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1325 OLD POST ROAD (CT & MM) - Health
1325 Old Post '%p,4 D A= 057-031 Lot 14W12�t�v�S � r ' Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Paul Higgins Property Address 1325 Old Post Road s; Owner Owner's Name informaticn is 5 r7 required fir every Mares IsOF Ma 02648 11-2-15 _ page. City/Town State Zip Code Date of Inspection =Pz. nn Inspection results must be submitted on this form. Inspection forms may not be altered in any rz, way. Please see completeness checklist at the end of the form. Important:When A. General Information / r filling out forms Sl 2l�8 on the computer, use only the tab 1. Inspector: key to mare your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation VQ Company Name 14 Teaberry Lane AA Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113747 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 CM 15.000).The.system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs F rther Evaluati by the Local Approving Authority > 11-2-15 Inspector'U31briature 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 17 I Commonwealth of Massachusetts . Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 page. CitylTown 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �N Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (coat.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 l Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 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 supp Y. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal . coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments �M Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® 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 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ 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? i ® ❑ 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 li Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal ruse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d see below 9 ( Y 9 (gP ))� Detail: 2013-60,000gallons 2014-46,000gallons 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 ElNo Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is Marstons Mills Ma 02648 11-2-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: pumper driver Was system pumped as part.of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? tank size Reason for pumping: Maintenance after inspection 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): Disposal stem•Page 8 of 17 t5ins-3/13 Title 5 Official Inspection Form:Subsurface SewageD p Sy g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 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: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26"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): 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 Dimensions: 1500 gallon 8„ Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" 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.): At time of inspection septic tank appeared to be in working order with liquid level equal with outlet invert. Tank was pumped after inspection for maintenance. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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•3/13 Title 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 ,M Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 page. CitylTown 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.): At time of inspection D-box is in working order with no sign of back up or carry over. 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4 Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is Marstons Mills Ma 02648 11-2-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (3) 500gallon chambers ❑ 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.): At time of inspection leaching appears to be in working order with no sign of hydraulic failure. Chambers had 4" of standing water at time of inspection. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 page. CityTTown 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 M Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 page. CityTTown 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: ® hands-sketch in the area below ❑ drawing attached separately C NMI- 6 A 3 O O O O O bt - 32' C3 - 1-7, RZ- -Lz a2 �s' car- 2� a3- to (�4- Zs' t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Paul Higgins Property Address 1325 Old Post Road Owner" Owner's Name information is required for every Marstons Mills Ma 02648 11-2-15 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: No Gw 144" 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: Aug-17-96 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Plan on file with BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Paul Higgins Property Address 1325 Old Post Road Owner Owner's Name information is Marstons Mills Ma 02648 11-2-15 required for every page. CitylTown 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 I t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r TOWN OF BARNSTABLE ✓ LOCATION / Z �rjxp /u51�- Z&yr SEWAGE # 0L7 7 VILLAGE 40� �,4&, ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY / .S7 G D y / X LEACHING FACILITY: (type)rAn�-,,licit (size) /� 7G NO.OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist - / within 300 feet of le ching fa ' 'ty) �YU�� Feet Furnished by /- / �— �� �/ 1 � �� �,� 2�' �1 ` p rF�.. s .iY � 4� No. r z Fee Ay- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ftprication for Migooal bpotem Construction Verna Application is he y pr�Pg, o ions t Q()or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. 4} �•"/n Owner's Name,Address and Tel.No. gP /64leK L'zl2s Ca A<,sessor's Map/Parcel All, 5 7 A 3/ Z 76 awmax1rf>idh's 141Vi 94/w sS Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. <,/�2 �.77/ O JJ J Sys" W1 .rrv7rxjV e75"7$V Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 33 0 gallons. Plan Date Number f sheets Revision Date Title Description of Soil r h V Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Dated Application Disapproved for the following reasons Permit No. � Date IssuedQ'r 5 `��{, ��yc.'�"^..®�. -, ,� ..