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HomeMy WebLinkAbout0326 SANTUIT-NEWTOWN ROAD - Health 326 SANTUIT-NEWTOWN ' (� �p A = 045 038 - I iI TOWN OF BARNSTABLE LOCATION 3Z4,_ ,,4y,'4 Mr_uj400,>m RL-SEWAGE# Z021 - y53 VILLAGE (I. ( ,'11.5 ASSESSOR'S MAP&PARCEL qT- 3$ INSTALLER'S NAME&'PHONE NO. g ik,g ExcaucA ion 14 111- 06S3 SEPTIC TANK CAPACITY /o00 o a I LEACHING FACILITY. (type) .SDo 9a.1 Llc (-0 (size) 13 x ZSx 7- NO.OF BEDROOMS 3 OWNER F-rc L 0-sory4o5 PERMIT DATE: ►2.22 .2 I COMPLIANCE DATE: l_qXJ 2 I 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 N c vp LL M 3�^ 43 , O g2, L49►L,„ A3. 93.b„ (33 9G,t 3 Ay, 93,L,, �3y , 95,5�� No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: YQ �l PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for Bisposal 6pStr tt Construction 3permit Application for a Permit to Construct( ) Repair(k) Upgrade( ) Abandon( ) ❑Complete System ®Individual Components Location Address or Lot No. 32(o San'f 4 - WQifowi R4 Owner's Name,Address,and Tel.No. K6 00. I �re d cisci S Assessors Ma /ParcelmaGStonS Mills b $o,,6k- 1�1IZO1 o, p �5 - 3 g 32 td MOrbtOrd AllS Installer's Name,Address,and Tel.No. 4 g Cr X CO3V tjQ,, IIK. Designer's Name,Address,and Tel.No. 3 4 tZo�i 13a Sandw;�l, Sag �I�� o(,s3 Mm 4,m fornt4ak West 60,(nS+0,\b1, Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(NO) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 3) gpd Design flow provided 1,50 gpd Plan Date 12 1 10 ( 2 Number of sheets I Revision Date Title Size of Septic Tank k 000 OAuOn Type of S.A.S.(Z) 5,00 nakkon G6ambec's Description of Soil Sf 1 Jos Nature of Repairs or Alterations(Answer when applicable) 1 n StL2,10_,6n Of (1) S U o p kko n dno,^6u Connec,k:n)� {-d ex.'ski 1000 o�&Uon S At nk,• Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date 9 Application Disapproved by Date for the following reasons Permit No. '"— 5-3 Date Issued oZ oL Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ) r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippliLatlon for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(k) Upgrade( ) Abandon( ) ❑Complete System ;=❑X Individual Components r-� • Location Address or Lot No. 32.(o SC,niu.t �uy 1 k({ Owner's Name,Address,and Tel.No. K[ .f r, I Fcc tk LA 3`fl r.: AssessorsMap/Parcel �n '�t'r`.ia :s Installeyyr's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 1-� cjQlJ �17Y 't�� j' t�(;'i3 VJ�JM �l1V.CJ�"Yl{(i{G� �Q;t �f�f!�>Tf:Ji4 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(N,i) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 50 gpd Plan Date 121 to 2 k Number of sheets Revision Date Title s Size of Septic Tank k 0ou c1:_,16ur, Type of S.A.S.(2) ;00 rx-,, o J _ Description of Soil C e c Nature of Repairs°or Alterations(Answer when applicable) �10 e,11CA wr% f')C, 4,u C211'1C0 r`v A Date last inspected: Agreement: The undersigned agrees to ensure the conAruction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. f Signed LQ ,�-� Date Application Approved by Date /ap Application Disapproved by Date for the following reasons Permit No: / "` "'Date Issued ,�,a_62 f r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliartr>e,'. THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( )' Repaired(Y) Upgraded( ) Abandoned( )by �l 4X C(aUCC or\ �11C at Van n{u. �I Q of o to l n 1�CI• .j {S has been constructed in accordance / with the provisions of(Title 5 and the for Disposal System Construction Permit No_.,#WcA( /�e dated Installer F').,.3 (� LK(,1 jN r, �!J( . Designer #bedrooms Approved design flow . gpd , w 1 The issuance of this permit shall not a construed as a guarantee that the syste ill funIs,cti o n a designed. Date �' / Inspector\_� Fee ------ r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( tt) Repair( x) Upgrade ��( ) Abandon( ) System located at �� jn�,� t ;,l 91 t,{u and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be co pleted within three years of the date of this permit.. Date Approved by, Town of Barnstable j"ETO'�ti Regulatory Services Richard V. Scali,Interim Director * iARN3TABLE. • . NAn Public Health Division D MA'S A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-8624644 Fax: 508-790-6304 Installer&Designer Certification Form Date: 11 Z�KVPWI Sewage Permit# QQ ( - �553kssessor'\Map\Parcel - - Designer: Installer. Address: �� Lj 1 1�.A(� C� Address: __ On I2 ZZ was issued a permit to install a (date) (installer) septic system at o ►`-'� V r based on a design drawn by A (address) -- TAAJig �3 ��' W2� dated ? ,® Z (designer) � V2 li�i I I ZI certify that the septic system referenced above