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HomeMy WebLinkAbout0195 SETH GOODSPEED'S WAY - Health L 95 S:- 07=7 arston= 12 N-4D �. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every OStervii/e MM MA 02655 1/18/21 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. Inspector Information S/4F / 513 Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 Cityrrown State Zip Code 508.272.6433 13010 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails le 1/18/21 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts ,�-p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) 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): t5insp.doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 I Commonwealth of Massachusetts �. Title 5 Official Inspection Form ((� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4'e •� 195 Seth Goods eed's Way Y Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �n ,io Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •� 195 Seth Goodspeed's Way Property Address Gazolla Owner Owners Name information is eve required for Osterville MA 02655 1/18/21 Q every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: 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 pormal 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form t~ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: 3 bedroom permit and plan from 2008 on file at BOH Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: 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)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Ii� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �o 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No recent pumping per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. 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): r f Approximate age of all components, date installed (if known) and source o information: Original septic tank new d-box and infiltrators 2008 per BOH record Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5. Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts �. ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 2' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank is 2' below grade, it is under the paver patio If tank is metal, list age: years II Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000g 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness 2" Distance from top of scum to top of outlet tee or baffle >2" Distance from bottom of scum to bottom of outlet tee or baffle >2" How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3yrs to prolong the life of the system t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 i Commonwealth of Massachusetts �. ,ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 I Commonwealth of Massachusetts li� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Cisterville MA 02655 1/18/21 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. 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.): H-20 box is 2'6" below grade, cover raised to 12" of grade, it is also under the paver patio, no adverse conditions observed t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ® leaching chambers number: 3 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ,io Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. City/town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leach pit has previously failed in 2007 it was left in place it was not inspected, the infiltrators were added in 2008, they were video inspected and are damp at this time, no indication of past hydraulic failure,bottom of chambers is approximately 5' below grade 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owners Name information is required for every Osterville MA 02655 1/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (ncte condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 14. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 i 1/18/2021 Assessing As-Built Cards TOWN OF��BA"RNSTABLE ���/ LOCATION ��J Cep( ©u.0 We v SEWAGE# UO biz VII LAGE 6 ASSESSOR'S MAP&PARCEL a a INSTALLERS NAME&PHONE NO. 5 WA SD j( aCA11 L)0lA SEPTIC TANK CAPACITY l".X�S� 1 U l�l] p C3oX r C Y Itt P.''L _ LEACHING FACILITY:(type) tJ (size) d?, .73 X /d. S K TTinCrN�t-�.'ttf+ts a Feet NO.OF BEDROOMS OWNER 3(_ct\ PERMIT DATE: i t u I O COMPLIANCE DATE: Separation Distance Between the: ( Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �i1 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 facirlity))� Feet FURNISHED BY ^'— `CAP i. _r— 3to A ko N"Rox a_5 A AM -l"I ft.Q04 toa 13+0 w P v� 3U P� 'L�aQct.Pa�k sy u - s • �1l1Spz�c��� 'r ol�i't https://www.townofbamstable.us/Departments/Assessing/Property_yalues/HMdisplay.asp?mappar-122077&seq=1 1/2 Commonwealth of Massachusetts ,�F Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �,. 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water Z Check cellar ❑ Shallow wells Estimated depth to high ground water: >144"feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 2008 NGW 144" Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: 4'seperation per 2008 compliance ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping puts the site at 44'msl and nearby surface water at 22'msl You must describe how you established the high ground water elevation: See above Before filing this Inspection Report, please see Report Completeness Checklist on next page. " t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 1 A Commonwealth of Massachusetts ,F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 195 Seth Goodspeed's Way Property Address Gazolla Owner Owner's Name information is required for every Osterville MA 02655 1/18/21 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, Ak ,M 195 Seth Goodspeed Property Address LA Scott Peacock Owner Owner's Name information is �A MA 02655 4/19/2018 ' required for every !'1 page. City/Town State Zip Code Date of Inspection ' t:f t Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important.When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not James Ford use the return Name of Inspector key. Ford Septic Services LLC r� Company Name P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S12482 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes F ❑ Fails %Inspecto Further Evalua ion by the Local Approving Authority ` 4/23/2018 nature Date inspector hall submit a copy of this inspection report to the Approving Authority(Board 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 1 of 17 t5ins•3113 �y�td ors Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 195 Seth Goodspeed Property Address Scott Peacock Owner Owner's Name information is required for every Osterville MA 02655 4/19/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): l5in5•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 195 Seth Goodspeed Property Address P Y Scott Peacock Owner Owner's Name information is required for every Osterville MA 02655 4/19/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) El 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 I Commonwealth of Massachusetts Title 5 Official Inspection Form M1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 195 Seth Goodspeed Property Address Scott Peacock Owner Owner's Name information is required for every Osterville MA 02655 4/19/2018 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 1/2 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 195 Seth Goodspeed Property Address Scott Peacock Owner Owner's Name information is required for every Osterville MA 02655 4/19/2018 page. Cityrrown 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 CM 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 Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 195 Seth Goodspeed Property Address Scott Peacock Owner Owner's Name information is required for every Osterville MA 02655 4/19/2018 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 �r 195 Seth Goodspeed Property Address Scott Peacock Owner Owner's Name information is required for every Osterville MA 02655 4/19/2018 page. Cltyfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: unavailable Sump pump? ❑ Yes ® No Last date of occupancy: currently Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): - Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a c Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 195 Seth Goodspeed Property Address Scott Peacock Owner information is Owner's Name required for every Osterville MA 02655 4/19/2018 page. CitylTown 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: pumped yearly for maintenance Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner),and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 195 Seth Goodspeed Property Address Scott Peacock Owner information is Owner's Name required for every Osterville MA 02655 4/19/2018 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: A leach field was added in 2008 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 13" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene y ❑ 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 H-10 Sludge depth: 2 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments •'�� 195 Seth Goodspeed Property Address Scott Peacock Owner Owner's Name information is required for every Osterville MA 02655 4/19/2018 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 25 Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 5 Distance from bottom of scum to bottom of outlet tee or baffle 10 How were dimensions determined? measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tees were present. No sign of leakage. Grease Trap (locate on site plan): Depth below grade: n/a feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El 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 Mom Title 5 Official Inspection F Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Form 195 Seth Goodspeed Property Address Scott Peacock Owner Owner's Name information is required for every Osterville MA 02655 4/19/2018 page. Cityf-rown State 0 Code P 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.- n/a Material of construction: ❑ concrete ❑ metal ❑ fiberglass 9 ❑ polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for VoluntaryAssessments 195 Seth Goodspeed Property Address Scott Peacock Owner Owner's Name information is required for every Osterville page. City/I own MA 02655 4/19/2018 .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 even' 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.): The H-10 D-box was normal, speed levers were present and the cover was 10" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Seth Goodspeed Property Address Scott Peacock Owner Owner's Name information is required for every Osterville MA 02655 4/19/2018 page. City/Town State Zip Code Date of inspection- D. System Information (cont.) Type: ® leaching pits number: 1-1000 gal. ® leaching chambers number: 3 infiltrators ❑ 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.): The chambers had 3" of water on the bottom. The scum line was at the same level. There was no sign of failure. The pit had 3'of water on the bottom 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 t5in3•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts l Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Seth Goodspeed Property Address Scott Peacock Owner information is Owner's Name required for every Osterville MA 02655 4/19/2018 page. City mown State Zip Code Date of Inspection D. System Information (cost.) 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.): N/a I t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts G v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 195 Seth Goodspeed eed Property Address Scott Peacock Owner Owner's Name information is required for every Osterville MA 02655 4/19/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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 1 I V I 3 L__F_,T 07 y � B 0112110 aq s 3 �°► 33 'c" a sY t51ns•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 19 5 Seth G oods e ed Property Address Scott Peacock Owner Owner's Name information is required for every Osterville MA 02655 4/19/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: 0 Check Slope ❑ Surface water 0 Check cellar ❑ Shallow wells Estimated depth to high ground water: 25' +/- feet Please indicate all methods used to determine the g high gr ound ound 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: using water and Topo maps. 