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0178 SANDY VALLEY ROAD - Health
178 Sandy,Valley Road Marstons Mills A= 101 — 076 1 i Town of Barnstable Health Inspector prr114E Regulatory Services Office Hours 8:30—9:30 Thomas F.Geiler,Director 3:30—4:30. BAM 14 # Public Health Division � 16S 10,etE p ,t A Thomas McKean,Director � 200 Main Street,Hyannis,MA 02601 Office: 508- 2-46 Fax: 508-790-6304 TY PROGRAM APPLICANT- SEPTIC QUESTIONNAIRE Date: September 21,2009 1. General Information: Size of Property: 5 5 GC r( Address: 178 SANDY VALLEY ROAD MARSTONS MILLS,MA. 02648 Map 101 Parcel 076 Name:EDWARD MCFARLANE&MARCIA MCDERMO^TT MCFARLANE Phone#: 508-419-1438 or cell 774-392-1923 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? \i S If yes,how many? 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? �J 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? YES or NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 7. Is a disposal works construction permit on file? YES +;or NOS"; M.�7 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 76 O tvo 9. Were any building permits obtained for construction of additional bedrooms? YES ' r NO 10. Is there an engineered septic system plan on file at the Health Division? YES dr NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES ®r NO . -----------------------------------------------------------------------=------------------------------------------- FOR OFFIOE,LQ,$F,:ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Si Date: Q:\GMD-Housing\Accessory Affordable Apartment Program\ADMIN\FORMS&LETTERS\Blank Forms amnestyapp 1.DOC Town of Barnstable Health Inspector oFtHe t�� Regulatory Services Office Hours 8:30—9:30 �.� Thomas F.Geiler,Director 3:30—4:30 STAB Public Health Division MASS. 9 1639. a�e� Thomas McKean,Director �ArFD MA'S 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE Date: September 21,2609 1. General Information: Size of Property: 5 5 a r�& Address: 178 SANDY VALLEY ROAD MARSTONS MILLS,MA. 02648 Map 101 Parcel 076 Name: EDWARD MCFARLANE&MARCIA MCDERMOTT MCFARLANE Phone#: 508-419-1438 or cell 774-392-1923 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? C S If yes,how many? 2c. How many bedrooms total are proposed at this property(including the amnesty unit)? �J 2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways. Please label each room clearly. 3. Is the dwelling connected to public sewer? YES or NO If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone? 5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells? 6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER? 7. Is a disposal works construction permit on file? YES or NO 8. If yes,how many bedrooms were approved according to this permit? Bedrooms. 9. Were any building permits obtained for construction of additional bedrooms? YES or NO 10. Is there an engineered septic system plan on file at the Health Division? YES or NO 11. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO ------------------------------------------------------------------------------------------------------------------- FOR OFFICE USE ONLY The Public Health Division has no objection to bedrooms at this property. Special Conditions: Signed: Date: Q:\GMD-Housing\Accessory Affordable Apartment Program\ADMINTORMS&LETTERS\Blank Forms amnestyappl.DOC Loft 15X12 Wood Deck Bedroom 18X12 0� seconcA V-,,.0\AS W I v at ow Kitchen Dining Room 11X12 13X11 a Be 12X17 c��r - < i iLr) 4 Living Room 20X13 C 6+ t, ��0 �,4 s Loft 15X12 vi Wood Deck edroom 1'�� 12 `i L\ WVA S - a - SO Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: // � yr��6 °Qr ' Lot No. --m Owner: 7_WCr Address: Contractor: G . Address: Notes: STEP 1 Measure depth to water table to nearest 1/10 ft. ................. .......Date l/ G' 71 ........................................................ month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.......................... �41)1V OB Water-level range.zone ..................................................... C STEP 3 Using montMy report "Current Water Resources Conditions" determine current depth to O� ®y water level for index well ........................... ! ( T month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) �y+ determine water-level adjustment ........:....................................................................... 41 STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) from measured depth to water levelat site (STEP 1) .................................................:........................................................... i Figure,13.--Reproducible computation form. 15 r Town of Barnstable Barnstable AFAm Regulatory Services Department 1110 �;�a�j BARNSTABLE. 9 ,.� Public Health Division `l'plfb µA,�A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO June 5, 2008 Sylvia Tucker 178 Sandy Valley Road Marstons Mills, MA 02648 The septic system located at 178 Sandy Valley Road, Marstons Mills was inspected on July 17, 2007, by Robert Bortolotti, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system needed further evaluation under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: System is located under driveway. Per order of the Board of Health this matter has been fixed. QD oinDas McKean,R.S., CHO Agent of the Board of:Health CERTIFIED MAIL# 7006 2150 0002 1042 0026 Q.'�SEPTIC\Letters Septic Inspection Failures\178 Sandy Valley Road.doc SHE Town of Barnstable Barnstable - 'L <<f. �L')- � "�CaC Services � 9a tb i 9. Public Health Division oATrO MAC A` 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO c January 30, 2008 Svlvia Tucker 178 Sandy-Valley Road Marstons Mills, MA 02648 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 178 Sandy Valley Road, Marstons Mills was inspected on July 17, 2007, by Robert Bortolotti, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system NEEDS FURTHER EVALUATION under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: System is located under driveway. You are ordered to replace the septic system or relocate the driveway within Two (2) Years from the date of this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THB BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health CERTIFIED MAIL# 7005 1160 0000 0191 0393 Q:SEPTIC\Letters Septic Inspection Failures\178 Sandy Valley Road.doc From:Kee Enterprises To:Debra Delnegrow Date:1/9/2008 Time:1:14:14 PM Page'2 of 3 —71 A& M ASPHALT, INC Invoice P 6IRM 1663 H WICH, MA 02645 Date Invoice# 508-4304774 9/7/2007 3315 Bill To Ship To Sylvia Tucker 178 Sandy Valley Road 178 Sandy Valley Road Marston Mills,MA 02648 Marston M111s,MA 02648 P.O. No. Terms Rep Account# AM WO# Project Due on receipt. MJC 508428-1629 35;42 Driveway 2007 WO 3542 Item Code Quantity . Description Price Each Amount DW DRIVEWAY-To be moved 78 SQ YDS 1,925.00 1,925.00 CUT AND REMOVE A 42'X 31'AREA OF ASPHALT