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HomeMy WebLinkAbout0009 STONEY POND CIRCLE - Health 9 Stoney Pond Circle Mars.ons Mills P _ A = 064 068001 �� Commonwealth of Massachusetts 0� "v Lq~ dC)/ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 9 Stoney Pond Circle Property Address INJ Stan &Ann Barnes Owner Owner's Name 0 information is Marstons Mills I/ Ma 02648 5-23-17 required for every 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. Important:When A. General Information SAY- 1 of-1 filling out forms c� 3 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Matthew Gilfoy use the return Name of Inspector key. B&B Excavation Q Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 SI 13640 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ` ❑ Needs Further Evaluation by the Local Approving Authority , 5-23-17 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or ,has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17 < Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. CitylTown 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: System was in working order at time of inspection. Town located a plan showing a garbage grinder was okayed at time of installation per Board of Health. (plan dated 9-2-1988) B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not . determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•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 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 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 '/2 day flow l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. Citylrown 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 ❑ Elthe 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 �^M 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. Citylrown 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): 678gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. City/Town 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 El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2016- 151,000gallons 2015- 164,000gallons Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. Cityrrown 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: Owner- last pumped in '04/'05 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 W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 9 Stoney Pond Circle M Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1988 per plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 8 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 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 gallons Sludge depth: 7 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 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 29 Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 3 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.): Tank was in working order at time of inspection with liquid level equal to outlet invert. Tank is in need of pumping at this time and should be pumped every two years for maintenance. Grease Trap (locate on site plan): Depth below grade: NA 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 11 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box was in working order at time of inspection but heavy carry over was present. No sign of past back up was found. 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.): NA 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 w Title 5 official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: (1) 6'x6' w/3' of stone ❑ 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.): Leaching was in working order at time of inspection. Pit had V of standing water with a high stain line 1' below invert. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration NA Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 9 Stoney Pond Circle M Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. City/Town 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 Front of house B 1 �J A2-26' 132-2S' A3 37' B3 35' 2 STONEY POND CIRCLE t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 Stoney Pond Circle Property Address Stan &Ann Barnes _ Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: NoGW@12'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. 9-2-88 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: Plan on file with BOH. 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9 Stoney Pond Circle Property Address Stan &Ann Barnes Owner Owner's Name information is required for every Marstons Mills Ma 02648 5-23-17 page. City/Town 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 V P &//ql o-- W OF BARNSTABLE LOCATION I_p� k S7b,�13\ cpp,�.� SEWAGE # 902 VILLAGE ro DNS (���� _ ASSESSOR'S MAP & LOT K���,�o) INSTALLER'S NAME & PHONE NO. ASEPTIC TANK CAPACITY /„oz) ALEACHING FACILITY:(type) (size) k%000 ENO. OF BEDROOMS . PRIVATE WELL OR PUBLIC WATER ®BUILDER 01�QWNER DATE PERMIT ISSUED: ;L �- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No t! t.���� `. _ �� ��y, ,� , 3� '* - \ a� ;- ASSESSORS NEAP NO: q1' PARCEL NO: _® (o a® 1 ©� No.----1 �t 13 I Fss...... ...... THE COMMONWEALTH OF MASSACHUSETTS 6 �O BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Dwpuual urA�®r milrur#ion rrmi# Application is hereby made for a Permit to Construct (L ) air an Individual Sew a e Dis posal al System at:/ A�/ ...» ... .- -- . --- ................� -- .. . . A ocati d s or Lot No O ner Address .... .. r -. ............•-•---••------•------•---------- ._..-----.....-•-•--..............------•-•�/ Installer Address Q Type of Building Size Lot__ 1_z 2V........Sq. feet U Dwelling—No. of Bedrooms_________________________________ _____Expansion Attic ( ) Garbage Grinder ( ) aOther —Type of Building ____________________________ No. of persons...... Showers ( ) — Cafeteria ( ) dOther fixtures _..--•-•------------•--••-•••--•-----•--------------••.-•------------------•-••--•--••-----------•----•-------•--•---•--••------------•..._.......--_. W Design Flow___ _____ ___ 5� ----------gallons per person per day. Total d*1 _ .3C.flow..........33_0..................... WSeptic Tank—Liquid capacil M. ._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. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water........................ L%4 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ Description of Soil___ ��"_____ ________��____ G1 ________________.__. x -------------------------------------------------------------------•--------------- U ---•-•--••------•-•-•-....--••--••----------•.__.__.._-•---•-----------------------••._..._...__----• •-------------- ................-------------------------------------------------------------••-•-----_._•--•---------------------•----••------_.._--•-------------••----------------••-.....-•--_.._.. U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________ ..................•---------••_---_..__._...--•--_----••--••-••-•--_.______._--_._...-__---_._.._..•--•--••-------_•----•----...._-•---------_...--•---------_.._.__.__.__........_..__........--------• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com%Jliance has been issued by the board of health. Signed -------------------------------------- -------------------------.............. Date Application Approved BY --------------- .--------------------- --------?a`- ce Da Application Disapproved for the following reasons- ------------------------------ ------------------------------------------- ---------------------------------------- - --------------------------------------- ...---=................................. Da�e PermitNo. .........9-9-" L-1_ ..................... Issued -------------------------------------------------- - Dare el C% Z7/ 4 o J FRs....t. l 0....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Y TOWN OF BARNSTABLE Appliratiaan for Dispnittl Works Tonotrnrtion lirrmit Application is hereby made for a Permit to Construct (v) or Repair ( ) an Individual Sewage Disposal System at ....• ........................................owl v ®' ...-----f�� hG ........-- -- ` ocati d s or Lot No. .......... �• -------------•-••-••-•••... -•----.... ......................................................................................'/ /V Installer Address UType of Building 3 Size Lot__�Z_-WI........Sq. feet Dwel . ....._.._.Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type ing oof BB ldi gms_______________________ No. of persons__--• ................. Showers ( ) — Cafeteria ( ) Ot fixtures ------------------------ person pCeeer/r day. Total dail flow----.....3_ 0---------------------dons. WSeptic Tank—Liquid capacit/M .___gallons Length_ t!---...... Width.. .... Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area___-.-..------------sq. ft. Seepage Pit No-----Z----------- Diameter____________________ Depth below inlet_................. Total leaching area..................sq. ft, Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.................. :.._.- ;3;, Test Pit No. 2................minutes per inch Depth of. Test Pit.................... Depth to ground water........................ -- --------------- -------------------------•------------------------------- 4144�� D Description of Soil....-_ __..�� ..._.v�� ___... W ---••......................•-----•----------------------•-•--------•-•-•-•-•----------•-•......-------•----•.•-------------------------•-•••---------••••••--••--••••••-•-•-•-••-••----•----•-----•---. U Nature of Repairs or Alterations—Answer when applicable................................................................................................ •---------------------------------------------------------•---------------------------•------••......--•------•-••------------•-------------••-•-----•--------••-----••••----•--•-•-•-•...........-•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com liance has been issued by the board of health. :._ «. .�...-.. ---------- Signed .... Dare Application Approved By --------------- v .-.. J =Dat Application Disapproved for the following reasons: ......:--------------------------------------------------------------------------------------------------------------------------------- ----------------------------- .......................................................------------------------ Date PermitNo. ------_-?..9-----"-----1 g--------------------- Issued ------------------------------------------------...._... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i TOWN OF BARNSTABLE Certifi ake of C omplian e THIS I O ERTIFY That the Individual S wage Disposal System constructed ( ) or Repaired ( ) by t �✓ '4c /p A-1 -------------------------- ----------------------- �j �t� I --i;er '; F at -------------- �........- - ..✓! "' . --�J ..C.-+lam L f ; ` / ( - - -- -------------- -- - . .R---.;b has been installe /X d in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ---------- -- ---------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 q TOWN OF BARNSTABLE No....k-1,a�._'13.5� FEE..l./Jn�...--•--- Bispoll 1 kg nn nr ivit' rrmit Permission ereby granted l l ...................................... to Construct ) or Repair ( ) an Ind'vid P Sewage Disposal System at No.......... ... . �.... ,l� !� //�Ll . I- �J ............................... Street as shown on the applica ton for Disposal Works Construction Permit No 13�'_�ated.. :........................n..�....... Board of H alth DATE---------------- / FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS u f N,777Vf''' L I TILEPO ', 1j>"r fygr.d 0 N D s ,r Py fi y - is T If✓"" a i �. J _ . Mt'�r'. co �9 Ld� �r s o / V � 10, Al i r / / 1 , A i LOT I_ o � Wof�r va / iC- ► o rpf SC.AL� Ar 7t S�zrtJ�s' Patio /20.9 a t• YTli9R5TLWs' A7/LL$ j G - 'L J cJ r3 SHEET 2 oid' 3 ' it/4TE /JJhx... ,,.., us/4e✓G »v��r�.a�fci=-- "Ve IAMOY is. �Tii.6s�tr[L3tori: AI,LV 10 x 3 _ 33o Gpd ��rlc TANK 33o x ZoOy = G(oO Ga.Ilons U9c ISO© Gallon Scpi-►C ..T3.nic x _. . DIsPc:)%AL Plr ti usc, loco gAl►ci , p; �.0 I f-I�t 3 �cc� o f arvsha�Q si�na ' Sl.oL--wAV- . ZZ� SI= PoTrom I 1 3' S1� �o�� RICHARD ,per �,C4i 0, ""4��' GAPgciTV I I )C (.O 1 13 G cQ o A. �"'• �� ST NEPHN• nsG BAXTER To7-Ru..3 , ,� �(r.� at...Y'. �. 678 G � No.24040 - GIST ERE1) P�'`' � IJu.3.)21^S /.. J T S¢ Al. roll, oisr, 1. 6.�) /soo .✓C� ♦ • �6.82, ejl / GS,00 BOX /N✓. G.�L, /(efe,bL i . 66,37 SE'PrrC r - b PGOy'r pc.4N 3• A,a MOM j t4E'r,;�'j� T�'.4T T.�,CE �/ovSE S•YoW.V. ,_;_), . �- -- .�Eav 'o.fE7'l�AG.I: .2EQV/,eE',y�NrS O.