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 195 Seth Goodspeed Property Address Scott Peacock Owner information is Owner's Name required for every Osterville page. City/I own MA 02655 4/19/2018 State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 I ' r Commonwealth.of:Massachusetts Title 5 OfficialInspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments operty Address / ell - Owner �( . wner's Name information is / �,,` required for MIA- (,bmPZ every page. City/Town State Zip Code—' Date of nspection ". Inspection results must be submitted on this form. Inspection forms may,not be altered in any way. fi Important: r When filling out A. General-lnformatlon form"s on the computer,use, 1-. .I ctor: only the tab key _ to move your cursor-do not use the return of•1.spector key, parry ame (� D C m ny Address , F a A C'ty%Town State Zip Code Telephone Number License Number B. Certification rr _ IQ 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: pefinsctton.The inspection was performed based on my training and experience in the:proper.:function.and maintenance of=on site-. sewage disposal systems..)am,a DEP approved system inspector.,pursuant to Section 15.340 of Title 5'(310 CW 15.000).The ystem. 07 ❑, Passes ❑ Conditionally Passes A [�iFa is ❑: Needs Furth valuation by the Local Approving Authority 1 , Intor 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 a*uthority: **"*This report only describes conditions attheAime 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 user t5irisp.do6•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 16 t r . i . Commonwealth of Massachusetts I 0 Title 5 Official inspection Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments P.o rtyAddre&s. Owner O r-Name 9107 information is 4A ,00 required for Q"/i/`► d every page. Cily/Town State Zip Code Date of Inspection B. Certif cation''(cont.) Inspection Summary:Check A,B;C D.or.E/alwaysfcomplete.all of Section D:•: A) System Passes: ❑ I have not found any information which indicates that any of the failure.criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criterial not evaluated are indicated below. Comments: B) System Conditionally Passes:' ❑ One or more system.components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,�as approved by the.Board of Health,will pass; Answer yes, no:or not determined(Y N;_.ND) in the ❑for the followingi.statements. if"not determined;"'please explain. The septic tank is metal and over 20 years old*or the septic tank(whethermetal;or not) is structurally unsound, exhibits substantial infiltration or exfiltt'ation'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. ND Explain: i ❑ -Observatiion of sewage backup or break out or high static.water level to the distribution box due to broken or obstructed pipe(s) or due to.a..broke.n,.settled or uneven distribution.box..System will pass inspection If(with approval of Board of;Health); . ❑ broken pipe(s)are replaced;.. ; obstruction is removed 151nsp.cloc,08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �p y Address" Owner i O. r s N e nformation is V,�.- required for /� every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due tobroken 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 ND Explain: 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 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. t51nsp.doc.08106 ; Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 i i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form-Not for Voluntary.Assessments i /J Pe erty Address T Owner er's Name information is required for �.. Cit /Town every page. Y State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board:of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less Y p than 100 feet but 50 feet or more from a private water supply well**.. Method used to determine distance: **This system passes if.the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicateS..absent and the presence of.ammonia nitrogen and.nitrate.nitrogen is equal to or less than 5 ppm, provided that no other,failure criteria.&e triggered.A copy of the analysis must be attached to this form. 3. Other: Dp System'Failure Criteria Applicable to All..Systems: h y :You-must indicate"Yes"or"No"to each.of the following for all;nspections: Yes No Backu p of sewage in to facility ors ste m com oven u p 9 t due to overloaded or Y P 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 El 10/ Static liquid level in the distribution.box above outlet invert due to an overloaded or clogged SAS,or.cesspool ElLiquid depth in'cesspool`is less than 6"below invert or-available volume is less than'%day flow ElRequired 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 orprivy 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. 151nsp.doe•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of.15 f Commonwealth of.Massachusetts Z _ Title 5 Official Inspection Form Subsurface Sewage Dis osal Sy stem Form Not for voluntary Assessme nts 9 p Y— ry P y Add r ss + Owner 0 . 's Name information is required for every page. Cityrtown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Ey 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 nitratenitrogen is equal to or less than 5 ppm, provided that no other faiitire 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,ownershould 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'ot 10000 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 40.0 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ 0 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. t5insp.doc•08/O6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 Commonwealth of Massachuset ts Title 5 Official Inspection Form Subsurface,Sewage Disposal System Form-.Not'for Voluntary Assessments J� - _ erty Address Owner A p is Nape— information equir is t p required for 'sL�t' 'T every page. Cit.yggwn . State Zip Code Date of 1 specti n 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.facillt or dwellln ,ins ected for signs of sewa a back u .� y g. p g g p. (l ❑ Was the site inspected for signs of break out? ❑ Were all'system components,,excludirig 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? r Was the facility owner(and'occupants if different from owner)provided with ❑ information on the proper maintenance of subsurfacesewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has . been determined based on: .