EXTEND DRIVEWAY Y TO THE RIGHT OF DRIVEWAY INSTALL 1.5"OF BINDER MIX:EXTENSION ONLY ' INSTALL 1.5"OF TOP MIX ENTIRE DRIVEWAY COMPLETED 9/6&9/7/07 DEPOSIT REC'D$962.50 CHECK#615 BALANCE DUE $962.50 F i POST 3 ' .a. Thank you for your business. Total $1,925.00- Fall::k Ile Credit Card Information Circle One VISA or MASIERCARD Phone# Check 508 430 4774 Print Name on Card q $_r� Fax# Account# Date Pav't Rec' Veriftcatin Code l 568430-9992 Expiration Date / Signature CALL TO SCHEDULE YOUR HEAVY SAND PICKUP,CATCH BASIN CLEANING/REPAIRS;ASPHALT,POT HOLE REPAIRS &CRACK SEALING I COMPLETE •N COMPLETE THIS SECTION ■ Complete items 1,2,and 3.Also complete ignature Item 4 If Restricted Delivery is desired. X ❑Agent ■ Print your-name and address on the reverse ❑Addressee so that we can return the card to you. e ed by OR Na e� ■ Attach this card to the back of the mailpiece, (J or on the front if space permits. D. Is delive address efferent from item 1? I�f 1. Article Addressed to: If YES, ter deli"48dre below: vv � C co lDk ..0 skp'v% 1\�� ill Pt b2c. % 3. Service Type Sp ®Certified Mail ❑Registered Return Receipt for Merchandise ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 'i I i=:i i 7 0 0 5 t116 0 0 0 0-0 1:'0 1%-9 1 -0 3 9 3 t t 1 (transfer from service labeo 41 ' ' PS Form 381.1,February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES•fbi '�sERVIE ' `' • Sender: Please print your name, address, al :kZIP+4 in,this box • i nT- r a� s Town of Barnstable � a Health Division 200 Main Street Hyannis,MA 02601 Ill££££51411111 All££:£££Ill A££I'll£iM£1£££4 tilt!£A1££££1£I£I 1 r From:Kee Enterprises To:Debra Delnegrow Date:1/9/2008 Time:1:14:14 PM Page 3 of 3 t - I t � $'-- .... Old " 1 1 R i 1 COMMONWEALTH OF' ASSACHUSETTS Y . EXECUTIVE OFFICE OF ENVIRONM* ENTALAFFAI:R:S.• ILO EPARTMVNT'OF ENUIR'ONMtN.TAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM. PART.A . CERTIFICATION Property-:Address: f � Owner's Name: Owner's Address: -�S jI,g1 -Date of Inspection`: e-7.,.L10 0-7 / f.` i Name of Inspec • (p,ease;�rint) Company Nara Ylailiris Address: 70 �le Telephone Nurn er: Q CERTIFICATION 8TATEMEN T 1.certify that 1 have personally inspyected 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 bite sewage.disposal systems; I am a DEP approved system inspectar pursuant to Section 15 340 of Title:s,(-no cmR,15:000).';The system: w o Passes -j Conditionally Passes. 00 ; iv Ni eds Further Evaluation by the.Local Approving-Authority a s r, In ector's Signature:. Date:. The system iri pector shall submit a copy of this inspection report to the Approving Authority(Board-of Health or. DR):within 30 days of completing this.inspection.If the.system..is.a shared system or has a desigM. n flow of 10.,000 gpd pr g eater,the inspector and the system owner shall submit the.reportto-the appropriate regional office-ofthe DEP.The original should'be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. Notes and Comments �/� -I j� ej y5 �1'1 /S �l� e/ C eevS�' t ****This,report only describes.conditions at the time ofirispection.and under.the c,ond tions:of use at that time.,This'inspection does not address how the system will perform in the future under_the same or different conditions of use. Title,5 Inspection Form 6/15/2000 page .1 Page 2.of 11 l OFI+I.CIAL:IiVSPECTION FOR-ML —NOT FOR. OLUNTARY r 5'SE SNIE NTS. . SUBSURRFACE SEW- AGE'DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 7 Property Address: 17 � Date of bspe . on:. OO-7 . Inspecti.on�Sum Mary: .Check`A.,R,C,D or E./AI;.WAYS complefe,all of Section.T3 A. System Passes: I have not'found any information which,indicates that any of the failure criteria described in 310:CiviR 1.5.303 or in 310 CMR 15304 exist.Any failure criteria.notevaluated are indicated below: Comment"s:. B. System Co ditz ona Passes: One or more system components.as described in the"Conditional Pass"section need to be replaced or repaired. fhe system, upon completion of the replacement or repair;as approved by the Board of Health- Vill pass. Answer yes,no or not determined(Y;NjND)in,the for the following statements. if not determined"please explain. The septic tank is metal and over.20 years:old,or.the septic tank(whether metal or not)is structurally unsound,exhibits substantial:infiltratioii or exfiltratian 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 ND explain: _. .. Observation of sewage .backup or break out.orhigh static water level in the distribution box due to broken or: obstrucied'pipe(s)or due to abroken,.settled or uneven distribution box. System will pass inspection if(with approvat of Board.of Health): broken pipe(s)are replaced. obstruction is:removed distribution:,box is leveled or replaced ND explain: The system required pumping more than;4 times.a year due to broken or obstructed pipe(s).The system will pass inspection if(with.approval:of the.Board 'fHealth): broken pipe(s),are replaced obstruction.is removed ND explain.: Paee_,of 11 OrrlCIAr:� ZN.SP CTION FOI�M -.NOT ri.O ..'VOLUNTARI'ASSESSMENTS SUBSU7ZFACTSEWAGE.DISPOS, SYSTElV1M1NSPECTIONFORM CERTIFICATION,(continued) Property Address: 17 � [ Owner. Date of Ins ction: QPf'J C. Further-Evaluation is .Required by .the Board.of Health: V Conditions exist which require firther 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 priory is within 50'feet of a'surface water 1 Cesspool or privy is with.i.n 50 feet of a bordering vegetated wetland or a salt marsh 2_ Systeyn wi11 fail unless the Board of Health:{and'Publ C,Wate'r.Suppl.ier,if any).determines that the system is`functioning in a manner that.protects the public health,.safety.and environmetia: _ The system has a septic tank and,soil absorption system (SAS)and the SASis.within 1001feet of a. surface water supply.or tributary to a surface water:supply: The system has a septic tank and SAS and the S`AS,is within a'Zone l-.of a:public water supply. The system has a septic tank.and SAS and the:SAS is within 50.fe'et ofapri,vate:waterstipply 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 I. "This system passes if the well water analysis;performed at a DEP Gertii ied laboratory, for.coliform bacteria and volatile orgap,-- compounds indicates that the well is.free from polliltion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that.no other failure criteria are triggered. Acopy ofthe analysis:must be attached to this.form. 3. Other: °f(/U. ZIAzliVa 3. Page 4 of 11 OFFICTAL.IIVSPECTION' Q.RIM. .1 T �0� 6�O]L.i71dTAR� :AS�ESStl1E�iTS ' SUBSU.RFA:C.E SE'WAGE,DISPGSAt SYSTEM-INSPECTION.FORM PART A.. CERTIFICATION(continued): Property.Addressr Owner: P Date of In4� t'o n:. D:. System Fail,ure,.Criteria applicable to a11'systems: You must indicate"yes" or."no"to each.of the,following for all inspections: Yes No _ _ Backup of sewage in to;facility.