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HomeMy WebLinkAbout0079 RHODY CIRCLE - Health 79 Rhody Circle Marstons Mills± \ A = 126 - 078 No. 2a V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for disposal *pstPm ConstrUttion 3PPrmit Application for a Permit to Construct( ) Repair 44 Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. h Owner's Name,Address,and Tel.No.An Assessor's Map/Parcel /A(y O S & - OW �D� , Aq A 0oX"y8 Installe;'s, ame,Address,a Tel.No.�,5-6g �_ 9 Designer's Namr�,and Tel.No. IVA 0A on ky Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) { gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Rep.'rs or Alterations(Answer when applicable) x 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 a and not to place the system in operation until a Certificate of Compliance has been issued by this Board�He . k Sign Date 1J101 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. 2 -'a J 0 Date Issued a ( 7 m? 2 o Zz �,g N -7o. � V � Fee r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair o Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. 0 9 � t��1-C Owner's Name,Address,and Tel.No.��ne L11 Assessor's Map/Parcel/.2 Instailler's Name,Address,and Tel.No. ,5 Alf• t/SQ _ � Designer's Name! ddress,and Tel No. dt tcci L a�`StYt �CJI I/ v r Type of Building: Dwelling No.of Bedrooms T +) Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ,* Design Flow(min.required) tJ gpd Design flow provided I1/ / gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil //��/ A ! Nature of Repairs or Alterations(Answer when applicable) TI.Pl -yl/lf_ . ./ /#", ",:7A /� :�'`/<,tr'- i X.,�fir3 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-C e and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health"'� /� Signed—✓�'/1 / �1p - ?1. Date �1', a Application Approved by �Y �i- �J P r�C.- Date h �•i�a t Application Disapproved by lJ Date for the following reasons Permit No. ✓ J Date Issued O /{ 7 j� 2 r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO�jCERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by l YJt� i��GL�t at�� ��f�a _.(� �1 1C+114�Cttt_naQ. 1y has been constructed in accordance with the provisions of Title 5 and the for Disposal System"Construction Permit No. 02�� (712dated /7J Installer i;", f ! ' ., - ... , . , ,,,G��,�c�_ ln')� �7,! Designer /��, ,r �X #bedrooms~ K 1 I it Approved design flow J�/�,lf 0, gpd Y f The issuance of this permit shall not be construed as a-guarantee that the system will function`as designed. - ` J �Date Inspector I No. ` .. �` Fee 1 ` THE COMMONWEALTH OF MASSACHUSETTS a PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS pof Misposal *pstem Construction Permit Permission is hereby granted to/Construct(/ ) Repair6O" (( Upgrade)( )) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio mustibe completed within three years of the date of this permit. Date ' ( � r Z Approved by ,1, !TOWN OF BARNSTABLE LOCPnON 79 ff/IOu�/G//C�� CcTS SEWAGE g � -��s VIU ACE ALIM 21//�5 ASSESSOR'S MAP d:LOT i 6610 T i INSTALLER'S NAME&PHONE NO. 77 g0!�D Lath/ CBebT. 77l-93iQ ---- SEPTIC TANK CAPACPPY /SOD - LEACHING FACILM:(type) (size) - NO.OFBEDROOMS—:a� - -- BUILDER OROWNER PERMITDATE: /�'ZZ COMPLIANCE DATE: Separation Distance Between the - Maximum Adjusted Gto®dwaterTableto the BottomofLeachingFacility Fed Private Water Supply Well and Leaching Facility-1f any wells exist on site or within 200 W of leaching facibri) - Edge of Wetland and Leaching Faciliry(If any welfands exist -- -within 300 feei of IeacAiag facility)---_ �. -- _ .— Feet - - Furnished by- - I i �e,.oF; iv -. ul 1.3 15,10:33p p.1 -079 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Cwvnees Name information is required for every Mafstons iir US MA 02648 7-11-15 page. City/Town state Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be�tesgd in any way. Please see completeness checklist at the end of the form. °i t�'� Important"When filling out forms A. General Information /_ `"��pinrrrurrrrrrr�� on the computer, p/f� l� use only the tab 1. Inspector: Of fl/ key to move your JAMES N' cursor-do not James D.Sears = ^`= use the return — 8 A R S1 Name of Inspector '•: key. CapewideEnterprises,LLC _ •.o o * _ Company Name 153 Commercial Street Irs iN`SpE0'1\ Company Address MAShpee MA 02649 Cltyrrown State Zip Code 508-477-8877 _ S1623 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 7-13-15 spector'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 flow the system win perform in the future under the same or different conditions of use. A I n 1-7 tSins•3113 Tdie 5 OfficW inspection Form:Subsurface Sewage Disposal Sys%m-Page 1 of 17 JSjl 13 15,10:34p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owner's Name information required for every Marstorrs Mills MA 02648 7-11-15 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary_Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal.Tank D Box and four chambers. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass_ Check the box for"yes", "no"or'not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old` or the septic tank (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins•3113 Title 5 OfieFal. hepetiion Form:Subvtuface Sewage Disposal System•Pape 2 of 17 Jpl 13 15,10:34p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owners Name information is Marstons Mills MA 02648 7-11-15 required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due n 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 ❑ Nb(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 Q 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 CNIR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Q 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 sail marsh tSins-3113 Tile S Offdal hspectian Form:Subsaface Sewage Disposal System-Pape 3 of 17 J1 l 13 15,10:34p p.4 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I p 79 Rhody Circle Property Address Gayle Shultz Owner Owner's Name information is Marstaris Mitts MA 02648 7-1 1-15 required for every page. city/Town state Zip Code Date of Inspection B. Certification (cunt.) 