was installed substantially according to the design, which may include minor.approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required)was inspected and the soils were found satisfactory. I certify that the system referenced above was construc_;�►A�-_:�-nuance with the terms of the IAA approval letters (if applicable) aF/14gsF, DAVID jr' 9. c. MASON m (Installer's Signa a A� S, No.toss a +, FQ/S tE�� �� s'tNI TARS (Design s Signature)-/ (Affix Design r s S amp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. QASeptic\Designer Certification Form Rev 8-14-13.doc Sv(c TOWN OF BARNSTABLE L/I1P�cc�•✓ LOCATION SEWAGE# C92`� VI;i.LAGE �rJ A SJvh j Ali/, ASSESSOR'S MAP&LOT(J 2'r 0 3 8 INSTALLER'S NAME&PHONE NO. 2 SEPTIC TANK CAPACITY 116066,11 LEACHING FACILITY: (type) t5 X 8,?/—,5i c'�� (size) 4 oU 0 Gam" NO.OF BEDROOMS 3 BUILDER OR OWNER DA Me4c `12. PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ��� '— Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �o® � Feet Furnished by GD R0 an `-Bv AM p V Z �o d TOWN of BARNSTABLEA S �..f AOE S . ASS Oit S 1�-P.&LOT VII.L iNTsTAL*LE'R'S NA NE&PT49M-NO. SEPTIC TANK CAPt1t�'I'Y �.(�D� LEAC.II€NGTACII:�1'Y {types} 7 {size) 1 o.C, o. s 3r BUILDER oR UtrdER � � cO r aC =DAB Separattan Distance Bey-'oen..Lbcl MaXiznum Ad ustect Crroundu+ater Z' €le to the Bottam o¢ ac img Fa i�ity Feet Private Water Supply;well and Lzac g Factiaty ,( auy we exisi oa.sits or within Zt1£9 feee of Iessttg facility) Iieei Edge of WetI6t and Leaching f�ac liry(If any wetlapds exist witwn:jOo feet of-leaching facility} j rfeet Furnished by, . B� w a � � _ yy° Lt r � 1 Tow� Commonwealth of Massachusetts Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 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 Ev luation by the Local Approving Authority 11-17-14 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspectio orm:Subsurface Sewage Disposal System•Page 1 of 17 r ' Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described I in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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): t t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N . ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply . ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ ® Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 years usage (gpd)): Well water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 2013Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information isMarstonsMills MA 02648 11-17-14 required for every 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: 1980's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24" at tank inlet 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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 18"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: 1000 gal Sludge depth: 12" t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from'top of sludge to bottom of outlet tee or baffle 20" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. Grease Trap (locate on site plan): Depth below grade: feet Maternal of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. 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 ass. P P 9 Y P Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good condition and empty at inspection with stain line at 30" below inlet invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately 39 Loi A -0- ylf z? 13 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 16' 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: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at 16'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 326 Santuit-Newtown Rd Property Address Kevin Amundsen Owner Owner's Name information is required for every Marstons Mills MA 02648 11-17-14 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, 6, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 i 1 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L. -it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FI., 36' Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is req u i red by l a+.iv. DATE: b Fill in please: "Y APPLICANT'S YOUR NAME/S: r o5 BUSINESS YOUR HOME ADDRESS: Lo -�: - Win t�S A TELEPHONE # Home Telephone Number - 01 NAME OF CORPORATION: NAME OF NEW BUSINESS TYPE OF BUSINESS IS THIS A HOME OCCUPATJON? YES NO ADDRESS OF BUSINESS o210 Lklajah ecl 4iy -001- Kits MAP/PARCEL NUMBER Q45 D $ (Assessing) When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. �S3NIJ NI linsDu Adw odwoo 1. BUILDING CO MISSIO R's OFFICE 0131�t111d3 �sN011tflno3� aN� s3lna This indivi ua e i or e a pe i requirements that pertain to this type of business.N0IiVdn000 31NOH HlIM AldW00 ism Aut oriz S' rra e** MrNTS. iv 1)-'rQ U--�p\ k 2. BOARD OF H LTH ' �" =L * This individual has been informed of t t; � e nts that pertain to this type of business. MUST' LL HAZARDOUS MATERIALS REGULATIONS Authorized Signature COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: r C I � TOWN OF BARNSTABLE Date: �.�// TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAME OF BUSINESS: BUSINESS LOCATION: - MA44SKIk INVENTORY MAILING ADDRESS: TOTALA,MOUNT: TELEPHONE NUMBER: LQ12- 570 -$o2g1 CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? TYPE OF BUSINESS: M'�,,n S-baK2 ( �I�S INFORMATION / RECOMMENDATIONS: Fire District: ccA W11 Y-D SPrac Y4 room 1 Ca ase . Waste Transportation: tJA Last shipment of hazardous waste: Name of Hauler: Destination: Waste Product- Licensed? Yes No NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use, storage and disposal of 111 gallons or more a month re uires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED - Degreasers for engines and metal Printing ink Degreasers for driveways&garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous(please list): Metal polishes Laundry soil &stain removers (including bleach) Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash — WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials Town of Barnstable Regulatory Services ` o Richard V.Scali;Director ILX . = Building Division 9cb 1639. `� Tom Perry,Building Commissioner �En tnt•'t 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: Permit#: . HOME OCCUPATION REGISTRATION Date `115_I 1 Name: Il'1.ST(q -SpmbS Phone Address•5p(�o � Village: ) Name of Business:it""``..�Yl s�)C) Q �( ,(C o nd Type of Business:A-��i(.�1�o4 SOS Map/Lot:_ a� I d INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling. there shall be no increase in noise or odor,no visual.alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: , • The activity is carved on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment • There are no commercial vehicles related to the Customary Home Occupation,other than one van dr one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant•```'-S—V—- (I"ktivvDa lto te: Homeoc.doc Rev.103113 ti. T Commonwealth of Massachusetts Executive Office of Environmental Affairs Department ofi� �►a,�� Environmental Protection JAN 3 1996 William F.Weld 111VrRJOFBgRf"TARE } Governor diF�1 NDEV[ Trudy Coxe Secretary.EOEA David B.Struhs Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 6 PART A CERTIFICATION Address of Owner: Property Address: 3d6 tvcwTo..h t2d. P1'PkRs ie.,%s 6.k\5 Date of Inspection: -Dec. 23,tcjc(S (If different) Name of Inspector: Go,%,3,.� Company Name, Address and Telephone Number: O C-e,4\ T_o.Sox L S`t CERTIFICATION STATEMENT 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 inspection. The inspection was performed based on my-training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: ec_ ,GCS The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. e. 1 revised-e/i5/95i One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500 A `= Printed on Recycled Paper t. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 3016 Owner: Nl�ai�io;v C1,1� Date •ji Inspection: Dec.a3,1MIS 61 SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled'or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed C1 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system•has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private-water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D1 SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded-or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. revised 8/15!55; 2 a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 3a6 ,ve�Tow„�1, Property Address: Owner: 'Sc�.� 3)ral`tecz.o Jt2. Date of Inspection: ZJec. a 3,��SS D) SYSTEM FAILS (continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. _ Required pumping more than 4 times in the last year NOT due-to clogged or obstructed pipe(s). !Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSITM FAILS: The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. • ;revised 8/15/95) 3 t t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: l Owner: ' o NI., Z). 