<or Sys tem component due to o.verioaded. or.clogged SAS or:cesspool Discharge or pondins of effluent to the.surface ofthe ground.or surface waters due to an overloaded or clogged.SAS,or cesspool . Static liquid-Eevel in the.distribution box above.outlet.invert due to an..overloaded,or.clogged SAS.or l cesspool - V .Liquid.depth in cesspool is less.than 6."•below invert.or available volume is:less than %2 day flow Re Hired u q. pumping.more.than 4-times in.the last.year NET due:to clogged or obstructed P ipe(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. VAny portion of a:cesspool.or privy is within.50.feet ofa.private water supply well: Anyportion of a cesspool or privy is.less.than 1.00 feet.but.greaterahan.50;feet,fro:m aprivate water supply well with no acceptable!water quality,analysis,.[This system passes if.the.well water analysis, performed a:t.a AEP certified 1a;boratory;for coliform-ba.cteria and,'vola tile:organi' compouzzds indicates that the.well is free from pollution from that.i;acilityand the. of antmo.nia nitrogen and;nitrate nitrogenis:equal:to or less than 5 ppm,.' fded!that no:other failure criteria are triggered..A..copy.of the.analysi&must'be attached to:this form.] (Yes/No.The system fails.I have determined that one or more of the above fail u A criteria.exist as. described`inJ re CMR 15303,tfierefore the system fails..The.system owner. should,contact the Board of Health to determine what will be necessary-,to correct'the:failure. f E. Large:Systems: To be considered a large;system the system must serve:a facility•with a design flow of 10,000 bpd to.1.5,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria.apply to large systems.in addition.to the criteria above) yes no _ - the system is within 4.00 feet of a.surface drinking water.supply the system is witkiin 200-.feet.of a tributary to a surface drinking water supply — _ the system•is located in a nitrogen sensitive area(Interim Wellhead Protection area—1WPA)or a mapped Zone II of,a public:water supply well.. If you have,answered"yes"to any question in Section E the.systew is considered a significant.threat,.or answered.- "yes"'inSection 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 3.10 CMR 15.304.The system owner should contact the appropriate.'regional office of the Department. Page 6 of l 1. OFFICIAL'.INS PECTION:FORiV1.-.3'dOT'FOR VOLUN T;�',I ASSE SSMENTS. SIJBSIJRFAGE SEtiVA GE,DISP,.OSAL SYSTEM-INSPECTION FORM AR:T:O SYSTEM_INF.ORMATION Property Address: 30e"l O.wner �-- Date;of Insiyeetion: /, Q FLOW CONDITIONS RESIDENTIAL Number ofbedtooms.(design):-,3 Number of bedrooms(actual),: DESIGN flow;based on-; 1ff.CMR 15.203 (for example: 11.0 gpd x r of bedrooms):� Number of current residents:. I _ // Does residence have:a garbage grinder(yes or no):.NU Is laundry on.a separate. Za system(ye or no).:WU.[if yes:separate inspection required] Laundry system inspected(yes.or no): G Seasonal.use: (yes orna) a, Water meter.readings;if avqK ble(last 2 years.usa.ge:(gpd)): Sump.pump(yes-or no) / y Last date of occupancy: v� C OMMERCIAL%IND USTRIALiAl Type of.establishment:; ; Design.flow(based on�10 CMR'15.203): ZIP Basis of-desigli flow(seats/persons/sgft,etc.):.- Grease trap present(yes:ormo); Industrial waste holding;tank.present(yes or no):— Non-sanitary waste discharged to the.Title 5.system(yes or no):- .Water meter readings, if available:• Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records ' Source-of information: Was system pumped as part ofthe.inspV n(yes or-no (� If yes, volume pumped: gallons-,How was.quantity pumped determined?K Reason.for pumping: OF SYSTEM Sptic Tank; distribution box,soil absorption,system _Single cesspool —Overflow cesspool _Privy Shared system (yes.or no)(if yes, attach previous inspection records,.if any) IInnovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be ob_tained from system'owner) —Tight tank, _Attach.a copy:of the DEP approval _.Other.(describe): proximate age.o�all com onents, date i stalle (if own) and source of information: . Were sewage odors detected when-.arriving at the-site(.yes or no): Page 5 of 1.I OFFICIAL INSPECTIONTOR 'NOT FOR 'VOLt TARP"ASSESSIVIENTS SIJBSUR ACE'SEW—AGE DI.SFOSAL:SY'STEM I3VSPECTION FORiNI p'ART'B CHI CKL:8't Property P l Owner• Nl �.'O_a'o Date of Ins etion: /7 CJ00 7 ell Check if the following have been done..You must indicate"yes"or"no"as to each of the following: Yes. o 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 as the'system received normal flows in the previous two week period? Have lame 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 WA) _ 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? �theaffles .Were the septic tank manholes uncovered; opened, and the interior of the tank inspected for the condition of- or tees. material of construction, dimensions, depth of liquid,.depth of sludge ancjdepth 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`determinedbased on: Yes-no 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 approxirnation of distance is unacceptable) [310 CMR 1 5.302(3)(b)1 5 Page 7 of l 7 or,FTCI.AL INSPE:,CTION FORM1 -NOT FOR•VOLUNTARY ASSESSMENTS SUBSIIRli'ACE SEW-AGLV DISPOSAL`SYSTENI INSPECTTONV .TORM: PART SS 'EM. +`O I2MATI ON-(continued) Property Address: 7 ,/ Owner: ?� ` Date of Inspe ion: 7 (-7 - BUILDING SEWER (locate on site plan) Depth below grade: Materials of construction:—cast,iron _40 PVC other(explain): Distance-from private water supply well or suction line:: . Comments(on-condition'ofjoints, venting, evidence of leakage, etc.): SEPTIC TANK: (locate'on site plan) Depth below grade: Material of constniction: Veoncrete metal_fiberglass • . .Polyethylene other(explain) If tank is metal list age: .L age:confirmed by a Certificate of Compliance(yes'or no).'._(attach..a cosy of certificate) , Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or.baffle:. 3 . Scum thickness: .0 Distance from top of scum to top:of outlet tee or baffle:. 7, �- i K Distance from bottom of scum to'bottom'of outlet,tee-or baffle How were dimensions.deterrnined: j11 � � —, Comments('on pumping recommefidati_o s, inlet and outlet tee or baffle condition, structural integrity, liquid levels related to outlet invert, evidenc of leak ge, etc.): D W/11— GREASE TRAP:A(locate on site plan) L , Depth below grade:_ Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom-of scum to bottom'of outlet tee or baffle: Date oflast.pumping: Comments(on'.pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels as related to outlet invert, evidence of leakage, etc,.): Page 8 of 1.1 'OFFICSAE..INSPECTI'ONi..-TOktM:-NOT:I'OE:vOLUINTARY. ASSESS.NSEIiTS SUBSURFACE' -SEW:AGE DISP,O$AL SYSTEM INSPEECTION,VORiY.l; PAST C.. . SYSTEM NFORMATION(continued) Property Address: _ r! Owner: Date of Ins ction: / U TIGHT or HOLDING TANY(s(tank must-be pumped at time ofinspection)(locate on.site plan). Depth,below grader Material of construction: concrete metal fiberglass.,polyethylene other(explain);. Dimensions:' Capacity: gallons Design'Flow: gallons/day Alarm present.