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 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 fora:. 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 asopeel is less than 6" below invert or available volume is less than '/day flow A Elic1111v--' t5ms-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of V J4a1 13 15,10:35p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owner's Name information is required for every Marston Milts MA 02648 7-11-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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. i ( ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. j ❑ ® 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 N 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 Tdle 5 Official Inspection Foam:Subauioao Sewage Disposal Sycem•Page 5 of 17 i l Jul 13 15-10:35p p,6 Commonwealth of Massachusetts Title 5 Official Inspection Form �- r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owner's Name information required for every Marston Milts MA 02648 7-11-15 page CityFrown 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? El ® 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 NIA) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? Z ❑ 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? ❑ 0 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)1310 CMR IS-302(5)) D. System Information Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t56ia•W3 Title 5 Official Inspection Form.Subsurface SawnpA Oiaposal System•Pape 6 of 17 Jul 13 15-10:35p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owner's Name information required for every Marstons Milts MA 02648 7-11-15 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal. tank D Box and four chambers. Number of current residents: 2 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 use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2013-152,000Gal g ( y g (gpd)) 2014-124,000GaI s Detail. Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commerciallindustrial Flow dondkions: 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=&13 - Title 5 Official Inspection Farm_Subsurface Sewage Disposal System-Page 7 of 17 a Ju11315,10:36p p.8 <C\ Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owners Name information is M MA 02648 arstvrts Mills required for every State Zip Code Date of Inspection page. CitylTown D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): I t General Information Pumping Records: 9-12/4-15 Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: r ® 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 [l Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t l [Sins•3113 T16o 5 Official Im pedaon Form:Subseaa;Sewage Disposal System•Page 0 Of 17 I Jul 13 1510:36p p,9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Rhody Circle ktzr'_; Property Address Gayle Shultz Owner Owner's Name information is required for every Varstons Md?s MA 02648 7-11-i5 page. city/Town State Zip Code Date of Inspection D. System information (cont.) Approximate age of all components,date installed (if known) and source of information: 1997- Permit # 97-255. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth belowgrade: 3 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.): Pipeing is 4" PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 27 p 9 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 Gal.Precast H-10 Sludge depth: t5ins-3/13 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Jul 13 15.10:36p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Rhody Circle k7ow, Property Address Gayle Shultz _ Owner Owner's Name information is required for every mc-u-stans Mills MA 02648 7-11-15 page. Cityffown 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 29,E Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 1711 - How were dimensions determined? Astwilt-Tape 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_): Tank at working level.Tank and outlet cover at 27" below grade w/ inlet cover at 10". In and outlet tees_ No sign of leakage or over loading. 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: flake t51n3.3113 TrNe 6 Official htspedion Form:Subsurface Sewage Disposal System Page 10 of 17 Jul 13 15,10:37p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owner's Name information is fiRarstons Mills MA 02648 7-11-15 required for every 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.): i 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 15ins•3113 Title 5 Official Inspection Fenn:SuLsurfam Sewage Disposal System•Page 11 of 17 Jul 13 15,10:37p p.12 CommonweaFth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owner's Name information is, required for every Marstans Mills MA 02648 7-14-15 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 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.): D Box is IV xlU'-3V'below grade wlone line out. Box is clean and solid. No sign of over loading or solid 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: 15ins•3113 Me 5 Official Inspection Form:subsurface Sewage Disposal System•Page 12 of 17 Jol 13 15'10:37p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owner's Name information is required for every Marstens Mills MA 02648 7-4?