❑ Fxisting.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 �v approximatibn of distance is unacceptable) [310:CMR.15,302(5)] t5insp.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-,Page 6 of 15 4 Commonwealth of;Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 411 /Rrop1Kt y Address _ Owner O r N me information is required for HT r' Qr�Cr/ !2 D� every page. City/Town State Zip Code Date o Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 god x#of bedrooms): Number of current residents: Does residence have a garbage grinder? ❑ Yes Pj""No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes Q No Laundry system inspected? ❑ Yes 01,""No Seasonal use? ❑ Yes 0/"No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes [2/No Last date of occupancy: Date Commercial/Industrial Flow Conditions: ( ..Type of Establishment: Design flow(based on 310 CM 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? .❑ A ❑ No Non-sanitary waste discharged to the Title 5 system? ❑.Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5insp.doc•08106 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 15 t Commonwealth of Massachusetts Y Title 5 Official. Insp ect'ion Form, , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Pr e rt Y Addres ' Owner O er's Narrle information is required for every page. , Citylrown I, State Zip Code. Date of Inspection D. System°Information:(cont:) General Information .Pumping Records: f Source of information: Was system pumped as'part of the inspection? ❑ Yes No If yes, volume pumped. gauons • How was quantity pumped determined? Reason for pumping: Type of System: i- ❑ Septic.fank,'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 5 ' maintenance contract(to be obtained from"system owner) ❑ Tight tank.Attach a.copy of the,DFP.approval. ©� Other(describe): App oximafe age of all components, date installed(if known) and source of information: Were sewage odors detected when arriving at thesite? ❑ Yes No 15insp.doc•08106 t, ' Title 5 Official Inspection Form:Subsurface Sewage-Disposal System-Page 8 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,,--PTisp rty Address ; Owner Q s Name information is required for every page. City(rown 'State Zip Code Date of Insp ction D. -System.Information (cont.) Building Sewer(locate.on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑other(explain): Distance from private water supply.well or suction line: feet Comments(on condition of joints,-venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feel Materia construction: oncrete ❑ 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 J �,Dimensions: , Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 15 i< i Commonwealth of(Massachusetts MW Title -5 Official Inspection, Form Subsurface Sewage Disposal System Form . Not for Voluntary Assessments erty Address Owner w is Name _ information isjg, required for every page. . City/Town ` State Zip Code Date:of Inspection D. System Information (cont.) Comments.(on.pumping recommendations, inlet and outlet tee or baffle condition 'structural integrity, (quid levels as related to outlet invert; evidence of leakage, etc.): f III Grease Trap(locate on site plan): `1 d,o Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): �I 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 lor baffle Date:of last pumping: gate 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): l5insp.doc•08/06 Tille.5 Ofricial'inspectlon Form:subsuAace Sewage Disposal System.,Page 10 of 16 Commonwealth;ofmassachusetts. Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rl`MVe1Y Address Owner is Name information is / ;, required for r����t' I�r ��k every page. Cltyfrown State zip Code Date o Inspe ion D. System Information (cont.) Tight or Holding Tank(cont) Dimensions: Capacity: .gallons Design Flow: gauonsperday 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 Distribution Box(if present must be opened) (locate on site plan):Ay . Depth of liquid level above outlet invert 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.): Pump Chamber(locate on site plan):, Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Ins p ection Form Subsurface Sewage.Disposal System- orm Not for Voluntary Assessments op y Addrejs Owner ow Y's-Name - i information is required for every page.. City/Town State Zip Code Date of nspe lion D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps.and appurtenances, etc.): ..Soil Absorption System(SAS)'(locate on site.plan, excavation not required):. If SAS not located, explain why:: . Type: . i leaching:pits number: ❑ leaching chambers number: ❑ leaching galleries.. number: leaching trenches numbe.r.;:length:.:. ❑ leaching fields number, dimensions: El 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.): l5insp.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.-Page 12 of 15 Commonwealth of Massachusetts r .Title-5 Official inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary-Assessments Prop ert dress 24 Owner Own ame information is required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont) Cesspools.(cesspool must be pumped as part of inspection) (locate on site plan): v 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 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.): t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 I Commonwealth of Massachusetts : Title 5 Official, Ins ection Form p Subsurface Sewage Disposal System Form N'ot for Voluntary Assessments .. erty Address Owner ar's Name information is required for eve page. Cilyjown every p 9 State Zip Code Date of Inspection D. System lnformation'.(cont.) Sketch Qf.Sewage Disposal System:Provide.a,.sketch.of the.sewage.disposal system including ties to at least'two:permanent reference landmarks or:benchmarks.4 Locate all"w`lls.within 100 feet. Locate where public water supply enters the building. p 2° CC) 2 l 600 0 l fie ' (DO t5insp.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 114 of.15 Commonwealth of Massachusetts _ ..,Title 5 Official Inspection Form Subsurface Sewage Dispos I System Form-Not for Voluntary Assessments rty Address Owner s Name information is required for ,� g every page. Cl yfrown State Zip Code Date of Inspection D. System Information.(cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: pate ❑ 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 ou established the high ground water elevation: t5insp.doc-08/06 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 15 Permit Number: Date: Completed by: c '1 HIGH GROUND-WATER LEVEL COMPUTATION Site Location: ? Lot No. Owner: t t Address: >� Contractor: C Address: Notes: l�rs� � 1��s STEP 1 Measure depth to water table to nearest 1/10 ft. . .......:. ......... ................................: Date •�� month/day/Year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: ,l �V O Appropriate index well........ .. :...... ......... ................. © Water level range zone ..................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... `�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 2B) ✓� determine water-level adjustment .........................................................................................: STEP 5 Estimate depth to high water by subtracting the water level adjustment (STEP 4) from:measured depth to water level at site (STEP 1) ...............:......................... . .. ............................................ Z' Figure 13.--Reproducible computation forma 15 i / Ed' -1c la ean -1 f -6-57 g' f Town of Barnstable 1He Regulatory Services BARNSTABLE,A Thomas F. Geiler,Director 9 MASS. 0 �1639. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This 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/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this 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 Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. i r•' 1 - H LID x Sit Vj 1 VT ( f P N t YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 yearsl A business certificate ONLY REGISTERS YOUR NAME in town (which you y1 must do by M.G.L.-it does not give you permission t--o erate.) You must first obtain the necessary signatures on this format 200 Main St., Hyannis. . Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601. (Town Hall) and get the Business Certificate that is required by law. DATE: Z�l ! FiII in please: APPLICANT'S YOUR NAME/S: rvc� l:"''!`''="''' >� :.•I',.a�i� BUSINESS YOUR HOME ADDRESS: l RS S�� C� o<-P— of Wa w 2-6 SS" 3 aL'�Iys' ti� TELEPHONE # Home Telephone Number (�p�l GO ' E-MAIL: O��✓l0.C- �� NAME OF CORPORATION: V NAME OF NEW BUSINESS � G n0. s on� � CL.Cc�✓�rt�i SC eV'C� TYPE OF BUSINESS `'\ ' IS THIS A HOME OCCUPATION?_ _YES NO_�, NUMBER + aj O-7:1 -(Ass.essing) ADDRESS OF BUSINESS. . I q•S i wc� MAP/PARCEL . 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 siness in this town. 1. BUILDING CO ISSIO ER'S OF ICE MUST COMPLY WITH HOME OCCUPATION This individ al e nt fof d a p mit requir erits at pertain to this type of business. RULES ND REGULATIONS. FAILURE TO COMPLY [VIAY RESULT IN FINES. Aut a S' nat e OMMENT +� an .. _ 2. BOAA OF EALTH ---. . This individual hoEi"been informed .f..h rt e-perm r uirements that peain to this type of business IU I(PLY�IYj'�H ALA --- FG AROOUSIW�TERIALS RE�C1�0! Authorized Sign ure** -- COMMENTS: ; 3. CONSUMER AFFAIRS.(LICENSING AUTHORITY) . This individual has been informed of the licensing requiremegts that pertain to this type of business. Authorized Signature** COMMENTS: . } 2`j I� Date: � / / TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: �caYz✓» lS BUSINESS LOCATION: IBIS Sc—�n C� �s�cc cA,/a INVENTORY MAILING ADDRESS: TOTAL AMOUNT: TELEPHONE NUMBER: CONTACT PERSON: Y.y,,c>,— EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE? _TYPE OF BUSINESS: INFORMATION / RECOMMENDATIONS: Fire District: Waste Transportation: 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 requires 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 Observe d / 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 P 9 (dry cleaners) Other cleaning solvents ' Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS pplicant's Signature Staff's Initials TOWN OF�B"A`RNSTABLE �/ �t LOCATION ��J am^ Cy®p(�S GIB �JJf�V SEWAGE# UO— 00 VILLAGE ` s✓�� ASSESSOR'S MAP&PARCEL ,�a —T r INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) oST (size) ay, j�3 X jot, d S K NO.OF BEDROOMS OWNER PERMIT DATE: 0 t -A I COMPLIANCE DATE: 0 Separation Distance Between the: wA4 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) I Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) A Feet FURNISHED BY ��. `�1 ��� A At A A-�o �'o4 JL 13 R -lr ,may U v 9 e ; y� f N9. ` V / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Mid onl *pgtem Construction Permit Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) El-Complete System ❑Individual Components Location Address or Lot No. L"1 C �/� S Own 's Name,�A(�ddress;and Tel.No. _ Wc,y GoI9C11C.vG,K Assessor's Map/Parcel a _ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. s�.CoG�c,�w Type of Building: Dwelling No.of Bedrooms J Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 3 gpd Design flow provided 2 gpd Plan Date 4-0 U Number of sheets Revision Date Title Size of Septic Tank ��[� �� 1 u 6 o Type of S.A.S. Description of Soil �i.C_ Nature of Repairs or Alterations(Answer when applicable) LA -VS (,( } Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal systemfn 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 t4 to aaSs' Application Approved by Date D U Application Disapproved by: Date for the following reasons V Permit No. OJ6o —1)�— Date Issued /`t it ——————————————————— —————————————————————-- �No .+lL �" �'1"�'' r n Fee / R . � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION'- TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Bigpogat *pgtem Cottgtruction Permit Application for a Permit to Construct O Repair(Upgrade O Abandon O ❑.Complete System ❑Individual Components Location Address or Lot No. A- , &00 SY "e Owner's Name,Addr ss,and Tel.No. �?�`�'i � S c a'tN VCr.(.C>PVC Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. G - S�� ac," .U,u to 5 U ` Type of Building: ., Dwelling No.of Bedrooms .ti Lot Size sq.ft. Garbage Grinder.,( ) Other ..Type of Building No.,of Persons yr Shoers( ) Cafeteria( ) Other Fixtures 4( Y v D Design Flow,(min.required) 3 gpd Design flow piwided gpd Plan Date -Y y (02 d V Number of sheets Rev Sion Date Title ( Size of Septic Tank Py 10 Type of S.A.S. <<, Description of Soil T\,z ^ed u Nature of Repairs or Alterations(Answer when applicable) � \7t-,,.