityfrown 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 27" Scum thickness 3" 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 11" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, tees were intact and clear. i plan):Grease Trap(locate on site p a ): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2010 every page. Cityfrown 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is Marstons Mills MA 02648 November 4, 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments yr. 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two 6x6 pits. ❑ leaching chambers number: ❑ 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.): Overflow pit was empty at time of inspection with a stain line 8-10"from bottom of pit. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 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 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is Marstons Mills MA 02648 November 4, 2010 required for every page. CityfTown 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.): 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.): 15ins•09/08 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 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is Marstons Mills MA 02648 November 4, 2010 required for -- -- — every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately Front -�-7-7-f7-T- / / / ! / \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ 3 2 33 33 31 29 41 41 New Old I' f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is Marstons Mills MA 02648 November 4, 2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 20+ Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USGS topo map and town GIS You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 40 and topo map shows property at el. 70. Inspection Report, lease see Report Completeness Checklist on next page. Before filing this Insp p , p p t5ins•09106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 478 Flint Street Property Address Scott Oakley Owner Owner's Name information is required for Marstons Mills MA 02648 November 4, 2010 every page. Cityrrown 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION SEWAGE # VILLr.GE 44 /'1/l/GL1 ASSESSOR'S MAP & LOT�O/- INSTALLER'S NAME & PHONE NO. �� f SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �1%- ( - (size) /6 NO. OF BEDROOMS PRIVATE WELL O IE-RATER BUILDER OR,0V-:� DATE PERMIT ISSUED: Z-0A DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes N NOR elG r r 1 yj No.. Finc THE COMMONWEALTH OF MASSACHUSETTS APPROVED BOARD OF HEALTH /d 0- a_- Barnstable Conservation Department TOWN OF BARNSTABLE sig �,� trtt�t>���nr �i►��ati��a� �urlt,� ��tgt���lYrftun rrmit Application is hereby made for a Permit to Construct ( ) or Repair P<� an Individual Sewage Disposal System at: --•----------�--�-�•��°� _ aL�S 'Location or Lot No. • -. . ---•------••-----------------•----•-•--.................---••--•---• •-•-•------......... .--- owner, Address --•-•---•-•---- .......----•-------•Installer Address UType of Building Size Lot............................Sq. feet t-, Dwelling— No. of Bedrooms................ ....._.--.......Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons-------------.--.----------- Showers ( ) — Cafeteria ( ) dOther fixtures ----------------•••------ ----------------------_-----------------------------------............................................................... Dest n Flow....................: �.......... allons er erson per day. Total daily flow.............. ..._. W g g P P P Y Y �-----------------gallons. WSeptic Tank—Liquid capacity/W---gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench--No. .................... Width.................. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------e�---:-- Diameter....../0....... Depth below inlet.......Ca......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by..-- ----•------------••--•---•------...-•---•----••--•----••-••-••---••-• Date...........................••---..