(yes or no):'. Alarm level: Alarm in work-in;order(yes,or no): Date of last pumping: Comments(condition of alarm and float.switches, etc.): DISTRIBUTION BOX:Zofpresent must.be'opened)(locate on site.plan) Depth of liquid level above outlet invert. Comments (note if box i-s level and distri ution to.outlets:equal;,any evidence of solids carryover, any evidence of i age into or out f ox e PUMP CHAMBER:;�,/lJ (locate on site plan): Pumps in working.order(yes or no): Alarms in working.order(yes or no):. Comments(note,condition of pump chamber, condition of pumps and appurtenances, etc.): Pabe 9 of I I OFFICIAL INSPECTION YORM.—NOT FOR YOY UNTAAY'ASSESSIYIENTS SUBSURFACE SEV�AGE :DISPOSAL SYSTEM INSPECTT'ON FOAM P.A TC SYSTEM INFORMATION(continued) Property Address: Owner: Dateoflnsp tion / SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not re wired' 9 ) If SAS'not located ex lain Why: y TYPeleaching Pits, number:, ( _. _.-leaching'chambers,number: :leaching.galleries, number: leaching trenches,number;'length:- leaching fields,:nunber, dimensions: overflow cesspool; number: -.inn ovative/alternative system. Type/name of technology: Comments (note condition cif soil. signs of hydraulic failure,level of..ponding, damp soil,condition of vegetation, /00(9 145wjl�KJ�%/&) P A AX 9-P, 'A 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 laver: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of-groundwater inflow(yes or no): . Comments (note condition•of soil; signs of hydraulic failure,:level of ponding, condition of vegetation, etc.*): 'PRIVY:-AAlocate on site plan) Materials of constriction: Dimensions: Depth of solids: Comments (note condition ofsoil, signs of hydraulic failure, level of ponding, condition bf vegetation, etc.): 9 Page 1.0 of 1. . i OFF1CIALINSPECTZOi+�-FORIY�; �3T 3k . 4� , Ti ,TAl t ASSESSMENTS.. SUBS RFACE SEW-AGE-DISPOSA-L SYS`EI-M.INSPIi✓CTION FORM PART C' SXSTEM NFORMATION(continued). Property Address:: Owner Date of Ins cti.om. i SKETCH OF SEWAGE DISPOSA%,SYSTEM Provide a sketch of the;sewage disposal'system.including ties to at least two perinanem reference landmarks or benchmarks,Locate all`wells within.100 feet.Locatd.where public water supply enters the building. do -�5g60K J5CA 1000 �IS OCV) Pate I 1 of I l OFFICIAL INSPECTION FORI'v7. -NOT FO t VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL S'YSTEMJNSPECTIM FORDS PART C SYSTEM INFORMATION(continued) Property Address: 7 � (/ Owner- Date of Ins tion: . 7 SITE;EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground water feet Please-indicate (check)all methods used to determine the high ground water elevation: Obtained from-system design plans on record -If checked, date of design plan'reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with.local excavators, installers- (attach documentation) Accessed USGS database-explain; You must describe how you'established the high ground water elevation: 11 . Town of Barnstable oF1He r Regulatory Services a� BMMSTABLE, ; Thomas F. Geiler, Director 039. A Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER A septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving the report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the Disposal Works Construction Permit. QASEPTIC\Disclaimer Private Septic Inspections.DOC F er fic AUS-ii'-2007 09:23 From:BORTOLOTTI CONST 5084289399 To:508 790 6304 P.F/14 COMMOnVEALTH OF MASSACHUSETTS "- EXECUTIVE OFFICE OF EimRONMEN'rALA r.ju S w 'a .L r"P-A-RTMENT�'oF ENV.T:RO'NMEN''1'At:']� R'OT13,CTION TITLE a OFFICI.-,U,INSPECTION FORM —NOT FOR VOLUNTARY A:SSESS:MtNTS ST-MSURFACE SEWAGE DISPOSAL, SYSTEM FORM PART A CERTIFICATION Property Address: _7 Own eir's Nam e: C%iner,s Address: lisPectian. l�ra,�,�,aernsl��� • ct�i �Be����r>d� 1� _ )t� ccmpnny Nam jV n lit g Address: 16 ' �✓ (�� � r Telep6ne Xumber* ,MMMFICATION STATEME NT I, ct.rtify that I have personally inspected the sewage disposaI'system at this address and that the information reported below is true, accur4te 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 an�-ite sewage disposal systems.J am a DE.F ` -approved system Inspecthr pursunnt to Sestlon 15.340 of Title 5(310 Cla1R 15.0.00). ''The system: Passes Conditionally Passes eds Further rvaluaeion by the.Local Approving-Authority a• s Ixispet orls Signatnre: Date: 'Che gystem inspector shall submit a copy of this inspection report to the Approving Auth®rity C'Doard of Health or D. p)with in;0 days of completing this inspection-If the systern.is.a shared system or has a design flow of l 0,C L�C1 gpd or 2reatar,the inspector and the system owner shall submit the report to the appropriate regional office of the 1:�sP,If-he originil should'be sent to the system owner and copies sent to the buyer, if applicable, and the approving !,,totes and Comments �amtrhis report only describes conditions nt the time of lnsp�etion and under the condltlons:ol use arthr.t ilme.,T11is inspection does not arldress`how the sysfm will perform in the futued under the same or diffe,cnt vine.Cons Of use, 'Title.5 lnspec.tion T•orm 6115/2000 page l r AUa--37--2007 09:23 Prom:eORTOLOTTI CONST 5084289399 To:508 790 6304 P.;;�14 Page 2 of I 1 � �TT®I�ii~FO IVJ IQT FOR VOLUNTARY ASSE Si1rt PlT 51��3STJJ2 'ACE r Gr ]DISPOUL SYSTEM JC�iSPE�TION FO1;M,; .. PART A. CERTIFICATION(continued) Pro pe-AyAdd•ntss: ]:°Seas'or Ins-oe:._on.: ®®� Lis PCrtio.n''3uinina7- C.'heck•'A,B•,C:,D or E•/ 'J Yf complete_all of Section.D JL system P-Isse•So 1 have act found amy information which indicates that any of the failure criteria described in;10.CNkR 1-5,303 or.Jn 310'CMR 1S'.304 exist, Any failure criterla.notevaluated are indicated below. C;o,xtanenrl B. _ System Condi'donally rasses: One or more system components.as described in the"Conditional Pass"section•nbea'to be replaced or repaired.The-syystem, upom completion of the replaee man t or repair;as approved by the Board df Healthl jXjII pass. P.bswer ye;, no or'tiot detetznjned( ;N; D)in the for,the foll9wing stacem ats. if"not decermincd"please wxplaun. __ The.septic;tank is metal"aAd:oN.r?r•a.Q year�,alda or the septic tank(wberhe.r metal or not)-is structurally unsound, e,°cltibits subsiantia].irifl�ation vi<e�ltratioti or.tank failure is imminent:System will pass inspection if the emistIng tank;?