-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativeialternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is four plastic chambers. Ck D Box and camera out to camberas. No sign of over loading. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No 15ins•3/13 Title 5 OTicial Inspection Form:Subsurface Sewage Disposal System•Page 13 or 17 Jul 13 1910:38p p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owners Name information is required for every Marston Mills MA 02648 7-1 t-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 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-3113 Title 5 Official Inspection For[Subsurface Sewage Disposer System-Page 14 of 17 .Jul 13 1510:38p p.15 Commonwealth of Massachusetts tipTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Rhody Circle Property Address -- Gayle Shultz Owner Owner's Name - require tifo is Marstons Mills MA 02648 7-11-15 required for every page. Cityrrown 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 feast 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 i tslns-31 M Title s offi6af,napxbort Form-Subsurface Sewage Orsposa15ys:em•Page 15 6 17 Jul 13 1510:38p p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owner's Name informatifor every on Is required Marstons Mift MA 02648 7-11-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells All, Estimated depth to high ground water: 4T 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: U.S.G.S. Well SDW 253 You must describe how you established the high ground water elevation: Bottom of chambers at 4'below grade. U.S.G.S.Well SDW253 @47' Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 .Jul 13 1510:39p p.17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Rhody Circle Property Address Gayle Shultz Owner Owner's Name information is required for every Mar-starts Mills MA 02648 7-11-15 page. Cityfrown 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•3113 Title 5 Otricial Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 Gl TOWN O BARNSTABLE � A LoE:t _'�Oid COJ� `7 3 ��7D G �G e SEWAGE# < Z •� YII.LAE /WlSAdeS ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS ff A, UILDE R OWNER L 1��os ATE: - -a1 -9 COMPLIANCE DATE: 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 Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by y ............. � 3s J TOWN OF/BARNSTABLE LOU 01 q �/®�l/ -Ilri`e Lo"�J SEWAGE# .> VILLAGE IV1t5"#,5 O�?/���5 ASSESSOR'S MAP&LOT A INSTALLER'S NAME&PHONE NO. Rkd iy Z u4t' G®XA,7- 7 7,/ne&,O SEPTIC TANK CAPACITY � c /J LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 7- COMPLIANCE DATE: 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 ®� 17 _� �` Z� Z TOWN O BARNSTABLE LOCATION �a1`5 3 ��c �C 42 E' SEWAGE# 2 VILLAG ASSESSOR'S MAP & LOT / 1- - d 7 y INSTALLER'S NAME&PHONE NO. ©r�O�JTf`/ LOti'� T SEPTIC TANK CAPACITY / D 0 LEACHING FACIL TY: (type) (size) NO.OF BEDROOMS UILDE R OWNER,_ L6•'�i�' ��rDS tE Ni ATE: S -;11 -I COMPLIANCE DATE: //-I La _C/�e 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 f Furnished by No. 9 7- n � � �� Fee �.v THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION'-TOWN OF BARNSTABLE, MASSACHUSETTS Application for M*05aY "tern Congtructiori permit Application is hereby made for a Permit to Construct( d or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. / ry L S3 12i�o� eu R z r-rc-"z,y asY�. , Line.? E. ! � a VA 17 1 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. STEPHEN J. DOYLE & ASSOC. 42 Canterbury Lane East Falmuth, MA 02536 Type of Building: Telephone: 5 0 8/54 0-2 534 Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3-3 gallons per day. Calculated daily flow -C-5�Do gallons. Plan Date ti -L` Number of sheets "7_ Revision Date Z ZZ- Title o- �&LLS i Description of Soil C r j- f�i� L o .S Ste; - t>E 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 ' ue b �this Board He th. Signed z Date Application Approved by 17 Application Disapproved for the following reasons Permit No. !n `J :� s- Date Issued 9 7 ` 100 , No. / f Fee . ! 9j � �, %THE COMMONWEALTH OF MASSACHUSETTS\ - PUBLIC HEALTH'.DIVISION TOWN OF BARNSTABLEi,MA'SSA, HUSETTS Iica�xt. f �i_"!g" p5tem Cou5tructio Cr it Application is hereby made for a Permit.to Construct( or Repair( )an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. f l..wc- S3 �b10►7�( �tL�..l�./ 'R.z F�c�z, tJsK1 t L'�oZ•wkYs� 'E., (, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ".'_.7A7J •,;� 9TEPI3EN J. DOYLE & ASSOC. �5 42 Canterbury Lane Falmouth,East MA 02536 Type of Building: ^r' one: 508/540-2534 Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow . 3 gallons per day. Calculated daily flow (SA 0 gallons. Plan Date MANJ Z.1 tR Number of sheets Revision Date —ZZ� Title or-- MLLS = 1 Description of Soil 5—C_�- �-f�t 1 vim` S}t�--�"_Z P R'— �I��, �ELJXhA 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 'ssue b this Boazd of Health. - Signed ZZ_:; Date -S " �)-2 Application Approved by i ` -5-- '2-2 ^ `j Application Disapproved for the following reasons Permit No. 9 �! � Date Issued -� .�— 9 THE COMMONWEALTH OF MASSACHUSETTS r PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( )on I y �17`dL� e'DyJS. for a 79 kA4A4w ,; has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. n7'7��SS dated _S"= �2-1 —r' 7. Use of this system is conditioned on compliance with the provisions set forth below: No. �"07`�> r: _ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwts po5al *pgtem Con5tructiou Permit Permission is hereby granted to Ao/- IL vS to construct(X)repair( )54n On-site Sewage System located at L and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within two years of the date below. Date: /U " Z 7 —�O � Approved by i