--•-- t-.1 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (i Test Pit No. 2................minutes per inch Depth of Test Pit..--.........---.... Depth to ground water........................ Ix --•--•--••...............•-••.----------••-•-•-•---------••--•.....-•-•.................._........-------••-••--•••---••-----•--....----.................... 0 Description of Soil........................................................................................................................................................................ W ---•• -•••.................•-----------•---•----•-••----••••--------•---.........-•------•-•••-•-••-----•--......................----•••----•-•...-•-•-•••-••-•---................•.... U Nature of Repairs or Alterations—Answer when applicable..............��........//1.'6V P -..lei - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha n ' sued y e bopnd of health. Signed ............... .............. .............. ... .................................... .... ..........�... Application Approved B ------�-- Dam Application Disapproved for the following reasons: ................................................................ .................................................................. ................................................................... �,/ Dare PermitNo. �j....-.... 'o..t5..................... Issued ......... ................................................... Dace _„ ..--... �_��. .�.. � •.ram....-.,,,,i� �P�� y .y.;.^�.av../',+ti.+�.. ,� �� s �"s..�' �..�. .. � .-�.•..lL L,r I ��s . .�, -• - ' v ... (jI�{. I 1,30 —' No... FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH A 6 TOWN OF BARNSTABLE Appliratiott for Diripooul Works Tonotrnrtion rrrntit Application is hereby made for a-Perm f Construct ( ) or Repair an Individual Sewage Disposal System at: Location—Anress j r� �/z JD�rGs cf;J or Lot o. ......................----••...............••--•......- `Y.i C=�._...... �-S7� -------------- ------------------------•-• ........... - , .....----- -•- o��ner / Address a .lam G..........1�.�%.. Gb�I Luc ... Los Cn1�-,IL�p ..._.. ........ 1'•-' i�rCS —� •. Installer / Address Type of Building �l Size Lot............................Sq. feet U Dwelling— No. of Bedrooms________________-- v --------------..-Expansion Attic ( ) Garbage Grinder ( ) WOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) aI Other fixtures ________________ ________________ _ -------------------- ------------------------------------*"•-----------.--------- W Design Flow........................ ..........gallons per person per day. Total daily flow_.___-_--__,_..................gallons. WSeptic Tank—Liquid capacity,/NP-...gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench--No. ........... .�..�Vb'idth.._..___�..._...... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........ :....._ Dtameter------ Depth below inlet_-_-__l.._.�..._.. Total leaching area..................sq. ft. Z Other Distribution box ( )!f Dosing tank ( ) aPercolation Test Results �� Performed by.......................................................................... Date........................................ Test Pit No. I..............minutes per inch Pepth of Test Pit.................... Depth to ground water........................ LZq Test Pit No. 2.................minutes per�nch,'`Depth of Test Pit.................... Depth to ground water........................ ................ •••••---•--••••--••••--••••••--••••••-••----•-••-••••--•---••---••••---•..........-•-•••---•......................................................... 0 Description of Soil........... ---...... ...... ........................•••---------------------------- V --------••..............•--................--•-•••-••-----•---•-••..............--•-...---•-••--••-•--•-••••.....----........ W V Nature of Repairs or Alterations Answer.when applicable--------------—A -......... ./.� - ..---...... Z�:.�J --------......---c�.- . _.. .!.,S_�_ �Ch.........= ..4f_. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the StatelEnvir`onmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued y t e b/oard of health. / C Signed ------------.