The URL can be used to link to this page

Home My WebLink About1812 SOUTH COUNTY ROAD - Health 1812 SOUTH COUNTY, MARSTONS MILLS - -- -- - -- - -- A = 098 008 002 09g oog ava- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3> 1812 South County Road X Property Address .. Peggy Plimpton Owner Owner's Name, . information is required for every Marstons Mills ✓ MA 02648 12/7/16 page. City/Town State Zip Code Date of Inspection r? ra t!1 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 filling out forms A. General Information 6-/py /a0.76P 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 Company Name P.O. Box 49 Company Address erm 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, I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000).The system: .® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Eva tion by the Local Approving Authority 12/27/16 Inspe o Signature Date The m inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 rs Ur- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1812 South County Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing p st g tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1812 South County Road Property Address Peggy Plimpton Owner Owner's Name information is required for every Marstons Mills MA 02648 12/7/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 1812 South County Road Property Address Peggy Plimpton Owner Owner's Name information is required for every Marstons Mills MA 02648 12/7/16 page. CityfTown 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 '/z 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 ' 1812 South County Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. City/Town State Zip Code. Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Nui ber of times pumped: ❑ ® Any portion of the SAi, 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 cesspl of 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. I ❑ ® 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 custodyI 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 halve determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To.be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. ,l 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 21 feet of a tributary to a surface drinking water supply El Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA)or a mapped Zone II of a public water supply well I If you have answered "yes"to any question i'n 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. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �N 1812 South County Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. CItyrrown 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 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 0(17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1812 South County Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No 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: unknown 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? El 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a,•''� 1812 South County Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1812 South County Road Property Address Peggy Plimpton Owner Owners Name isrequired for every Marstons Mills MA 02648 12/7/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: system installed - 1979 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 4 P❑ ❑ 0 VC 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: 12-0 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ® other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 H-10 Sludge depth: 5" 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1812 South County Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. Cltyrrown 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 Scum thickness 2" 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? 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 baffles were present. The covers were 12" below 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M a 1812 South County Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain): N/a Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1812 South County Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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 D-box was clean. The cover was 2 below 1 Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on.site plan, excavation not required): If SAS not located, explain why: 15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °°M ,•• 1812 South County Road Property Address Owner Peggy Plimpton information is Owner's Name required for every Marstons Mills MA 02648 12/7/16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 - 1000 gal. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The pits were dry.There was no sign of failure Both covers were 20" below. A camera was used Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): A Number and configuration n/a 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 El Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 1812 South County Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. Clty/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/a l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1812 South C unty Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. Citylfown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately JGAr �ron A Q A� � 6 r9a14 Y6 ay6 p 3 SY 3y a 3 y t5ins-3113 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 1812 South County Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. Cftyrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 2b,+/- feet Please indicate all methods used to determine the ground high g g nd 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: Topo and water contours map. ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above Before filingthis Inspection p tlon Report, lease se p , p e Report Completeness p p Checklist on next page. t5ins•3113 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 1812 South County Road Property Address Peggy Plimpton Owner Owners Name information is required for every Marstons Mills MA 02648 12/7/16 page. Cltyfrown 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 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is required by law. in E,,m mqg P` DATE: _� ' �� F I in please: Ui�r � " APPLICANT'S YOUR NAME/S: BUSINESS YOUR HOME ADDRESS: raw.. µ' ELEPHONE # Home Telephone Number 2 D NAME OF CORPORATION: NAME OF NEW BUSINESS v1 S('cr ' a TYPE OF BUSINESS IS THIS A HOME OCCUPATION? YES NO n Q (�os—o 0 Z ADDRESS OF BUSINESS PD r� - G� �5��! /` —MAP/PARCEL NUMBER (./ U (Assessing) fl r(J 2 181 p rvi Ile- 2 � S� CD c�- M P.,vrr q e KC, When starting a new business there are several thins you (nust do in order to be in compliance with the rules and regulations of the Town f 9 Y P 9 0 Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMMISSIONER'S OFFICE This individual has been informed of any permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 2. BOARD OF HEALTH This individual has een i ed°I the permit requirements that pertain to this type of business. MUST ;,OMPLY WITH ALL • [ litf V!(n HIA7ARDCLIS M:gTFR!ALS RFG(._il..ATrr)niS Authorized Signature* COMMENTS: 3. CONSUMER AFFAIRS(LICENSI G UTHORITY) This individual hastooen inf r he licensing requirements that pertain to this type of business. Authorized Signature COMMENTS: Date: 6/ /�/ /� TOWN OF BARNSTABLE TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY NAME OF BUSINESS: • 4�oeqlle o /S BUSINESS LOCATION: � P�, U41cj Q�l , 65-(Cry/l�eINVENTORY MAILING ADDRESS: F0, 956K /q( ��{e�-ii�//P, D�-ll,¢. 6??? :5.70TAL AMOUNT: TELEPHONE NUMBER: ;Z - 6?!;�F CONTACT PERSON: EMERGENCY CONTACT TELEPHONE NUMBER: 6O,7 -e7,7;?-V010 MSDS ON SITE? TYPE OF BUSINESS: WJ/_sG'��o yYQi6lz�c�o�ll�l�l['�y 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 re uires a license from the Public Health Division. LIST OF TOXIC AND HAZARDOUS MATERIALS The board of health and the Public Health Division have determined that the following products exhibit toxic or hazardous characteristics and must be registered regardless of volume. Observed / Maximum Observed / Maximum Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive ❑ NEW ❑ USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road salts (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor Oils Pesticides ❑ NEW ❑ USED (insecticides, herbicides, rodenticides) Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers) Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED Miscellaneous petroleum products: grease, Photochemicals (Developer) lubricants, gear oil ❑ NEW ❑ USED Degreasers for engines and metal Printing ink Degreasers for driveways &garages Wood preservatives (creosote) Caulk/Grout Swimming pool chlorine Battery acid (electrolyte)/Batteries Lye or caustic soda Rustproofers Miscellaneous Combustible Car wash detergents Leather dyes Car waxes and polishes Fertilizers Asphalt& roofing tar PCB's Paints, varnishes, stains, dyes Other chlorinated hydrocarbons, Lacquer thinners (including carbon tetrachloride) ❑ NEW ❑ USED Any other products with "poison" labels (including chloroform, formaldehyde, Paint&varnish removers, deglossers hydrochloric acid, other acids) Miscellaneous. Flammables Other products not listed which you feel Floor&furniture strippers may be toxic or hazardous (please list): Metal polishes ' t4h 4,0� 04 G 00L( /�l� (!;J P. Laundry soil &stain removers (including bleach) ��v Q / Spot removers&cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers Windshield wash WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS )ncpplicar#Signature Staff's Initials 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIO T 1 � o�s; TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1812 South County Road Marstons Mills. 