-5 replaced with-a complying septic-thnlr as approved bythe Board of Health, 'l,k xnctal septic tank will pass inspection'if it is structurally sound,not leaking and if a Certificate of Compliance indical:ing that the tank is Jess.than 20.years old is available.' ND explain: Chse:yaticn nfscwago.backup br break out or hid static water level in the distribution box due to broken or. ub�strocted pipe()or due to a.broken, settled or uheven distribution box, System will pass inspection if(with a,`:prc ynLcfBcard.ofHealth): broken pipe(s).are replaced, obstructian is:removed distri.bytion,box is,leveled or repladcd , NJ explain: _ b hie system required pumping more thanA times a year du.e to broice•n or obstructed pipe(s).The sysmgi will ps-.ss irlspeeti®n If(veith,approval,of the Board or Health): broken nipe($),4re-replaced a struetion ls:remo.ved AUG-l 7-2 07 0=':23 'F-o m:B0RT0L0TT I CONST 5084289399 T o:508 790 6304 P.4/14 Fage 3 o: 1 l " OFFICIAL INSPEC'-'ION FIORNl - NOT"FOR VOLUNTAR'Y'ASSESSMENT S SUBSURFACE St*VVAG'C DI'SPOS`�-1L S'YSTEMINSPECTI01470:12M PART'A , CERTIFIC: TION(t ontinued) 'Proper cyAddress: 7 JA&44Z.�Oa�01 t�wner. j Date ofIns -don: C, Fair ther Evaluation is eq,uired by the Board:of Health: r° 9 4_ conditions exist which require farther evaluation by the,.,Board of Health in orders to derennino if the sys'cm is failing to protect public health, safer},or the environment. 3. System will pass airless Board of Health determines In accordance with 310 CMR 15.303(1)(b)that the system is not runctionl'ng in a mannerwliich will:protectpubli'c health,safety and•the envirommeno Cesspool or privy is within 50 feet of a surface water Cesspool or prniy is within 50 feet of a bordering vegetated wetland or a sdItImarth 2. Systeni will fail unless the Board of Health f and'Pub11c.Water Supplier,If achy}determines that•thy: system is ftrnetioniitg in a manner that protects the public health,safety and environmork: _ The system has a septic tans:and soil absorption system (SAS and the SAS,it within I00`feet®fa surface water supply or tributary to a surface watersupply, I The system has a septic tank-and SAS and the SAS is within a:Zone 1 of use ublic wat®r supply. The system has'a septic oink and SAS and the;SAS is.v;lith.in,50 feet oAa private-•water supply wdJl, 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 paises if the-veil water analysis,performed at aDEP cerEifiied,1a*atory,'for coliforin bacteria and volatile organic compounds indicates that the well is.free from pollddon from that facility;:.nd the presence of ammonia nitrogen and nitrate nitrogen is t:qual to or less-than 5 ppm, proNiided that no ocher failure criteria are triggered A cony of the analysis must be attached to this font:►. I i i 3 rUG,17--2007 03-:24 F'rom:BORTOLOTTI CONST 5084289399 To:508 790 6304 P.5/14 i - 1 g-C:T. -!Q.NT-QRM, �:TIT.©R V0 LUWT'A1WASSESS'1y1ENTS ° SUBS—UR- AMSEWAGL DISPOSAL SYSTEM-INSPECTION FORM FART A a CERT-1r 'C-A miN(continued): i :l'roperty.Address_ 1:��te of J:nsp; tfono o �, - EX S}stem Fai ure-,Cr:iteria appllcnble to.all'systems, you r r�asG indicate "yes" or"n . to each-of the-.fallowing for all inspections: W�� I Backup-of se.v(agc into,faci:lity;or system.,Component due to overioaded,or clogged W or-cesspool Di9charge or pomdirig bi'effluent to the'surfagc ofthe ground.or surface waters due to an overloaded or clogged SAS,or cesspool _•_ Static liquid,] ,Yeliin the,disrrkution.box above,.oudet invert due to an overloaded or clogged SAS or cesspool, Liquid—depth—in cesspool isless•than b"'below invert or available volume is.less than !/j day flow Required pumping]Shore.thati 4 runes in•the last year a due to clogged or obstructed pipe(s).Number �. of times puinged _ Aany ponion of the,SA ,.cesspool or privy is.below high ground water elevation. _ Anypordan og cesspoof dr privy is,within 1004eef of a surface,water supply'or tributary to a.surface water supply,] _ nyportion,of a cesspool.or.privy is within:a Zone 1 of a:public well, t!J o portion 41 a:cess ool:or riv is within 5a'feei of d'. rivatc water su 1 wej'l: _ yp _, P P y P pAy: 4n y�ortion of©�cesspool or'privy'Js jc9s.than 1.00 feat but.gre�ter.than 56 feet from a,private water supply, well vdth no acceptable•water-quality.analysis.,[This system passes if the,well water analysis, performed a#::.a-D-E cer'tlned lbbo-ratery, for collfor-m bn,cteria and,volat'11e or;anlc compounds fndicates that tho.wollI r free from pollu,tfon from that fadlity and the preshco,of ammonia nitrogen and.nitraie niftooen,is equal, or less Mart 5 ppmT pr-av>'dedttlia.t nb:oth`er failuro'erlterki are triggered,A coprof the analysl�..m-ust,be attached to this forrb,]• I. . (YeeANo)The system fails.,I have-determith6d.thar one or more of,t a above failure criteria exist as desctibed ri�W CMR 1�";303, therefore-the system fails. The.system--owiter should contact the Board of 'ieslth to.detdrmin•e•what will be necessaryto correct the failure. ' I E- ,1�axg.e;Syste:rrhS: , To be considered a large-systetn the system must serve.a facility with ad e5ign ilow of 10,000 gpd to 1.5,000 Ja do You imusc indicwe either`des" or"no" t® each of the foJlowiho: following,criteria apply to large systems.in addition to the criteria above) .yrs :iho _ the system.is within 400.feet of a.sUrfaoe drinking water supply the system is within�004eet-of a tributary to a surface drinking water supply the system-is located in a nirrogen:sensitive area(Incerirn Wellhead Protection Area—iWPA)or a rnappcd Zone 11 of a pulxlic water supply well 7'f y.Uu ha%,e answered"yes," to ally gties0bn in Section,E the system is considered a significant threat, or answered "yes" ii,Secion D'above thr.large sj(stem has failed. The owner or operator of any la' c system considered a signdfllc.ant di ea,t under Section E or failed under Seetign D shalt upgrade the system in accordance with 310 CMR i 1 i.304. The system owner)should contact the appropriate.regional office oftha Department. AUG-17-2007 09:24 From:BORTOLOTTI CONST 50e42B9399 To:50B 790 6304 P.E./14 y Pal-e 5 of I I OFFICLAL m4SPECTION FOMM—NOT FOR VOLUNTARY A 'sJ✓SS. ivTS Stl�StiRFA CT, sF� :�G .DZs.P os .s s"rEM T3v5rR CtT6 :FO. . PART 13 CHF CTIM18T ' Property Address: �l O W_n e'- Date of Las ctlon: Check if the following have been done.You must indicate`eyes"or"ho"as.w each of the tollowing: m4 i ,!:s Flo Pumping,information wns provided by the owner, occup'ant, or Board ofl=Iealth, Were any of the system components pumped out in the previous two weeks ? as The system received normal flows in tho previous two week perlod ? a v art ofthi in ection ? I-twe large plumes of water been introduced to the system.recently or as s , sp j/ Were as built plans of the system obtained and examined? (If they were not availtible tjote as N/A) Was thie facility or,dwelling inspected for signs of sewage back up ? ' F 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 sludgeiand depth of scum ? Was the facili'ey owner(and occupants if different from owner)'provided with.information on the proper rna,_ntenance of subsurface sewage dispostil systems ? The size and loentien of the Soil Absorption System (SAS) on the site.has been detertniAd based on: Yeses ro Existing information. For example, a plan at the Board ofHe'alch. jm'°✓_� Determined in the Feld(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMP. l S_307(3)(b)l -- I i r t 5 AUG-17-2007 09:24 From:BORTOLOTTI CONST 5084289399 To:508 790 6304 P.i 14 aaa 6 of l T0R v®IJJNT..