-/��!.1. -N./----./...(.... ._. ........: Date Application Approved By .. ............. -p-............. ....... -.- ._.................. -------._.-.................... ........ .. ........................... Date Application Disapproved for the following reasons: .... ............................... ...... ........... . ........ --- ............-- -- --........ ......... ................................................................................. .........-.....----------..-------------------. . ........... ................:------.-.-._. ...... ............. . ...........-- Dm Permit No. .........C�._3....-..... -?.z................... Issued Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of (11IImpliance THIS IS TO CERTIFY, That the-Individual Sewage Disposal System constructed ( ) or Repaired (per) by ...................................................... Qi'.............Gl3 /........L LJ� ................ ��' Insraller at ......................................... �� ......�L=...... ........... ...........: has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..._... .. - dated J ..........................................._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUN lC�T16N SATISFACTORY. /� DATE...... _.. ( f /?. �. Inspector /! l� .//� Jl l Yl �f! I�:- �T _.' -------_--------- --•.--_----_-_-- ----_,-_.---------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / TOWN OF BARNSTABLE No... �j FEE..,-?6 — Rapnoul Worb Tonotrwtion f amit Permission is hereby granted...................... ......................lJ �--•.-----(-'.-"�`�� to Construct ( ) or Repair an Individual Sewage Disposal System at No. 4 z�1T- -�-----------'`-----°�'I LC= ............................. Street --��ff as shown on the application for Disposal Works Construction Permit No. 3rn)/ Dated........................................... ............................ �-=--�-•------------- ............................................. / f /l/ ( ................................. Board of Health DATE................... -----•---•---�-..t.. FORM 36308 HOBBS h WARREN.INC.,PUBLISHERS . LOCATION ��� SEWAGE PERMIT NO. . ,CST f=/,ur�� Fa -4�� V V L L A G E IIySTA LLEU'S NAME 8 ADDRESS BUILDER OR OW13ER DATE PERMIT ISSUED , DATE COMPLIANCE ISSUED r I �S 3�w�33-6 �,'� - a � 2E'ra,� ,� � � • �� No...8 9 _ Fmc....b?................... THE COMMONWEALTH OF MASSACHUSETTS -•�. BOAR® OF HEALTH ...............OF.........,,1' ��..-......... Z ....-........ 1 1 1iration for Disposal Work,i Toustrurtion Famit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: � 3 %/'t<� l- ...srJ%.'! //lam.!.!✓....r -.--- v .............. Location-Ad----"dress ,( . -------- r. �t_..v.es.. ....... Owne Address a ....................................... ••----------------..........................Address.-•••--•---•-.............................. .--... Instal r Type of Building = Size Lot............................Sq. feet Dwelling—No. of Bedrooms..........Z--........................Expansion Attic Garbage Grinder ( ) Other—T e of Building No. of persons....._�............... Showers / —,Cafeteria Other fixtures --------------------------------- W Design Flow............................................gallons per person per day. Total daily flow........:J�Z.®....................gallons. WSeptic Tank—Liquid*capacityJ0.139.gallons Length___Ca......... Width....... ....... Diameter________________ Depth................ x Disposal Trench—No.........�...... Width.................... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No......... #*"...... Diameter......46......... Depth below inlet....... ,........ Total leaching area__?4r,.4r,..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Resu is Performed by...... � /Pe��sN...... rx_ -------------- Date_...__.._ ..��CT Z Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------ ---------•-------------•--•--------------------------.........------------............................ ----- --.................... ••-- O Description of Soil........ -_C.'o......... -C'°`... 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 iITLL 5 of the State Sanitary Code—The undersigned fu-Ttl:er agrees not to place the system in operation until a Certificate of Compliance has been iss d by the board o health. Signed---- ------------ ------•- - • ---------•--------.----------•--- � � -�ate DAPPlication Approved By_____________4-- !... -- -- -----------•----------•------ �- t'e Application Disapproved for the following reasons-.........................------......---------------------------------------------------------•-----•---•-•---' ...............•-•-•••----....------......-----------------•---••--•-----------------------•----------...--------....-------•--------------------•-----------------------•---•-•----•---------------•--' Date PermitNo......................................................... Issued....................................................... Date i THE COMMONWEALTH OF MASSACHUSETTS ` J BOARD OF HEALTH .....................-- ..............OF..............................I............... e Appliration for Bftipog al Works Toat vurtioat ".egad# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .... ��...... ......... .�f �l/� ....... ..._� "____ -Address �� or�_. t�N'o. .............. ..+�G_.... l..l ge �....�.- aE ......... ".d.— ......... Owne Address a .. ......... ......... In Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms_........... .Expansion Attic (4—+-- Garbage Grinder ( ) Other—Type of Building No.., of persons......3................ Showers Cafeteria Q' Other fixtures -----•-----------------------------••....•--- - ----------------------------------•--------- W Design Flow............................................gallons per person per day. Total daily flow......... .3.4....................gallons. WSeptic Tank—Liquid capacityZ gallons Length.._. r...... Width....... Diameter________________ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......... Diameter.......6-------- Depth below inlet................ Total leaching area..-Z6_G__sq. ft. Z Other Distribution box ( ) Dosing tank ( ) f• Percolation Test Results Performed b ��. ..�...._�' . .._-.-P.. -.-._- Date........ Test Pit No. 1�r/.� nutes per inch epth of Test .................. ground Depth to wate��. �.] � 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ .,.. DDescription of Soil........ --------- — '` •-----•--"'---------------------------•----------------------•-•--------•---•-------------..........---- I x V .....---•--•---•-----•------•-•-••......................•--••-••....._..-•--------------.......--•-------...-•--••---•-•-----••-------••---•••--••------------.....-•------.......-•--------.._._._.._... VNature of Repairs or Alterations—Answer when applicable............................................................................................... -------•--------------------•----------------------------------------------......._...-•--------------••-----••-•-•••-----•-•-It.......................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issue y the board of health. Signed. 1 ... � ,ems y Date Application Approved BY _.... ���r Date ------------------------ --•-------•--- Application Disapproved for the following reasons--------------------=------------------------•----------------------.......-----•----------------------•--••----- .........---•----•-•---•------•••----•---••--•---•-•----••-•••-•--••••----------•--•-•-------••-••-•---•.._..._..-••-••--•-•-----••-------•--•--•----••-•-•-----••--------•---•=---------•--•------------ Date PermitNo......................................................... Issued...................Da ................................ THE Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F..................................................................................... Trrtifiratr of TootpliFattrr THIS IS TO CERTI .Th Individual Sewage Disposal System constructed ( ) or Repaired ( ) by ------- -- -----------------------------------�..-_-----.------------------------------....