11M4 Owner's Name: Jack Harmon Owner's Address: Same Map: 098 Date of Inspection: March 28, 2001 Parcel: 008 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford. Mailing Address: P.O. Box 49 Osterpille,MA 02655-0049 Telephone Number: (508)862-9400 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority F Is Inspector's Signature: Date: April2, 2001 The system inspector shall su ' a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ; Notes and Comments t at ****,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 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS , :•; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' CERTIFICATION (continued) AL Property Address: 1812 South County Road Marstons Mills. MA Owner: Jack Harmon Date of Inspection: March 28, 2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired...The.system,upon completion of the replacement or repair,as,approved by the Board of Health,will pass. Answer yes,'no or not'determined(Y,N,ND)in the for.the following statements. If"not determined",please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will .pass_inspection_if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1812 South County Road• — - - t. - E. =i'••-'t ';� :` Marstons Mills. MA Owner: Jack Harmon Date of Inspection: March 28, 2001 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 Wafer 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1812 South County Road s Marstons Mills, MA Owner: Jack Harmon Date of Inspection: March 28, 2001 D. System Failure Criteria applicable to all systems: You must indicate either"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 '/z 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 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and.nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will.be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 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 11 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1812 South County Road._ Marston Mills, MA - Owner: Jack Harmon Date of Inspection: March 28, 2001 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? F ,�, ✓:_`;" a''' 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: Yes No ✓ Existing information. For example,a plan at the Board of Health. ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. h 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' 'SYSTEM INFORMATION Property Address: 1812 South County Road t Marstons Mills. AM Owner: Jack Harmon Date of Inspection: March 28, 2001 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no); No _,(if yes separate.inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow,(based,on.310 CMR_15'.203):_ gpd - Ba'sis'of design flow(seats/persons/sgft'*c:): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Never pumped-per owner Was system pumped as part of the inspection(yes or no): Yes If yes,volume pumped: -- Qallons--How was quantity pumped determined? -- Reason for pumping: Maintenance/repair of D-box 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) Tight Tank Attach a copy of the DEP approval Othdr'(describe): ;, r Approximate age of all components,date installed(if known)and.source of information: Approx. 1979-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM`INFORMATION (continued) Property Address: 1812 South County Road .a^__..___ Marstons Mills, MA... Owner: Jack Harmon ' Date of Inspection: March 28, 2001 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction,line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" Material of construction: ✓ concrete _metal _fiberglass _polyethylene _other(explain) If tank is metal list age: Is age confirmed by a.Certificate of Compliance.(yes or no): ' (attach'a,copy;of certificate) s Dimensions: 1500 gal. Sludge depth: 6„ , Distance from top of sludge to bottom of outlet,tee.or baffle: 26" Scum thickness: 12"+ Distance from top of scum to top of outlet tee or baffle: 9" Distance from bottom of scum to bottom of outlet tee or baffle: 5" How were dimensions determined: Measuring stick 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 baffles were present. The liquid level was even with the outlet invert. The tank was Pumped for maintenance. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top,of.outlet tee or baffle:. Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid'Ieyels as related to outlet invert,evidence of leakage,etc.): ------------- s H• s Page 8 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1812 South County Road t . Marstons Mills, MA Owner: Jack Harmon Date of Inspection: March 28, 2001 „ TIGHT or HOLDING TANK: None (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: Y Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX.: ✓ (if preserit,must he opened).