�„�..rS t� h L( 'r.y-S 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. iJ Signed at Date 1 it) Y '-Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. �[f)�� r�L Date Issued 7 ———————————————————————————————————— ——— `� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (� Upgraded ( ) w Abandoned( )by 0-tc-•c,U(-L—' at t1��,� e v �1E \kt_. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. " t dated Installer S r—c Designer 0 f� #bedrooms Approved design flow /y! gpd The issuance of this permi/shall t e c nstrued as a guarantee that the system wiMluad siigneDate 1 /l Inspector ,/i�' 1 -------------------------------------------- No. �-�_V Fee­ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS lwigoml 6pgtem Coowaruction Permit Permission is hereby granted to Construct ( ) Repair (v ) Upgrade ( ) Abandon ( ) System located at k ci 5 iEt :b, G p yk d -, c- o U \\\.e and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided- Construction must be completed within three years of the date of th's pe it Date f I Approved by �- t Town Of Barnstable Regulatory Services Thomas F. Geiler,Director + IAItN.Sl'ABEE, + a Public Health Division �. AIFo � Thomas McKean,Director 200 fain Street,Hyannis,IOTA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: b ZDDa Designer:a')D Zf>. 114 A- Installer: Address: . Address: y'�Gl- S�j�i On, �L1 � �1 P� /�a�`T; �� t� 4 was issued a permit to install a (date) (installer) septic system at 5 based on a design drawn by (address) dated (designer) V •certify that the septic system referenced above was installed substantially according,to o T';,die design, which may include minor approved-changes such as lateral. relocation of the d1stiibution box and/or septic tank. a •t I certify►,that the septic system referenced above was installed with--ma r:"ii changes greater than`10' lateral relocation of the SAS or any vertical.relocation of any component of the.septi6,system)but in accordance with State&Local;Regulations. Plan revisioxA of certified as-built b designer to`follow. �H� Mqs (Installer's Signature) B. cn IO SON m W iO66 I(01's sgN1TAR�Pd (D er s Signature) (Affix gner's Staiizp Here) PLEASE RETURN TO BARNS'TABLE PUBLIC HEALTH DMY SION. ° CERTIFIC ATE OF C2WLIA-NCE WILL: N® SEl." SSUED.3: OTH` TDIS 3FORM AND A5= BUILT CARD ARE RECEIVED BY.THE:BAR, STABLE PUBLIC BtEA7GTkI D SION, THANK YOU. s: Q:HealtidSeptic/Designer Certification.Forr. ra Town of Barnstable P# L/ Department of Regulatory Services WLWA" i Public Health Division Date MAW •63y 200 Main Street,Hyannis MA 02601- FD Date Scheduled Ae 17, w7Tftne ®�y !d Fee Pd. Soil Suitability Assessment for Sewage Disposal 1 Performed By: Witnessed By: C/ < _LOCATION& GE ERAL INFORMATION Location Address `pi.` �'���` ye Owner's Name Address # Assessor's MaP/Parcel: �`�• Engineer's Name i T' �L.,`►\� ��+`,S�V� s NEWCONSTRUCTION REPAIR �/ Telephone# �04�C1 SGd Y7, Cr1 Land Use Slopes(95) cri Z D Surface Stones- Distances from: Open Water Body / ft Possible Wet Area / ft Drinking Water Well �ft Drainage Way_ ft Property Line 7 l� ft Other -it SKETCH:(Street name,dime ions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) AA �1 r � Parent material(geologic) `q Depth to Bedrock Depth to Groundwater. Standing Water in Hole: ry Weeping from Pit Face -- Estimated Seasonal High Groundwater bd DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In. Depth to soll mottles: In. Depth to weeping from side of obs.hole: In, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level- Adj.factor.,,,._.,.. Adj.Groundwater Level,,,® PERCOLATION TEST Ditte�..__, Time Observation Hole# 'rime at 9" . Depth of Pere 3 Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak , M I Rate Minllnch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health.Division Observation Hole Data To Be Completed on Back-------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTIMERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Consistency. Gravel) 6 - C. �� �► z l y G /Al2t 7 DEEP OBSERVATION HOLE LOG ' Hole# Z- Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency.%Grav DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other C Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders. Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes v__ Within 500 year boundary No '� Yes Within 100 year flood boundary No V Yes =` 4 Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pery ous m.terial exist in all areas observed throughout the area proposed for the soil absorption system? Lf If not,what is the depth of naturally occurring pervious material? Certification I certify that on �� (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed y me consistent with . the required training,expertise an experience described in 310 CMR 15.1 Signatur Date y Z0 Q:\.S,EP'nCPERCFORM.DOC THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tiertifirate of ToraylianrP IN THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by ..... �vc.k��----------QzVz%�' — ........_._......... lnsra- at .........t J. S�' e�®off S`p�.�P...... W�` -...... - - ......... - _. - - ..............- - has been installed in accordance with the provisions of TITLEc5�of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .L..lh...._7- 4/..__......- dated -----------------------_............._.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATIVACTORY. DATE....../... .."`.. -./......:.... .. Inspector .... - ......- - --- �G!Zi ------------------ -------- r ,,,;;ijj0007i 07 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App iration for Ui_rip ial Worlai C owitrurtion Vrrnfit Application is hereby made for a Pexn4it to Construct ( ) or Repair (/K) an Individual Sewage Disposal System at: A09, Location-:\ddress or Lot No. Owner Address a k C_\LL= ..---. rg,S��' ---•---• 5 ......................•-••--------•---••---••------••-----•--... ---•-----.......-•---- Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons........................... Showers ( ) — Cafeteria ( ) 04 Other fixtures _______________________________ •. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity__.____---.gallons Length................ Width---------------- Diameter....------------ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------------_------ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) � Percolation Test Results Performed by.......................................................................... Date...................................... Test Pit No. I________________minutes per inch Depth of Test Pit-_.__...--___-____-- Depth to ground water------------------------ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ t: -----------------------•-------•••-•--- •-•----•--------•---•---. •-----••. •-------...................••-•-•---......-•-------••---..........-••-...... 0 Description of Soil....:Q-.7 .........S-J-�- ..........................................................5, '' -------------------------------------------------------- WU ------ -�---------•-•-•----•---------•-•--•-------•--------...-•-------•-•-----------•----------•---••-•-•----•••--- x £ --------------------------------------------------------------------------------------------------------•--------------------•--- U Nature of Repairs or Altera�t, °0& Answer when applicable-..'�- -�..........OP�_`..._k��Z-?..._..... t ? ........ Agreement-. `t�l�-���•t,,.l� t � The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. . -------------------------------------------- ......Signed . 1..........�....C.....:.... Application Approved By ---------- a e �.. ...... - Application Disapproved for the following reafonr- ------------------------------------------------------------------------------------------------------------- -------------------- ............................... .......................................................................................................................................................................... ...................................... Date Permit No. ...... .............................. Issued ...........,1..--^..r��-cl."-- - ............... Date No...97 - FEs...�?� ? p r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Uhvipoittl Works Tonitrurtion ramit Application is hereby made fora Permit to Construct ( ) or Repair (/(-) an Individual Sewage Disposal System at: ,. + 9 a` SLE o SPs4 ��.� � 2°r�V��-�i= ---------- Location-Address or Lot No. N S......................C t�.a G � ` -- ------------•----------------- ---S to --------.....------......---------...--•----•-•-•----.............-- _._ Owner Address .................................... Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------------------------.....----------------.....-------- --......---------•----------------•--•--•••-•-••••......••••. W Design Flow............................................gallons per person per day. Total daily flow.............................................gallons. WSeptic Tank—Liquid capacity........-...gallons Length................ Width..-_---------- Diameter.----------.---- Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1-4 1 Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ -••-----••------------ ------•••-••-•--••••-•--•......•-•••--•••-•---•••-•••••••-•--•••......------••-•---•-•--•-•••••-...-•••••......-•••••••--•-..._....-- D Description of Soil----- .......... ................................................... r-- W v .-----••••---••••------•-•••----•••--••••••-••••-•-••••••--••......••••-• yam+ ..W ��----------------- ------------------------------------------------------------------------------------------------------•----__-•-- UNature of Repairs or Alterat Vs�-Answer when applicable.... ---------Z?!'? -`.-._-�4_9PP......... ........ Agreement: 4�c--� \'7`t"_�, R I The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ........ r? -. -�1..i:.. .... --^ '��^L4�S r to I Application Approved By ........ �_e� .r- .� ;/ -_. 2-�...... ...................... ...--...-.... Date Y Application Disapproved for the following reafonf: ...................................... . . ....... -- . .......................... ............................................................................................................................................................................................................... ................Date.----------------- Permit No. ��— 7kip.�.-------------------------- Issued ............ .. .Q.- .�1.........-..... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Gertifi ate of C�antplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (),f2 ) ?- ...te.. by �tlC � ' Installer at ........i. ..� Sf ------- 0100. .S P F- 'Q �- -....... Q S has been installed in accordance with the provisions of TITLE 55--of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -/...-_L --..._-7�f_----------- dated .....-_....._.._--------------_......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ��� '........................................ =DATE Inspector ----------------------------------------------------------------- -------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH p �7 TOWN OF BARNSTABLE FEE.. .......::........ Dwpo d Vorffi5 Tonotrnrtinn "unfit Permission is hereby granted_.._. ....O N.s�----------------- -------------------------------•--------•-•--•-••-•-•-•-•---....... to Construct (_ ) or Repair ( �an Individual Sewage Disposal System atNo........ �! S � � ^q J '\1..._.. -`,"?.t� --------------------......`............-------------------------------•--............. Street as shown on the application for Disposal Works Construction Permit No. ........... --•------•.............. Board of Health DATE --.... ......