01 S2, Date of Inspection: �eC. a3t\oiciJ� Check if the following have been done: IL-I"P—Imping information was requested of the owner, occupant, and Board of Health. ZNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as pan of this inspection. �As built plans have been obtained and examined. Note if they are not available with N/A. _jL*'T_he facility or dwelling was inspected for signs of sewage back-up. Z'The system does not receive non-sanitary or industrial waste flow ZT—he site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. ZT—he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition oN)affles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Zhe size and location of the Soil Absorption System on the site has been determined based on existing information ov. approximated by non-intrusive methods. ,t/"The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. - 1 ° revised Si15195; 4 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: t° Ac-;Tu r., Owner: Sc�•n �a�Tect,o;S2: Date of Inspection: �eC.a3)�CAS FLOW CONDITIONS RESIDENTIAL: Design flow: 336 gallons Number of bedrooms:3 Number of current residents: Garbage grinder (yes or no):NO Laundry connected to system (yes or nol.�!e5 Seasonal use (yes or no):Ng Water meter readings, if available: Last date of occupancy: COMMERCIAUIN DUSTRIAL: Type of establishment: Design flow: gallonsJday Grease trap present: (yes or no)_ 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) 5 ,revised 8/15/55) c. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection:S�'�`^ 1�.�t3fCeli��)Zk. 'b SEPTIC TANK:J (locate on site plan) Depth below grader Material of construction: izIc"O'ncrete _metal _FRP —other(explain) Dimensions: 7/ jo" } S 9 Sludge depth: I „ Distance from top of sludge to bottom of owlet tee or baffle:-3 Scum thickness: f�Ti�J��/�� °'n Distance from top of scum to top of outlet tee or baffle: O-/'/o .Sc: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tee or baffles, d qth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) leoj f)Pab %A GREASE TRAP: (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) e revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 3 al. Property Address: t'tA21ZoN�`�\S Owner: Date of Inspection: ���^ �•�t��Te2�o JZ, 7ec.a3;\�i�i5 TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: galIons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:V (locate on site plan) Depth of liquid level above outlet invert: Eve Comments: / (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 G SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 3a6Me..To.,, �. Property Address: Owner: So`.,•1,�S�LT�2.a,�R. Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: /' /mob 6A) leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: 'Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) v s16 nj e ro CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) 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.) trevised B/:5/95) $ r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 3a6 r•��.:�'�aw��� C'�AnTo�� h.\\► Owner: _ Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' OC,r2 i DEPTH TO GROUNDWATER \ r Depth to groundwater:C284 feet /' ,-(— method of determination or approximation: 9 izevised 8/15/95) TOE OF BAMSTABLE LOCA170N SEWAGE # VIL+ _ /1 t G 1- 5" ASSESSOR'S KAP&LOT IhTSTAL1-WS NAAdE&PHONE NO. . SEPTIC TANK CAPACM _/0 DU _ LEACHING FACILrlr: (type) _ (size) NO.OF BEDROOMS 3 BUILDER OR OW-rZER PERMITDATE: C©i1VLJANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Fees Private Water Supply Well and Leaching FPcility (If any weUs exist on site or within 200 feet of leaching facility) ?=ceet Edge of Wedand and L.eaclung Aacil.ity(If any wetlands exist Co C C 12 77,E � N r D I No. W- .0 o 12'b37 Fee BOARD OF HEALTH TOWN OF BARNSTABLE Zfpprtcattou _for Yell Con0ructtou Permit Application is hereby made for a permit to Construct( Alter( ), or Repair( ) an individual well at: SG us� — )''`Ills Location-\Address Assessors Map'and Parcel Owner Address Installer-Driller Address -2 i Type of Building o I Dwelling Other-Type of Building No. of Persons Type of Well Capacity Purpose of Well 17MS� t,rrck Ac--y..9.rn.eXA Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Pro ction Re u -The undersigned further agrees not to place the well in operation until a Certificate of C m c a been issued by the oard of Health. Signed i 1 �Z Date Application Approved By Date Application Disapproved for the following reasons: Date Permit No. W d D 11- 0 3 :2 Issued- Date --------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed( ), Altered( ), or Repaired(') by Installer at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. ((��� 1i'y�� Feel]< BOARD OF HEALTH TOWN OF BARNSTABLE 2pplication if or Yell ConfStruction Vermit,' Application is hereby made for a permit to Construct(Alter( ), or Repair( ) an individual well at: 3 (- SG W A — V,3 ewt o rl W . )A M S Location-Address Assessors Map and Parcel Owner Address IA 11 Cape wek\ T C. �o� 1-k(--. .,s- QY Installer-Driller Address Type of Building o Dwelling, Other-Type of Building No. of Persons Type of Well Capacity Purpose of Well t"` mS-C t.