(locatite.plan) {: k e on s 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 D-box had a hole on the side and was structurally breaking down. A new D-box was installed(Permit#2001-188). PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C • SYSTEM INFORMATION (continued) Property Address: 1812 South County Road Marstons Mills. MA Owner: Jack Harmon Date of Inspection: March 28, 2001 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: n'pe ✓ leaching pits,number: 2-6'x 6'with 3'stone(per design plans) leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: ...Innovative/alternative,system Type/name of technology: - Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): One pit 04)had Y of water on-the bottom and was taking all of the.flow,the other pit.03)was dry. The scum line was 6"up from the bottom. The covers were 20"below grade. The bottom to grade was approximately 8'6"on both pits. CESSPOOLS: None (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 or no): Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: None locate on site plan) ( P ) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION (continued) Property Address: 1812 South County Road y, Marstons Mills. MA -.__._-_ Owner: Jack Harmon Date of Inspection: March 28, 2001 Map: 098 Parcel: 008 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. GArA c e Fro,� al A a' . � O A3- sy a -1c�' all- Soy 3 y 10 Page I I of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1812 South County Road Marston Mills. MA „ Owner: Jack Harmon Date of Inspection: March 28, 2001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) ✓ Checked with local Board of Health-explain:topographic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: f E You must describe how you established the high groundwater elevation: The bottom of the leach pits to grade was approximately 816". Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing approximately 20'+1-to groundwater at this site. • This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report. I1 Lf TOWN OFBARNSTABLE RZeAir LOCATION SOA CQUolk RCS. SEWAGE #a00I • FS VILLAGE Al. Mils ASSESSOR'S MAP & LOT09S OO pot INSTALLER'S NAME&PHONE NO. Garca^ ?-->UMPUS . SEPTIC TANK CAPACITY G4 LEACHING FACILITY: (type) rr-s (sizeQ, 1400 6a). NO. OF BEDROOMS 3 BUILDER OR OWNER AC,� IJArto0f\ PERMTTDATE: Z"9'Zoy� ',COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist -on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . l Ai yo A� �3 A&- yy 83- ay co A44- 91 a By- 3`/ 3 AS �9 � � y S y�TOWN OF11BARNSTABLE 'Poo t - l LOCATION I FI A SQU/-in C OUA F,�, SEWAGE # -�9- a 0y VILLAGE MArS�,i ' M1 I Ls ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY l SUS LEACHING FACILITY: (type) (size) NO. OF BEDROOMS 3 BUILDER OR OWNER SAQ 14A(MOe PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachin facility) Feet Furnished by Fo r �Coxr As- �y o p 63" 3y ,ay- a L0 C T IONS S EW.A G E PERMIT N0. 7_1 VILLAGE lna4-57d&.5 /711 INSTA LER'S NAME & ADDRESS 8U1 DER OR OWNER DATE PERMIT ISSUED e/112. 17�9 t DAT E COMPLIANCE ISSUED - �� ,.r /� '�'%fie j< ` �\ .�.. � ��,�' 1 �V i � � _� a No. -zoo/— Fee /O v a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: `\ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pprication for Migooaf 6petem Con5truction Permit Application for a Permit to Co ttZt(YRepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. SA V' f�uw�/•/�1�/� Owner's Name,Address and Tel.No. Assessor's Map/Parcel o / 8 C3(� �.m 0®-1,00' " t 00 1950 I all Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �: (,1 a IS W, 'S4;,e„vsrAt lL � (55r4lpui (l.� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) A// ,:� 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 �,? d 1 Application Approved by Date 3 U Application Disapproved for the following reasons Permit No. Z-VV — Date Issued 3 ' 2?W s TO OX Re(�At<` WN OFBARNSTABLE SO LOCATION c Ut COU/lf"I '-- RCS. SEWAGE #900 I VILLAGE M. M)15 r ASSESSOR'S MAP & LOT 0L INSTALLER'S NAME&PHONE NO. Ga<c�vn QVmPVS . SEPTIC TANK CAPACITY ./Sow 6� LEACHING FACILITY: (type) ��TS (size)3-1— NO.OF BEDROOMS 3 BUILDER OR OWNER: 'YA6� ��Ar✓oor\ Zoz1I COMPLIANCE DATE: PERMPTDATE: 3 � Z�� Gr Separation Distance Between the: i Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet i Private Water Supply.Well and,Leaching.Facility. (If any wells exist on site or within 200 feet of leaching facility) Feet Edge,ofWetland and Leaching Facility (If any wetlands exist within 300 feet of'leaching.facility) Feet Furnished by. O$ -Sv. 6L -sd tis, -hg 10 0) h� -Sa 1 PJ Oh - Ib -No. CJ�v�'" �O Fee SZ, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Tipprication for Mizpogal *p.5tem Con.5truction Permit A. Application for a Permit to Construct Abandon_t( Repair( )Upgrade )• * ,. ( ( ) ❑Complete System ❑Individual Components Location Address or Lot No. S p u• G v Lw �r Owner's Name,Address and Tel.No. O ry Assessor's Map/Parcel c) 1 8 d Q — d Q t/1/( /M G 0 / e o s.CoL,►.r )V AlLr In le ' Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 0 MwUS