�Y,ASSEESSNIENTS S: 3S.7 ACC S;E?+ 'AC :JDxSP,OS .SYSTTIZ T1V.S 'EC'g' ON rOR11�1 'PART.C SA RMATioN �'a°crd�er:y address: � ' � • 2Z v , :�.7te,cf,�n action: CONDITIONS Nuinber Bf bedrooms(dgsagja), Number of bedrooms(acrual}: D)�S10P rlow used"onfi310'.C1vfR 15,203 (for example; 110 gpd x bf bedrooms):� I�?rirnbel:oa'eurb enL rbsidents:. 1 / Does re!!den ee have a garbage grinder(yes or no): N� Is l,suns3ry on.a separaee sewage system(ye va;no),:�(J.[if ye9 separate Inspection required] Lacmdry system""inspected �(or no); 0 i.3:idP1�l use: (Yes or nc�" Vlattr meter readings,.if ava&ble(1t:st 2 years u sage.(gpd)): a241 La6 SI.arnp.pump(yes or-no)., / Lasr.date of occupancy: Y4aA_-1A /V'�A"d&w T"pe pf;;s',flblishrnenc 1 Design flow(b�sa-d On a10.CMRA5=3): gpd Bctds of design.flow(seats/persons/3 Crease trap present(yesior no): Indu.srHal waste holding tank present(yes or no): No.nvsanatary waste'dischacged to tbe.Tide S--system(yes or no): Water metier readings, i I available:- Las date of oceupancy! se: O JCBER,(describe): GENERAL INFORMATION Pumping Records ; "source of lnfb�mation: 'r -M sy.tera pumped as part of the.inspe (yes or no :f yss,.volume pummped: Ballow—How was quantity pumped determined? Acasort for pumping, 11'+'111 or( SYSTEM !'Sept c dark, distribution box,soil absorption,system �._ Sinjgle cesspool ®� Ovtrtlow Tesmool„i _ iPrivy, L Shared.SyStern (yeS;or no)(if yes.,attach previous inspection records,if any) nnovative/Alternat ve technology.Attach a copy of the current operation and maintenance contract(to be Obtained frorst system-owner) _ Cig :tank, _A I itach.a c.opy'of the DEP approval tVtHr,: (�eScribe): +` �+ 041mate ge oL'al,l ca mponents, ?late i stalle (i own)and source of infonnation: 'Wdt scwag.- o4ars:detected when arriVing at the site (yes or na) AUG--17-2007 09:24 From:BORTOLOTTI CONST 5084299399 To:508 790 6304 P.EI/14 Pau-7o:fll O'VIFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AlSSESSrMENTS STJFS`URr1A:CE SENVAGL)ISS'O8AL'SYST:E'MYNSrt6T]JQ1V,Fdp2m PAR- S`ISTENI INVORIVIATT®N(continued) i j R-operty Address:/7 "Owner. Mite bf Inspe lo 07 - ]YVT.LDING SEWER(locate on site plan)A/U Depth below&radc: Mat,mrials of construction-. cast_.Ton _40 PVC_other(explain): DYstann-from p.rivate water supply well or suction line:, Comments (on condition'ofjbiats,venting, evidence of leakage, SEPj'1C TANK;Zocnre on sate plan) i // 'Depth below grader Nfaterial of construction'. concrete�metn.]_�ibarglns; _ Uolyeehylane _otlies'(explain) , I:f'ra',ik is metal list age:� Ts age confu•med by a Certificate of Compliance(yes-or n'o):;._(attach a copy of certificate) , Dimensions: Sludge depth: . '' 3 /,i Distance from top of sludge to bottom of outlet tee orbaffle;_ , , Scum thickness:&" Distance`fi•om cop ofscum:to top o'fou'tlet-tee or baffle., Z Distance from bottom ofscum to Bono of outletetee or baftle; 6 /V Holy were 0i.mensions.determined, conun�nts (on pumping recomm datio s, inlet and outlet tee or baffle condition, structutial integrity, liquid levels related to outlet invert, evident of lea ge, etc,): • Lek GR*EASE TRAP:) (locate on site plan). rjc�pt'h below grade: M terial of construction:—concrete metal_fiberglass_polyethylene_other • (e:�},twin): Dimensions: Scum t'hi.clenesd: D stance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle; Date oflast.pgmp.ing: C:ontme.ncs(ori pumping.recommendations, inler.and outlet tpe or baffle condition, structural integrity, liquid levrls as r-elated to outlet invert,evidence of leakage, etr,) AUG--17-2007 09:25 From:BORTOLOTTI CONST 5094289399 To:508 790 6304 P.9/14 1- I l i Page 8 of 11 01+FI'C'J��.INSPECTI:ON.,FO —NIO :FOR:-'4�'OLUI TkRX AS9ESS1YtE TS S7[TBSTJR ' CE S 4,GE DISPOSAL SYSTEM INSEIECTION'FORM PART C• SYST M, 'FORMATION continued), I I?a'operty, Ad dress:� �1 DaA,e dins ction: JAI U i TIGHT or FOLDING '(;P.I Va(tank.alpst-be pumped at time ofTinspectio.n)(loeate oa site plan) 'Drp-1,beJow grade: ml. m ial of construction; concrete metal. fiberglass_polytediylene ocher(explain);. Dirn ensio%Is:" a� �;::p;�e;6y:._ gallons • a'w::ign h1c+w:_ I gallons/day r-Jl xrs prdsent(yes or no). Ajwm level:., A-1i rm in working order(yes or no): D ats of lest pumping: C;ucrsments,(con ditio.n of alarm and float switches, etc.); DY I'I2JBUTION.BOX:Za,presentmust be opened)(locace on site plan) Dlelith of:hquid level above outlet invert;. (6 Cor-nmrrts(note;if box i3'level and distri ution to outlets,equal,any evidence of solids carryover,ony evidence of J o k:�ago fnto or out f box, �,;,1�, AD A PUMP CHANiBER:LSJ (locate on site plan). Punipa in working order(ryes or no): .da:rms in working order ayes or no): , C o.=ears(note condition of pump c�amber, condition of pumps 4nd appurtenances, ecc.); AUG-1.7-2007 29:25 From:BORTOLOTTI CONST 5084289399 To:508 790 6304 P.10/14 ?age 9 of 11 OFFICIAL INSPECTION FORM-.NOT i FQRV0LYNTARYSSLS$MXNTS ON:I bS'UBST1R+ACESTNVAGEDIS:PO.SAL '.ST-C �5 '' CT RM PART C SYSTEM INFOR1vCATION (continued) .1 roperly Address: Owner: � Date ofInsp tion i SOIL.A33SORpT7 N 5Y'S:'Eldi (SAS):Zooente on site plan, excavation not required) i :if SAS'not located explain sv.:ay: Typ e r jeaching,pits, number: f ,-leaching chambcrs,number: leaching galleries, num-oer: lt:aching trenches,number, length: �_leaching flaTds,,numbar, dimensions: overflow ca spool, number: _ .innovative/ultemati.ve s�yste.m- Type/name of technology: Eoo ants (note condition or'soiI, signs of hydraulic failure, level ofponding, damp soil,`condition ofve,getatio.i, etc.): ,i r 'J d goo (J rassPOOLS; (cesspool must be pumped at,part of inspection)(locare on site plan) Number and configuration: Depth'—-top of liquid to inlet,invert: :depth of solids laver: Depth of scum layer: :Dimensions of cesspool: Materials of construction: Indication of.groundwater inflow (yes or no): .. iComrnents (note condition of sail; signs efhydrau.lic failure,leyel ofponding, condition bfvegetatlon, etc.): ocatr on.Site»lan) Materials of Constmetion: Di-Mansions. :[depth of solids. Comments (note condition of soil, signs of Itydb•aulic failure, level of ponding, condition bf vegetation, etc,)_ 9 ' AUG•-17-2007 09:25 From:BORTOLOTTI CONST 5094289399 To:508 790 6304 P.11/14 ' S Page );Q'of 11, I 4 • • OP)71zCY:AL-,T. 'SPECTIO.NTORM---.NO. FORWLUN.T.ARY ASSESSMENTS . SUBSURFACE StWAGE-DIS26SAL SYSTEM 1,-NSPLI CTION EORNi. I CART-C. SYS"TEM°JN,FORKATION(continued). . P y N,te of Ins tioa;. 