� Th'� B,d Xr2=,2�- �/rE/.cic, • �WiV O/F.Ds9a2NSTi1BC� Avv 4. / ::ov— �2EG/ST ,p�OrG4NG7.5�/.21/�C s r�usr- `- 'y.41V.29 ;—ACE COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION RECEIVED Property.Address: P(yxd MAR 1 2 20 03 Owner's Name: TOWN OF BARNSTABLE Owner's Address: HEALTH DEPT. Azad Ail da�U Date of Inspection:k.-�.�g 3 0�/1_ MAP "r' Name of Inspector: (please print) -U4- 7j PARCEL ' ®� Company.Name: idi&7 Mailing.Address: y� LOT xiill 'Telephone Number: c5C7" 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 Fails Inspector's Signature Date:: /� ,0-3 P The system.inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the . DEP..The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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 6/15/20.00 page l Page 2 of 1 l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 'p Inspection Summary: Check A,B,C;D.or E/ALWAYS complete.all of Section D A. (System Passes: 4/ .I have not found any information which indicates that any of the failure criteria described in 310 CMR 15303 or in 3.10 CMR 15.304 exist.Any failure criteria not_evaluated are indicated below. Comments: ell B;jystem Conditionally.Passes: One.or.rhore 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 ornot)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 1 l OFFICIAL INSPECTION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: 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 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 I 1 OFFICIAL INSPECTION FORM-,NOT..FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Ly 10 Owner:Ld vl A, Date of Inspection: � j 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�/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _. Any portion of the 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 I of a,public well. _ Any portion of a cesspool or privy is within 50 feet of a.private water supply well. . Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet-from a private water supply well with no acceptable water:quality analysis.[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.] 1 to (Yes/No)The system fails.I have determined that one r Y o more of the above failure criteria exist as described in 310 6MR'15.303,therefore the system fails.The system owner should contact the Board of . Health to determine what will be necessary to correctthe failure. E: Large Systems: To.be considered a large system the.system mustserve a.facility with a`design flow of 101000 gpd to 157000 gPd You must indicate either"yes"or"no"to each of-the following,: (The following criteria apply to large s stems in addition to criteria above)PP Y, g Y o e yes no _ the system is within 400 feet of a surface drinking water supply the system is within 260 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 questibn 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: n HA Owner: Date of Inspection: 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: Yes ng- _j✓ Existing information. For example,a plan.at the Board of Health. _ related to Part.Ci s at issue approximation of distance i a of the failure criteria _ Determined m the field(f any PP is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 8 of 11 -'OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART'C . SYSTEM`INFORMATION(continued) Property Address: y,? Owner: ; Date of Inspection: 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/day Alarm present(yes or no):. v Alarm level: Alarm in working order(yes or no): Date of.last pumping: Comments(condition of alarm and float switches, etc.): V " DISTRIBUTION BOX: if resent must be o ened locate on site plan) ( P P )( P ) ;Depth of liquid'level above outlet invert: 2��� P�IJ�� 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.): � rX /9 / PUMP CHAMBER(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: Ce Xl Owner: t Date of Inspection: �� ��XjU 3 SOIL ABSORPTION SYSTEM (SAS):__LZ(locate on site plan,excavation not required) If SAS not located explain why: T�aching pits,number:L leaching chambers,number: leaching galleries,number: leaching trenches,number, length: leaching fields,number, dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, et a. oo _ . CESSPOOL (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 cessp.00l:. 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/ (locate on site plan) Materials.of construction: Dimensions: Depth of.solids: Comments(note condition of soil,signs of hydraulic failure, level of pondin&condition of vegetation, etc.): 9 Pace 10 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address: C)a,4� Owner Date of Inspection: 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. 0 3t7` 7 10 Page l l of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C SYSTEM INFORMATION(continued) qaProperty Address:, Owner: C Date.of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water. Zi�O'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 1.50 feet of SAS) Checked with local Board of Health-explain: Checked with.local.excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 Permit Number: Date: Completed by: HIGH GROUND-WATER.LEVEL COMPUTATION Site Location: y ©�� /�� Lot No. Owner: b) �t°i� Address: y Contractor: � ��> l� C0��5 Address: �y�fi�l � yPy p Notes: /�C� !�✓r— ,/.ilk STEP 1 Measure depth to water table tonearest 1/10 ft. ............................................................................... .Date month/day/year. STEP 2 Using Water-Level Range Zone and Index Well'Map locate site and determine: OAppropriate index well.......,............................................ 0 Water-level range zone ...............................................:..... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level-for index well ........................... 2 . 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 26) determine water-level adjustment-............................:.............................................................. �' STEP 5 .. Estimate depth to high water by subtracting the water- level-adjustment (STEP 4) from measured depth to water levelat site (STEP 1) ....................................:........................................................................... Figure 13.--Reproducible computation forma 15 i i 1 - U N 1.� -R 77,