a�s W. VA A`I�, d 1 - Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building 404PIP No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow /jo gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil } l�- Nature of Repairs or Alterations(Answer when applicable) Date last inspected: I 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 Healt Signed Date ,3 a d Application Approved by Date U 1 Application Disapproved for the following reasons Permit No. 7,0V — Date Issued 3 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (fertificate of (tompliance THIS IS TO CERTIFY,}that the On-site Sewage Disposal System Constructed(�)Repaired ( )Upgraded( ) Abandoned( )by �rw C�yw•/h1 at /4 r0 lc't,,5� -01 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 ro 1dated 3` Installer Designer The issuance of thjs penpit shall not be construed as a guarantee that the sys °will f ctie designe . Date Inspector iaj --------------------------------- No. 0 Fee 91 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mizpooaf *pztem Conotruction Permit Permission is hereby granted to Construct( c)Repair( >YU rade( )Abandon( ) D System located at coo d h C Oy►�y y �� /��Y' 1 y Yl�� 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:Construct' n 7u,,)/ t be completed-within three years of the date of th' a it. Date: 3 ,, Approved by 0 v FES............ w....�.. ,. THE COMMONWEALTH OF MASSACHUSETTS 0� �� EOAF� r O,F HEALTH 'Q'.W..t.4....-------....OF. f !� --1.�1F7. ----------------------------------- ApplirFation for Dispasal Workg Tonotrnrtiun Famit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: f6\ ! Location Apddrreess �/� or. Lot No. .....--•.............._��4?r .( .....`' .BLS!4C: ��.lse[..................••. -•---••-•-----•------•--......................-W------ -----------................ .............. caner .... .... •-•-••.Address ................. ------------------ Installer Address Type of Building Size Lot__._I ............ U Dwelling—No. of Bedrooms___________ _______________ _____Expansion Attic ( ) Garbage Grinder Other—Type of Building No. of persons____________________________ Showers — Cafeteria Q' Other fix ures ____________________________ f W Design Flow__________..................._______ gallons per person, pr day. Total dail�flow____._._.___.____________ ......gallons, WSeptic Tank—Liquid capacity.� Ggallons Length__��.._ Width.__.___ Diameter________________ Depth___S $ x Disposal Trench—No. ................__.. Widt _ ...............______ Total Length___________________ Total leaching area....................sq. ft. Seepage Pit No.____.____�___-____._ iameter.____� __ Depth below inl�t_�� _��tal leaching area.. q. ft. Z Other Distribution box ( � Dosi ank Z d o Percolation Test Results 'Performed by. _Y_. ___=._e ;... Date................... __ . a . Test Pit No. l.__._`�tninutes per inch Depth of Test Pit_______�........... Depth to ground water........................ GL, Test Pit No. 2......`.Z�-_minutes per inch Depth of Test Pit_________L Depth to ground water_____ `______... ...............................•............................................................................................................................. 0 Description of Soil................ ..................... ---------------------=----------------------------------•-----•-----•-•----•------------------ �., -----------------------------------------•---._. obi_L = ' � ------------------------.._..------------------------......_..------•-•----•--••---•---- W •••-----------------------------------------------------------------••--•-•••--••--•••----•----•---•--------•--------------------------------•••--•••------•-....-------•---------------._.....--------- UNature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: �. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIT .;,, p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. -•---, Sig d--•------- - •--_-•................•----•----•--__••-•------------•---••-•--••-- -•-•----•----•-----•---..._.... Date Application Approved By- . 0 ____-�___ Date Application Disapproved for the following reasons_________________________________________________________________________________________________________________ ....................•--•--•------------•-------•••----•-•----._...._..--•--••--•--•••------------....•------------------------------•--••--••---•---•••------------------------------•-•--••---...._._.. Date Permit No...................... ..................•- Issued_....................................................... Date N0.. . .............. F]MIN............ ............ THE COMMONWEALTH OF MASSACHUSETTS BOARQ OF HEALTH >r f'�.0 ......... ......OF..... Appliration for Disposal Works Tomitrnrtiun Prrmit Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at i 1 ................__...... ---7.....1....----• 1 --•----•--••-•••-•-•--•-•-•---•••-••-••-• 1_0_r 11 .................... Locatiorf}Address or Lot No. ........................ ? 1G�... i1 b ..................... ............._...__.._.....__...................._............................................... ICI Address Installer Address �� t Type of Building Size Lot____.....................c Sq fe-et. Dwelling—No. of Bedrooms............ ...........................Expansion Attic ( ) Garbage Grinder Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) Otherfix ures -----•------------------•-----------------------...---.-•-•••--•-•----•-•---•---•-•-•...........-•-•-••-•---•---------- WDesign Flow.......... ......................gallons per person per day. Total daily flow............._.._........ -..._ ..._..gallons' WSeptic Tank—Liquid capacity..,.COgallons Length__0.-IOL Width.:?_'-f".. Diameter................ Depth... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.--__-__-_----- Diameter..../�....... Depth below inlet-----6t.-._.... Total leaching area_-"?` ?f n--_sq. ft. . Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by ? L lJkl .: ! . Date.... ........ 4,7k,.9. ,.,.a Test Pit No. 1......_.':__.___.minutes per inch Depth of Test Pit........_Z-_...__ Depth to ground water......................:. rs, Test Pit No. 2-_-__":.minutes per inch Depth of Test Pit........-__• Depth to ground 'water........................ a ......................................................._------ --------------•--•-------------------------------------------------------------------- Descriptionof Soil ......... - ---------------------------•--•---------------•---•-•--•-•-•--....••-•--•-•-•- W -------••--•----------------•••---------------••-•--•---------••-_...:_ VNature of Repairs or Alterations—Answer when applicable`':`.......................................................................................... --------------------•-----•--------------•----------------------------•-•..............--•------•----•---....------------------.....----------------------------------------••-------..._•-•----•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed.....--- _--- --- •----•---•---•--------••--•-----•• _.... Application Approved By *a l ..................................t, --••.................•. ---•- .------ `/ •---•---------•---•...............................•... --••--...Date Y Application Disapproved for the following reasons_____________________________ -_---___-_---_ ----...---•---•-----•........................•--•--•-------------........----------------....------------'-----------------------•-------------------------------------------•----••-•----•--••--•-•----- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS ,,. BOARD F HEALTH ................. '�.........OF.............>•. .. ....................;._... Trrtif iratr of fanntpliattrie THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed <oRepaired ( ) by € I :....-------•-•--(it-------------------------------------•--------------•--------•----------....-----••-------------- 14. �! o Yler,has been installed in accordance with the provisions TLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit _f_____._'__ _. %'_____________ dated__... _ -'_ r r_ ------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector....----------•--........•..:..--------------•-------........._..------............ THE COMMONWEALTH OF MASSACHUSETTS ... �.-. BOARD OF HEALTH t t � fI- „f ...................................... �� OF......� 11 ...... ......... .r........:............--•--........ No- .............. ... FEE..:::... ......... Disposal Vorkg Tonstrurtinn rrntit Permission is hereby granted `�s :r ......r . to Construct (: or Repairs(:, ) an Individual Sewage Disposal System at No........i.__50+. ca �a__ c' QI�j r '.--••-•T? -------------------- ---•--------------------•-•-••-••-----••--.............. Street 7", as shown on the application for Disposal Works Construction Permit No..,e...............Dated.... __....`......:....Z:.......... jrz_ l Board of'Health Yr DATE - - ....._.. -----------------••-•------------•-•-- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS `.*4 vrLc,,dv n i to k 3 imS- 4 i5 ct5TroAA ' aCZQ t ftW Oe cam- yr u l ire G,_ 12 "f SST t �-c ; �. 'roe F �a too' + ,� P.v� vc�r. Ou �a • q�,.7 Scpric L .� TU+Jk a•. } PITPS 4 tmwb ��T� { T Skis 12 i.Jo 5�.a.c.C:. cSG �-� 111= Z t Pi-A.t--L tz�E�z 17--*x.tc.[.. t Ca=r)PY T"AT r+.4ti M•aNC'L,cz-�O..A f.:o�c pr.:Y W�t't�t -rc•trt= r ttyE.t.a a ti c b. er 2 + Wt> eG't AGtc. oft TWf-!- pop- �PuAO:J c" UX :;TEt;s� • �frl"jT�i 'tZt:3.L`,? 1.�� j(,�,'�..t/`a...`-�t7ti�.-a TW4 PL&W 14 uor &ns6D OU au 1"4TM)MFLT oer-raimv%L Ao(A coC,. °auL:�tG`t 4 -r"r. o;:Fsur;; '3t-EL' LI> UOT 33 Olvet> APPt-tC. l►W r 'rd T�GrCtU�tit•.►�. t47 .t.tt.t�S. ��t,.1- ,•'.'-L1ph� f a 01 ✓/ O'l fr wr W_ r f t j l 4J , t R F 9 � y , < 3 'Y r S M ;y '`, v s rr IF y \.S - i .;... � � #" ,-:^Fky.� .. Mom',:.. s r -, k Y,R s..:3 t•T ,.i¢'%tk T ?� - > I u 4. - N of