-r c—k Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Com nc hal been issued by the)Board of Health. a '! Signed t 2j 1 k ,Z Date Application Approved By Date Application Disapproved for the following reasons: Date Permit No. w ,)D 11—0 3 :2 Issued 1 Date i BOARD OF HEALTH TOWN OF BARNSTABLE r j Certificate of Compliance I THIS IS TO CERTIFY,that the individual well Constructed( ), Altered( ), or Repaired(' ) by Installer 1 „ at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. — Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Vert Construction Permit No.��1�..--' b ?j� Fee `( ----- Permission is hereby granted to jLk (AAa— !!i � I Installer to Construct( ), Alter( ), or Repair an individual well at: II' No. f rn Street as shown on the application for a Well Construction Permit No. W 0) `L Dated t �� 1 Date '' �� Approved By —o= �- 1) Th lation steal!comply with the State Environmental Code Title V rand Town of 4 TEST HOLE LOGS ASSESSORS MAP. kI Board of Health Regulations. + PARCEL: . 2) The,septic system as proposed on this plan shall not be installed until SOIL L=VAtUATOR. p u i a iicensed.town q Installer receives approval and an installation permit from the applicable town. REFERENCE: WITNESS: 3 Prior installation, . . I ion the installer sh all all verify the location of utilities,sewer inverts, I ' tQ b sewer lines and existing septic components prior to installation. DATE: 4 All gravity sewer} g tY piping is to be 4 inch schedule 40 PVC at 1/8' per foot. The first 2 .�, � lI 7� VAIWPERCOLATION RATE: �✓ � � feet out of the distribution box shall be level. All piping connections to be glued. ' S) This septic design plan is not to be utilized for property line determination or for any T.H.#1 ELEV. ADD T.H.#2 ELEV. other purpose other than the proposed septic system installation. LOCATION MAP 6) All Title V components are to meet Title V specifications. 7) Parking shall be prohibited over Title V components unless components are H2O 1X j loaded. 8) The existing leaching or cesspools shall be pumped and filled with material per Title V + rye ' abandonment procedures. Leaching and cesspool(s)and contaminated soils within 7Athe proposed SAS shall be removed and replaced with`dean sand per Title V specifications. 9) Septic components are to be 10'from a water service line.Sewer lines crossing a water line shall be sleeved with an appropriately sized schedule 40 PVC with ends Ile! _.. V� r 4 i { grouted. The water service line or the septic line can be sleeved with the sleev b i 1ti � ,(�� Pt e e ng a distance of 10'on both sides of crossing the line. 04, 10)If a garbage grinder exists in the structure,it is to be removed if the septic system is y not designed to accommodate a g 8�d garbage grinder. , 3 - 21)The installer is responsible for care of excavation around all utilities on the r h property Igdv' SEPTIC SYSTEM DESIGN CALCULATIONS and protecting the structural integrity of all structures during the installation process I of the septic system. f FLOW ESTIMATE: 12 This a ) s plan only represents that a septic system can be installed on the property meeting Title V requirements. BEDROOMS AT ��� GAL/DAY/BDRM= ��:/v GAL/DAY � 13)The property owner shall review design criteria to approve the total number of SEPTIC TANK: bedrooms and design flow.Installation of the septic system asproposed and recei t 'Rt�.�uR•Vl-� � � � � pt Y p f = of payment for e design - GAL/DAY/BDRM X 2 DAYS _S GALLONS P Ym the shall be deemed approval of the design criteria by the I USE GALLON SEPTIC TANK K. ;) ( ► property owner or agent of. Vol 14)The validity of this plan shall expire with the expiration of the town installation perm'p t (GARBAGE GRINDER IS PROHIBITED) issued for this plan or the validity of this plan shall expire on the expiration of the _t - Certificate of Compliance issued for the installation of the proposed system on this i s I - SOIL ABSORPTION SYSTEM: `+ plan. r � ��" �+�/� t �M t 67,4 5 -.4- SEPTIC SYSTEM SECTION , BENCHMARK G u• b ZCX� fQ,1 � TOP OF FOUNDATION ,m ELEV. -7400 OD ¢ 101 (DATUM ASSUMED) 6"STONE BASE j ID ® � � H2O D- t- BOX t� t 6g STONE BASE OR COMPACTED BASE p WATER TEST FOR LEVELNESS ., GALLONS DF 71b T 1 - r y SEPTIC TANK . i I SITE AND SEWAGE PLAN - _- ( , I LOCATION. �� � d M UA�VII� MASON rn R\ PREPARED: W4- t2- SCALE: DATE: /% . /r M { I