-----------------------.----- Installer has been installed in accordance with the provisions of TITLE 5 f Th State Sanitary Code as described in the application for Disposal Works Construction Permit No.__._8�.`. ..._.._. dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE..................................................... .11..--...... Inspector..................i;:Z--/Af---2........................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - .....................................OF..................................................................................... No...... �7'.�I FEE.....•-----•--••-•-•--- Disposal rks VUumtrWivit Virrmit Permission is hereby granted z = -------------------•-•-------------•--•-----------.................................... to Construct f or Repair an Individual Sewn iosal Sy stem ystem � --. ( . P J Street as shown on the application for Disposal Works Construction Permit No...................../Daat�d------------------------------------------ f ..... f ' ------------------------ DATE. f g Board of Health ' FORM 1255 HOBBS & WARREN. INC., PUBLISHERS •e .:,i � • r tl .. q F � � ���� , agu.rm...aa +a t� y Y- ft OF Ilk l GN plr. 22r1•a0 SEP77C 774NK:• j 0 3 i Y M ?2, l_ SY . �1 O E-"L.0 /L7 2� Y 4 ;rrt I .• rt ,� ��g� L.�i N G� - /\ � • - ' r Opp! 'a : �`3LF6 a 47 ' f. Hof- pGbA WA•r �IN� �. x.o. FR k /3 [^ Via,« 4 ; LEGEND oF. CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION CaO EXISTIN® CONTOUR -® 0 — AL Lo.T FIN13HE0 SPOT ELEVATION m A 570I ; M < c LS FINISHED CONTOUR 0--- �RSE , No.10951 4 Q APPROVED , BOARD OF HEA-LTH Pp�FSGis7EPa�t'�'� � � S/ONA1.� x, . Z- GATE AGENT SCAt.E�"/ "- .40 /DATE, 7/ 3v � L®REW ENQINEERIN3 CGt jy i cl uc�A . CLIl�T,'` ,,,,. I C,ERTLFY THAT THE PROPOSED EGISTERE REGISTMCD , OD �0S' BUILDING', SHOWN ON THIS PLAN CIVIL LAND -t`t ;AONFORMS TO THE ZONING LA - E I DR.61Y� ,QP OARNSTAS E, I,11�lSS. 712 MAI N STREET CH. E►Y� NYANN141, MASS: "` SHE T < OF ',� Al1 (RO. LAND SURVEYOR :;:w�o�'+L*"L•+M1h•1 Wwi.Ya':.1=.:NtY....'AL1S..a .L.iw.c r t .wv. .._ .. -- .. _ .... ._. ... .. _.. /MOTE /F E/TNER T.NE SFPT/C TAN/C OR f` 20 FT.. M1/1! E�4G/•//NG P/T ARE MORE 7Ai l,`/ /2"SE40!•V /0 FT::/NON rRAOE�,4 2p IO/AM E.TE ' G'0/yC'RETE COVER SHALL BE B/?Ouayr To G-TA OE.��+N EXT.?A ` CONCRETl' 4 rPYC P/PE �y E,g V y CA S T /APON C o YG-R Sh�.4 L.L DE U S ED M/N. PITCH /F//V DR/VEN/A Y I/. /D Z-,a COVERS /B i�FiQ FT 2 . MiN. CO/VCRE"TE A :za *4140ff COVER CLEAN SAN L7 LJQ[J/D LEVEL - t 4`' 4•t�sT - LAYER /RON P/PE 0 l?f� G/I L • • a o ��'Q o or //8- MIN. ' do • • • • • • • •• WA 5HEO STONE D/ST., lp o jor - � • t FECT/VG' � �� '3 ;x _ ` w v , ',a.. 1 •- • • . � O O I ..i C ��i` 1V.43'.�iEO STa s o is• p f /"88 X =2 � c �7� �•• t � 1 O • • • • Op p r 78,. ► a. t • e • • • • / D .�p. PRECAST SEEPAGE lNIi�RT L"LEY�IT/ONs � • � E��V 92 .S, `!/VyERT.Ar ASU/LD/NC, q9.5 FT, M . T�4/VK ` 3 FT o FT. O/A1►� C SEE TABULATION, `INLET ;SEPT/C _ v OU7LET`SEOTICTAN/4:: 'q�t. .1 q. GROvNO NITER A®LE /AILET O/ST�IBj/Ti®N BOX- 9 6 . F7. ;S'EG rION oF'. T 98;•77 FT SE. AGE GlSP Y. ASA 1. SST4CM INCET LL�ACN//VG P'/T TA46ULATION L EACH/NG P/T 2 5 FT A SCALE /4 DIES/GJV CR!?ER/A D!.►f Fxs!o/v 8 FT N[/MdER OF BEORQOMS 3 D/MENS/CN C FT. M iN GAR®AGEDlSPOSAL-VA//T SOIL. LOG SO/1- TE5T TOTAL ESTfAlXrED FLON/ 330 GAL./DAY SOI L. TEST At'/ $O/L 77EST*2 98B 99, 2 6 1 fuMBE/?&C L�AC.V/NG R/TS f.F[EK. jf"ELAWA4 PATE OF .SOIL TEST S/OF 4eACH/NG PER P/T /R& _Slit PT. —� RESULTS iV/TNESSED BOTTOM/.F74CK/NG PER P/T 78 SQ..FT. O— 3 © — 3 y PtRCOLA-r/O D N ATE l Lp,4yt t� LOt�-/�j �k•_ � L�� MINIINGhf TbTAL LEACH/NG AREA►. 7'66 SQ. FT. Ti�r's ort T,'P'T PERCOL4T/DN RATE A '° MJN.�INCH t RESER{�E LM4CN//VCr AREA Z�'b 54 FT. ZHOF OFA%S S77 NAL E t -/z,4✓CG c`, +�f?vL L /'�'.�` ' c Cr/�;`r 0 8 coo RSE ti ' 874 p No.10951�O `o vo FQ/ � 0� o9p�FG/STE�V���' r r EL.0A EDGE hrWr EAR/NG.CO,/NC. ,yD V�y� Fss/ONALEa CL.— EL EL ? �. 7/2 MA/N S7, , AlYANN'S, MASS, sup ya GROc//VO yVAr2`R E/vCOUNTfREo el-Mc"T;IvfCKUL A S DRTE : 7 3 [� GR0UND yv<1TER AT ELEi/ — JOB /VO: Z '