1 C:II OF SE1'VAGE DISPOSriL SYSTrm Provide a sketch of they sewage dispc-sal system including ties to at least two pe,misnenc refgranec londmarks or benchmarks.Locate all"wells within NO feet:Locat®where public water suppIx enter the building, 1 �4- �m� 000 I!v �S r i bvA:or. Leach ✓� AUG.17-2007 09:25 From:BORTOLOTTI CONST 50e4299399 To:508 790 6304 P.12/14 Page 11 of.]l OYFICI AL DISPECTION FoRt4✓!:-NOT FOR V'oLTJNTARY ASSESSMENTS SUBSURFACE SEWAGE DISP®SAL SYSTEM INSPLCTTOrNPO IM PAIN C SYSTEM INFORMATION continued P; operty Address: f 1/ P O wrmr; D1Ye of 1 -7 SITE EXAM Slope Surface beater t;hicic celliut Shallow wells Estimated.depth to ;round water feet Plesse`indicate (check)•oll methods used-tb determine the high ground water elevation: Obtained from system design plans on record -If chedked,dace of design plan reviewed: y�Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board ofAealth-explain: . Chocked with local excavators, lnetallers-(attach docurnewarlon) y Acce5sed USES database-explain: You must describe how you established the high ground water elevation 4 .571 4L _ 11 P AUG•-f7-•2007 09:25 From:80RTOLOTTI CONST 50e42e9399 To:508 790 6304 P.13/14 Permit Number: Completed by: ,0Y HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 040e /">±" s Lot No. Owner: 7XC, Address: Contractor: G Address: Notes: STEP 1 Measure depth to water table �r� s �t 1/10 ft. Data �P to nearest .......... month/doy/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and ds•tormino: � n� l�A Appropriate index well................. ...,............. �/,,..... �J Water-level range zone ................ ....................... C STEP 3 Using monthly report"Current Water Rosourroc Conditions" determine current depth to ® 4/7, wator level for index well ..................... ..... 7 month/your STEP 4 Using Table of Wator-level Adjustments for index well (STEP 2A), currant depth to water level for index well (STEP 3), and water-levol zone (STEP 2B) determine water-levol adiustmant .......................... ................. ....., .............. .... .... .. ... S 'E 5 Estimate depth-to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ......................... ................................................................................... _. 'J Figure 11--Reproducible computatlon form. 15 d- I v m M ' tD m T 1`- O] m Ln 0 F- TO ! 00 rr OD CU OD tIC l aKx co z O U H 1- � y O 's O o m E 0 L L.L Ln N T m Lei . O CLl _ t _ _ (T --vLlY 11 "70 on��- z5/8 L 0 CATION0141k'l- I ��$ SEWAGE PERMIT NO. y)414 D �/ VILLAGE Y/lr3follx �o s NS L LE R'S NAME A ADDRESS 10 B U I L D E R OR OWNER 0 DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �, N i o � � �t � No.$..��... '`... R • ® I �✓ �Q Fmc............................_ THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH Town Barns tabl e ..........................................O F.................. Applua#tnn for. Dtapusa1 Works (fnnui#xn.r#uan Famit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: Lot #1� - Sandy Valley RdXarstons Nlills i. MIA ............ ___..__....................................•---•_••---•--•----.._......---•-• .................,............................................................................. Capricorn Rea�tjrAi� st 765 Falmouth Ro �;NYiyannis ......................--._.....- - ..................••---------•-........ ......------------....-----•---•------•-••-------••--•-•---------•-------------•-------.....------ W Steve 'Lebel Owner Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.3........................................Expansion Attic ( ) arbage Grinder ( ) Other—T e of Buildin ranch - a Other—Type g ____________________________ No. of persons___.._______-______.___.____ Showers ) — Cafeteria ( ) Otherfixtures -----------••---•--------------•-------•--------•"----------------••--•--------------••-•--=--------- 0 ................Design Flow______ 5_............................... 000 gallons per pers peg day. Tot I�d�i.flow......................................._ , ons. WSeptic Tank—Liquid capacityl____._._:__gallons Lengt _______________ Widt __.__._._.°_.._. Diameter................ Deptl................ Disposal Trench—No. .................... Wid i_____-__-__________ Total Length..... _.________.Total leaching area.... sq. ft. e 266.. Seepage Pit N4.................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosi t �ladredde Engineering 11-25-81 Percolation Test Results Performed bY_____________________________........____ _ Date________.____....._.__________.-_._...-. a ;•------••---•-•--- — a Test Pit No. 12�_�_..__._minutes per inch Depth of Test Pit___ _______________ Depth to ground water e2iC... r ------ Cii (i, Test Pit No. 1_A______.___minutes per inch Depth of Test P�>��/..A_............ Depth to ground water-_.`ti��_._________... •---------------------------------------------•---------...... ---•-------------- ------•------------------------------•----------------•----- O Description of Soil_____._.9_0____ 21 loam & to soil ---- •, -•-- •-------•----•••• •- -------- - - x 2 - 0 Nie ium ye low sand---•------•-•-----------•------------•--•-----••---------------•--•----------- v .................................................... -__.--•---- W - 12 med. wYiite saric�/traces of graver/rio'wate-r-"at 121 --•---•------------------------------------------------------------•---•------------:.....-------------•--.-.--------------------------------......................................................... 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 TITIE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance as ssuead the oard f h igned- .............•--......- Pre s . 4/ /84 — - ate Application Approv --- ------------ •--...._-•-•---------- ------�- Date Application Disapprove or a following reasons:-------•------••-- •----------------------------------------------------------------------------•-----••-•--•--- .............••------•-----.._----------••---------------------•-•-•----------•-•--------....--------•=----------....•-•------------------•-------•----------------------------•--------•-••------•-•-•- Date PermitNo......................................................... Issued_....................................................... Date No........ .............. FEs............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ............................OF.......................................................................................... AppfirFation for Disposal Works (911us rnrtinn rrntit Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at: Lot A4 - Sandy +lalley Rd.Ylarstons Mills it 14A .............................................. ......--------------•----•-•••---••-.....--•-•-•---------•------------•-------•--...........---•-- Capricorn R&Qalty Trust 765 Falmouth R® ;0-Hyannis ............... . ....................................Steve Lsbel �"ner A....................... ..........--..........-------•-......_........-ddress ess.---•----•---------•------:..............-- W ---........ -------------- Installer Address d Type of Building Size Lot....:.......................Sq. feet aDwelling—No. of Bedrooms 327Ch ..__..Expansion Attic ( ) (�'arbage Grinder ( ) p4 Other—Type of Building ............................ No. of persons..................._-------- Showers ( ) — Cafeteria ( ) a' Oth fixtures -•-•• ••--••-•--•----••---•-----•••-•--•-••----•••---•••-•-••--•••--•-••--•-•......----••-•-••-•••- 5 330---------------------------..-....------ W Design Flow..•-••••......•••-•••-......-•.W)"gallons per pers�gq day. Toti gVow--------------------------------------- .- gjj)ns. WSeptic Tank—Liquid capacity_.......__:.gallons Length................ dth................ Diameter---------------- Dept ................ x Disposal Trench 1—No. .................... Widt .r•-----•-•-._--•• Total Length...... ............ Total leaching area•___. sq. ft.6 2>5�'------ Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) DosingEjaa} ,4a e Engineering 11-25-81 Percolation Test Res Its Performed by................. ..................... * Date•-•---•--•-.------. . --. . a .0 1Z '"•"--"'""--•••-•• • nbhe-••eYicbunteS— ,� Test Pit No. A-----_--_minutes per inch Depth of Test Pi Depth Depth to ground water_1,�/A............. g fi Test Pit No. ................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ -- - .......................•-------.......................................................... WO Description of Soil_--------d-i----_---�-r--- Loam �OpS01Iadx z ---_--1-0-,---•-.TVRdium...yellow- ----------------------- ----I.01._ _..•1V-----me3- wT1i'te---sandf`tra ?;---ag---gr°a-velfnu� water•--at-.12 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ,_ 4/ /84 -Signed.............................................................................x'1_eS . ApplicationApprov . ••••-••••. -----•----. ----------•...............................••--•----...•---- s . ........... j Date Application Disapprov for a following reasons----------------------------•--------•------------------•----•-----------------------......••-•-•-•----•-•--_.... ................................•---•-••--••••••--•••-••••---••--••--••------••••--•-----•••••--•----•- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ........... ........ O F................... ..... . .... . ...:..»...;- (Irtaftrtt#rzt�r rr THIS IS TO CERTIFY That the n lv'dual Sewage Disposal` ystem constructed (X ) or Repaired ( ) by.................................................Steve LeDe'1 - Lot A4 - Sandy ,ralle=_ Rd . InstalleMarstons Mills , fhA }'` at. •---•-......--•-••••---•--••••••-•----•........-•-............:.•-•---......-•••--•-•--••-----•••-••-------•-••--••••-••--••••••.....................s. has been installed in accordance with the provisions of T TL, 5 of The State Sanitary Code as described in the r. , application for Disposal Works Construction Permit No.._....r.__ _ .......... dated__...__.._...................................... THE ISSU NC OF THIS CERTIFICATE SHALL NOT BE CONSTRUED A GUARANTEE THAT THE SYSTEM SATISFACTORY. 7 DATE--- �TION --•............................................... Inspector......... ............ ................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable Ste`, No......................... FEE........................ Disposal Works T11ntr uan Vprrmit • Steve Lebel Permission is hereby granted -------------- ----•-----. to Construct ' or Repair ) an� dividVdSei&,age Disposal System at No.._..Lot -'� - 6an--y Va-.�ey x • , arstonS lls ,, 1�1A .=:•:,. ,........••••-••....•-•••---••••-••-•••-•................. Strom fJ � I as shown on the application for Disposal Works Construction ' it o..................... Dated.......................................... y ...... --...-•-......•••-•-•-•-------•-•-••--•--••...--•••-•••.........-•.........- DATE. ........................................................ Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS /VOTE /F JF17,YeAr Tip/&SEPT/C TAN/C OR ti 20 FT M/N bd GEACIy/ivG P/T 14over MORE TNA.N la"0ZLOW /O lrr M/�/ 'rR•�Oa�r, Al 24'D/AMETEK CONCRE7'!= C'OtWE.! �"i�Ye` PIPE StIALL BF B�POt16.•lT TO 4R�A!®E:.C.4N Asrnvva E�Ev CONCRLTE M/N. .o/TGN NEAYy CAST SHALL 04- US--CO i 63.S COVERS a.: Co✓ CL EAN SANG 4 _ L/QyID LEVEL 4: 2 LAYFR 4"CAST � .. IRON P/PE G/I • o o _ 0 Q QF �E - �d MIN.PlrCW i DOO L. ' a • • • . • • • • • d •,, WASHFO 570NE W PE'R TT. SEPTIC TANK DIST. • s , • . . • • , e . BOX o • • • B • s do �e e 2C. s 1 .• • • 3�4 = I �2� C L�ff ELT•7✓Z • r • • • D1�PTt/ • • 1 • • • WA5NED S70NE 0 .a • o rr • • • •• • 1 �• o , .:i . • • • • • • r• • •po - , o. . • • . • • • • • • p •�j, PRECA.ST SASJ5R44:r-E P/T DR LVU/V. iVv4wKr G'LE✓AT/O/VS !SO-S 'A 2-S= 2,7.7 a •. • • . . . . . • • e o . t FLU 53•5 /NYERT AT 0!//LD//VG o-S FT X I.0 11- 3 gFr o�ia�r. .SE�'T/C TANK 6 O •3 FT, 4 O G RD FT O/f1 M. C CSFE T�tital TIOiv) Ot/TLET SEPT1c.-TANK 2 / FT, per CAPRG�Ty INLET DISTR/454MON BOX F7.' SEG'T/ON OF GROVNo It�iTER Ti�QLE A S Ot/TLET,&,,s7 /BUT/ON BOoX S9 -7 FT, SEAVAGE OISA2 SA t SYSTMM INLET AEACX/NG /="-r s� sFT TABULATION L EACH/NG P/T SCALE %s" /-0 O/MENS/O/V A DES/G/Y CRITERIA DIl`IENs/oN 8 -F7- NUM9ER OF 9E&ROOM5 G4,q,S tGED/SR05AL UN/T SOIL LOG TaTA FLO*V 3 00,4Y S4/L TEST / So/L 7L5S7 2 S01L TEST A/UMBER QF LL�ACX/NT+ P/TS_�_ f ELE✓. 47,Lf rELEY, PATE OR- SO/,, TEST -1�� 4' 19&4 S/DE LEACH/NG PER P/T 5�9 PT O-3 LoFar• RESULTS h//TNESSED BYQ-BE -LJ000 61 9OTTOML04CN/NGPERplr—LL -1 w. A�: �•; & yo�� PERCCLAT/0l1/ MATE•/ G 2 M//V�IINCH i TOTAL LE4CH/NG AREA 21,14 SQ. FT. : 3 _ AERCotAT/ON RATE 12 RESPRl�E LE4CN/N6 AREA 2 a L+ SQ. FT 2 . y10pu` ME171LlM �RsvD PEli�f�j� -�f� p �/ 1/RG J ��`/ .� C�4C6� V✓ATR NBERu 1 r RoaEc�T �li�, , ��1=�t. 39- 2 ,{�ArA�t. !� VR�cep �� /Jl,�aS•v.ys ;�i �' �"� � No. 366 BRUCE a PF c g �D2ED °�FSS ON.LE .�q s EL DREDGE EArrl 441 NG. -.� 7/2 MAIN -5Til HYAiVN/9, /NA.SS. NOGROUND kV,�4TER JWCOU/V7AK .L�o Ct/ENr: FRR„�c:v 0.47 ffilu/zL,9 �NO sli d` Imo. GRouNa JW.4 rFR Ar-ELE "2 .IOB' NO.S _2, OF 2- - 4 CATGh$AS,pI )'I V A 4 G 6 0 g L. 604 9,7 o 100 a SE Y ,30+ #k PRop r a tu �.f - �.•/ /"r,,.I�i Wit" __ ".,ti` _ F�.; w � � '/y��/I..•-ter '� _- 0� � �`M_ S�' � + x Lo T I14 4 TEST' 4 7 i o, 0 86 9 6 y > P x o S"''`� �/ys 4 LEGEND h: 'EXISTING SPOT ELEVATION 0„0 ZONC RF OF ` CERTIFIED PLOT PLAN ' ' EXISTING .CONTOUR ---- p --- - 9T !y $ANDy VI94LEy R �4p2 FINISHED SPOT ELEVATION ACi?E P MARs 7-OW--S- M/LLS FINISHED CONTOUR 0 ERG :s366 IN F. APPROVED BOARD OF HEALTH 3o/jc/!�. ��oF ,C7A �RA/ 5 7,q 9 LE S�QNkL DATE AGENT SCALE 0 DATES 312-9 18y LDREDGE ENGINEERING Co' IN `'` '�.;y� of CLIENT '���� `�' I CERTIFY THAT THE PROPOSED eA' PE ROBERT EGISTERE REGISTERED JOB NO. 2 � 6RucE - BUILDING SHOWN ON THIS PLAN CIViL LAND _ ELDREu v' CONFORMS TO THE ZONING LAWS " ;•S ENGI!;EER URVEYO DR BY, ,� OF �r�+s,•.!s% c'�EE , MAS ' f It, 712 M A IN STREET . CH. 8Y `r i ,C WAEY HYANNIS MASS,' REG. LAND SURVEYOR r