� Sys .. -. ..i '_ .. � y-r r _ _!,. � .'x - «. �F4•. .-..! .. No. Fee��T> k THE COMMONWEALTH OF MASSACHUSETTS t� .,. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS 0(pprica�tion for �Digoogal *pgtem Construction Permit Application is e y ad�for P o - n t OO or Repair( )an On-site Sewage Disposal System at: ., ° Location Address or Lot No./d y- /I f 6 _J) y014 `'�"' ,Q,O� Owner's Name,Address and Tel.No. 4 z b I T ;'.1J/�/,if�S J Assessor's Map/Parcel � Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �'33-¢77s y �r S9s W�F�a.�noy7-y d2.S7��� Type of Building: r ` Dwelling No.of Bedrooms ._ .3 Garbage Grinder( ) . Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 4601?06W gallons per day. Calculated daily flow 530 gallons. Plan Date A' /7 VZ Numberpf sheets Revision Date Title Pl/tom ae /r//Gre(_14AT d1.:!)G�, CO Description of Soil D o` /4 54wh v L6mv 2.5'Y 41 Jr Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate''of Compliance has been issued by this Board of Health. tp. Signed Date A plication Approved by Date '" 6O Application Disapproved for the following reasons y Permit No. Le'_ Date Issued THE COMMONWEALTH OF MASSACHUSETTS * BARNSTABLE, MASSACHUSETTS Certificate of Compliance, THIS I,S'YO CE ' at the On-site Sewage Disposal System installed(f// )or repaired/replaced( )on by lL` � r� Installer at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Constru—Permit No. - dated Date Z�� �... Q/ Inspect THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTE r'FHAT THE SYS- TEM WILL FUNCTION SATISFACTORY. -- --- --------------------------- No. Fee r v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpogal *p! tem Congtruction Permit Permission is hereby granted to to construct( repatr( )an On-site Sewage ystem located at No.# .? 01 It Street and as described in the above Application for Disposal System Construction Permit. r "' G 9 No. Date The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed with/in three years of the date below. Date: r' Approved Board of Health AsBuilt Page 1 of 1 'LOCATION /3 Z r✓1/r0 /u�,I"- Z�Z SEWAGE#i VILLAGE YZ ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. 4/ SEPTIC TANK CAPAC= /SU LEACHING FACIT.rI Y:(type) (size) fp X ?G NO.OF BEDROOMS 3 BUILDER OR OWNER /le/r'c �v�a PERMrrDATE: COMPLIANCE DATE:, Separation Distance Between the: f Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Ira Feet Private Water Supply Well and Leaching Facility (If any wells exist j� on site or within 200 feet of leaching facility) - 46,,+' Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le ping fa ''ty) .N/U,4oe Feet Furnished by h tp://issgl2/intranet/propdata/prebuilt.aspx?mappar=057031&seq=1 3/23/2018 i SOIL EVALUATOR& PERCOLATION TEST FORMS �tHt t� Town of Barnstable Page 1 of 4 BARNSMABt.E. Department of Health, Safety, and Environmental Services y MASS. 019• ,e Public Health Division AtfD MAC A 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 FAX: 508-775-3344 Soil Sul lahlll Assessment-for Sewn e Dls �osal ASSESSORS MAP Na PARcallo: �/ NO. ` �_� � Date: Performed By: � Q _ Date• Witnessed By: /7)tj &OGGOA�o Location ress C) Gj Owner's Name , p CML", Lot#: / L/ Address,and e/A/Q L7t-ix (s Assessor's Map/Parcel: Telephone# Yfi NEW CONSTRUCTION (� REPAIR Office Review Published Soil Survey Available: No Yes nit �G ON 7 Year Published --=1 Publication Scale / Soil map u l� rlh'i°�2 Drainage Class 1,4xvC—/L Soil Limitations '�Y Surficial Geological Report Available: No V/ Yes Year Published Publication Scale Geologic Material(Map Unit) 1i-tZe Landform Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No Yes Within 100 year flood boundary No _Z Yes Wetland Area: National Wetland Inventory Map(map unit) AM Wetlands Conservancy Program Map(map unit) 1114 Current Water Resource Conditions(USGS): Month Range: Above Normal Normal Below Normal Other References Reviewed: DEP APPROVED FORM- 12/07/95 FORM I1 - SOIL EVALUATOR FORM Page 2 of 4 Location Address or Lot 140• 10 On-site Review Date:. Deep Hole Number ?i g-/S-f G Time: 12%30© Weather C�12, w/9�i Location (identify on site plan) Slope l%) Surface Stones OI/ONLG Land Use juSTED' view- 7 Vegetation Landformthe back) s Position on landscape (sketch on Distances from: �jp feet Drainage way /V/A feet Open Water Body Property Line feet Possible Wet Area 1206 feet � ... ..:...: .:. : Drinking Water Well W� eet other DEEP OBSERVATION HOLE LOGS �. VA T 2 i� r or Soil Other Depth from Soil Horizon ;,u ext re Munsesoil lill Mottling (Structure,Stones,G avellrs, Consistency. °� Surface(Inches) 6 '/d " L.dAMy pyR/0 4611 -14+11 2150f Depthtogedrock: N� Parent Material(geologic) Weeping from fit Face: Death to Groundwater: Standing Water in the Hole: EAtimated Seasonal High Ground Water: DEP APPROVED FORM-12/0719S Nd, Lo 7- IDS pL U ,oasT ��d FORM 12 - PERCOLATION TEST Page 4 of 4 1 Location Address or Lot No. COMMONWEALTH OF MASSACHUSETTS Massachusetts Percolation Test* Date: .. 8 "/'� - � Time:, / D Observation dole # Depth of Perc Start Pre-soak End Pre-soak Jf,� - 10 Time at 12" e.A'-V£-z To Time at 9" Time at 6" jv / To dnvT�li� /� Time (9"-6") Rate Min./Inch Minimum of i percolation test must be performed in both the primary area AND reserve area. Site Passed [3/ Site Failed ❑ Performed By: - Witnessed By: /7l'2� 2/Zy — Comments: :..:::..-.............. �H:.._.....�., .::.:..... ...._...:.�M-. .� w:.-.-..:._.._. ....,... DEP APPROVED FORM•12/07/95 DORM 11 - SO1l, )✓VALUATOR NORM Page 3 of 4 Location Address or Lot No. w/ IVO, 14 44,0 AA57- 124,-M Determination for Seasonal High Water. Table Method Used: ❑ Depth observed standing in observation hole inches ❑ Depth weeping from side of observation hole... inches r❑ Depth to soil mottles inches U Ground water adjustment .................. feet Index Well Number ... .......... Reading Date ........... .... Index well level . Adjustment factor ... Adjusted ground water level .... _.. L�5;r11#1JZ� Se45")Ot- !- // �T EGA 1/O fT U GO/L`" /�✓ X � `/ll/C' �%S, 1 , / . De th of Naturally Occurrin4 Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? Certification I certify that on �O �� (date) I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. 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