— /�- FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS _ �pFtHe rp� Town of Barnstable Barnstable P ti Regulatory Services Department 11111.1 �ca� li% BARNSTABLE, "A�. Public Health Division Op i6�9. `q Arf0 nna�°' 200 Main Street, Hyannis MA 02601 2007 Office: 508-8624644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO January 2, 2008 Richard Griffith 195 Seth Goodspeed Way Osterville, MA 02655 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 195 Seth Goodspeed Way, Osterville MA was inspected on September 19 2007 by Robert Bortolotti, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system FAILED under the guidelines of 1995 TITLE V(310 CMR.15.00) due to the following: Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool. You are ordered to repair or replace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDE F TH BOARD OF HEALTH 7007 0 710 0005 5820 7489 cKean, R.S., CHO 9 Agent of the Board of Health 7007 0710 0005 5820 7489 7007 0710 0005 5820 7489 . Q:\SEPTIC\Letters Septic Inspection Failures\727 Shootflying Hill Road.doc t)' o rnt y m m CLm CL m ka7 � 3a 3a i No. V Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: !✓ Yes .PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Mizpogal *pztem Conztruction Permit Application fora Permit to Construct( )Repair(A)Upgrade( )Abandon( ) X Complete System ❑Individual Components Location Address or Lot No. 33 M"tta t65 l&v4-_ Owner's Name,Address and Tel.No. 4 ZY-69:7o 0a Ft wv k i tw- Z�,,per 10*-&e �12�cB✓cis, Zie, Assessor's Map/Parcel 11.7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. AZT—c 13 i %:✓f"Xwe t, 6,14t nc-. EAZ i` ai&% 5'-• Type of Building: Dwelling No.of Bedrooms + Lot Size I'-?j j—)q sq. ft. Garbage Grinder(A,I) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 110 �c 4 = 4 4-0 gallons per day. Calculated daily flow 1440 gallons. Plan Date G/`/- fk* Number of sheets / Revision Date Title .nlu- 45%t::, ,406a& o,P 3. �Y11e.o�mi�/u.�!'. Size of Septic Tank 1 SCxy Type of S.A.S. L C"_(„MQ C_uft,4ig0,s•• Description of Soil Nature of Repairs or Alterations(Answer when applicable) Yq,.pL&,, _�L�r �LSS iQcficsl S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date V—DL Application Disapproved for a foll ing reasons Permit No. p Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( �Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1=i5pogar *potem Construction Permit Permission is hereby granted to Construct( )Repair(1/5 Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by 1 F FeeC/C./� E - Entered in comp TH uter: 1� COMMONWEALTH OF MASSACHUSETTS Yes - - PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 3pprication for Migonl *proem Cow6truction permit Application for a Permit to Construct( )Repair(� )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. 33 m ca�W lam Owner's Name,Address and Tel.No. 4?�'^O S'SO Ost-ev°v�`f It �iili� /!7'1ca�,C A/bc>Pucfs, .T/1G. Assessor's Map/Parcel 11-7 165 yo A/fir Schv/z cf �rkcr RJ Os.>fi/ri%�� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 4Zg''ri 13 1 F n aAxTwe t f l`t O Zvic-. BIZ, m cm,% 54-. ' O s 4z S Type of Building: Dwelling No.of Bedrooms 4- Lot Size�'1�sq.ft. Garbage Grinder(4) Other Type of Building No. of Persons Showers( ) Cafeteria( ) w 'Other Fixtures Design Flow i io x 4 s ¢ gallons per day. Calculated daily flow 440 gallons. Plan Date c;.,Ly. ye Number of sheets I Revision Date Title Size of eptic Ta k 1 15tSv Type of S.A.S. _Le-aek,mg C_ka Wibens Description of Soil (tv :<3 s K 2 3 . Nature of Repairs or Alterations(Answer when applicable) ��I� �«9 e�ca rowel s Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date `Application Approved by Date � ——'a o Application Disapproved for e foll ing reasons Permit No. a T , j Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( e00�Upgraded( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. .316 dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector ----------Fee . t No. THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS _ igpogaY pgte�nt Cogtructivr� rrrrtt t;_. --?f l , _ .. Permission is heieby granted to-Construct( )Repair( yYUpgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by r , fi ASSESSORS MAP : �`� _ NOTES: TEST HOLE LOSS PARCEL: 7 FLOOD ZONE: SOIL EVALUATOR : I�YI � ,� 1) The installation shall comply with Title V and Town of Barnstable Board o-_ W 1 TNESS : 1 0W I4 1a1-�M�.f�lt��J Health Regulations. REFERENCE: � �� /, �Ld% � DATE: , 17 2) The installer shall verify the location of utilities, sewer inverts and septic PERCOLATION RATE: rs 3)q X 7e2. t' A j R j k�54 � � t components prior to installation and setting base elevations. �� -- 1 rag 4ADO ul -47 V 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8 per foot. The first A47'eo /D TH- t TH-2 two feet out of the d-box to the leaching shall be level: SS __ )4 This plan is not to be utilized for property line determination nor any other s purpose other than the proposed system installation. t 166 5) All septic components must meet Title V specifications. " to '� ti ► E 3 �� 6) Parking shall not be constructed over HI septic components. 7) The property is bounded by property corners and property lines. LOCATION MAP ( t , rl�trl_ PI CO, � y� � 8) The property owner shall review design considerations to approve of total 6*A design flow and number of bedrooms to be considered for design. Receipt n of payment for the plan and installation based on the plan shall be deemed 21' ? C-I approval of the design flow by the owner. �� Z'Z7� 9 The existing leaching or cesspools shall be pumped and filled with material 1 52 ) g � p p p per Title V abandonment procedures. Those within the proposed SAS shall be removed along with contaminated soil and replaced with clean washe h sand per Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if •rr •-� ct� SEPTIC S Y uJEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the f owner to ensure such. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line. �C, /` 13)The installer shall verify the location, quantity and elevation of the sewer BEDROOMS ITT GAL/DAY/BEDROOM -35C)GAL/DA Ee � Imes exiting the dwelling prior to the installation. V/ J S E P T I C T 2- -- •- � C� GAL/DAY 2 DAYS - GAL ` USE IC: GALLON SEPT t C TANK -%s5n Zr ---- .� SOIL ABSORPTION SYSTEM -- —� — �< 2 q',3�, { IZtZ.rj' X Z Y, a� = 3 SIDE AREA: Z lot l �ci'� �� ` BOTTOM AREA: SEPTIC SYSTEM SECT I ONL , . l cSs2 ram, I / IT------------------ z Aa 1 C.91�Fum. w v t _ 51 Z� D- a GAL v e s f=� SEPTIC T KDAVID ---------------- �C) so . r S I TE AND SEWAGE PLAN ---I =zoGfS74F` LOCATION : 195 S� � �P +Ww-j t All PREPARED FOR : L*pE, CowST, H�foMt_jie71A ` 17 SCALE: DAV I D B . MASON R" DATE: I z .���_�� �-• • � ,� _ DBC ENV ( RONMEN AL DESIGNS EAST SANDWICH . MA i'`� M C ATE HEALTH AGENT ( 508 ) 833- 2177 Z