HomeMy WebLinkAbout0121 TIMBER LANE - Health i
121 Timber Lane
Marston Mills
A= 149 -051` _
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YOU WISW TO OPEN A BUSINESS? !}
For Your Information: Business certificates[cost$4D.00 for 4 years). A business certif!.cate ONLY REGISTERS YOUR NAME in town (which you
.L. ;1
must do.6y M.G -tt does.rfot give you.permission to operate,) You mustfirst obtain the necessary signatures on this form at 200 Main St., Hyannis. .�
Take the completed.form to.the Town Clerk's Office,1st FI., 367 Main St., Hyannis, MA 026.01 (Town Hall) and get the Business Certificate that is ?
required by law. -�
DATE'3 /� U I Fill in please:
1 YDUR NAME/S:i>c, tyr APPLICANT'S T I�
";!•,` '•1 .`�"�� 'r`•1' ' �x•t� BUQSIINESS YOUR HOME AgDRESS. M
TELEPHONE '# Home Telephone Number 1 Cc),,
,n�:iiylv`1Vig�.p�%-- OR EIN #: SD E-MAIL: Cc C?12UICl�-S 1
NAME OF CORPORATION: G >J G TYpE OF BUSINESS r
NAME OF-NEW BUSINESS
IS THIS A HOME OCCUPATION? kE NO
ADDRESS OF BUSINESS 1 ere i� n MAP/PARCEL NUMBER 'b [Assessing)
When starting a new business there are several thln.gs you must do in order to be In compliance with the rules and regulations of the Town of
Barnstable. This form is.irften'd•ed to assist you In obtaining the information you may need. You MUST GO TO 200 Main St. - [corner of Yarmouth
ermits and licenses required to legally operate your business in this town.
Rd. & Main Street) to make sure you have the appropriate p
'f. BUILDING CO 15 IDN 's OFFICE MUST COMPLY WITH HOME OCCUPATION -
This individu I e n i me y p •r • raq r erns that pertain to this type of business. RULES AND REGULATIONS. FAILURE TO
COMPLY MAY RESULT IN FINES.
Aytho.r Ig at a**
OMMEN •
l�
2. B OAR D OF HE TH
This individual has been info, e h permit requirements that per fain to this.type of business.
Authorized Sknat&e**
COMMENTS:
3. CONSUMER AFFAIRS [LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS: _- -
f —
Town of Barnstable Health Inspector
oFtHE r Office Hours
ti Regulatory Services 8:30-9:30
Thomas F.Geiler,Director 3:30—4:30
a ■
BARNSTABLE.
9�A MASS. � Public Health Division
rFn �A Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT — SEPTIC QUESTIONNAIRE
Date: l l/6/08
1. General Information: Size of Property .47 acre
Address:,121 Timber Lane Marstons Mills,MA 02648 Map 149 Parcel 051
Name:Robert&Pamela Fragosa Phone#: 508-428-3778
2a. How many bedrooms exist at your property now?3 total(two in main house one in apt)
2b. Are you planning to add any bedrooms?NO If yes,how many? 0
2c. How many bedrooms total are proposed at this property(including the amnesty unit)?3
2d.Please include a copy of the floor plans for the entire property. Neatly use a straight-edge. Show all existing
rooms in the home and the proposed amnesty apartment. Provide width measurements of any open doorways.
Please label each room clearly.
3. Is the'dwelling connected to public sewer? YES or NO
If the dwelling is connected to public sewer,skip questions#4 through#9 below.
4. Location of dwelling is INSIDE or OUTSIDE a Saltwater Estuary Protection Zone?
5 . Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells?
6. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER?
7. Is a disposal works construction permit on file? YES I or &0
8. If yes,how many bedrooms were approved according to this permit? 5 Bedrooms. t J
21
9. Were any building permits obtained for construction of additional bedrooms? or N YEO
cza
10. Is there an engineered septic system plan on file at the Health Division? Y S o cnNO
tti l
11. Has the septic system been inspected by a DEP certified inspector within the last two years? Y S or NO
-------------------------------------------------------------------------------------------------------------------
FOR OFFICE USE ONLY
The Public Health Division has no objection to�bedrooms at this property.
Special Conditions: nSI ( ( &Lr I
i/
l'0 VV"k &
Signed: Irn Date: 9 06
Q;/heal th1Wpfiles/amnestyapp
1�
TOWN OF BARNSTABLE
LOCATION SEWAGE #
�`. VILLAGE Dt2 — ASSESS 'S MAP & LOTS q
INSTALLER'S NAME&PHONE NO. .
SEPTIC TANK CAPACITY f o�O t att"cam -
LEACHING FACILrry: (type) y (size)
NO. OF BEDROOMS 3�
BUILDER OR OWNER
PERMTTDATE: l 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
loofil - --
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:' Av ID LQ
Date of Inspection:
SKETCH OR 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[he building.
I
I' �Q�
TOWN OF BARNSTABLE
,LOCATION 2(o M, C.4Lv4g SEWAGE #
VILLAGE UI l�S ASSESSOR'S r MAP & LOT 9
I'`INSTALLER'S NAME & PHONE NO. L(R)N A 00 IA3. C/L
SEPTIC TANK CAPACITY rip
LEACHING FACILITY:(type) ���` (size) ` 9'� CAS
NO. OF BEDROOMS J PRIVATE WELL OR PUBLIC WATER 6/e- -C-
UILDER OR-OWNER 0, L j oD
DATE PERMITJSSUED:
DATE . COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes Noi
0
i
r.
No.--... ._.... D�SIGNIPJG _1vr:P o,: ....._.....
t_� " �1lIEtITtNG
T %MAC
T-o.�.. .................oF.............................T.....�-LE------...._.........................
Appliration for Uiipntittl Works Tnn,itrnrtinn ramit
Application is hereby made for a Permit to Construct (A or Repair ( ) an Individual Sewage Disposal
System at:
L-b T Z. Ti.. .�3...c.l :...... •--------•............. ......
11�� emotion-Address or`Lo No.
/.......•.. ......-•-••-•-•--- . .....� 4_tv w-------1°'IA30.c.---•------•............................
Address
Wz— w,. r�� K s tL/r_ice. �` /�' l.._.
Installer Add ess.
d Type of Building`` ii��' Size, Lot.... _fa3...Sq. f t
a. Dwelling L No. of Bedrooms., __.� ESI�i!✓_ _3 xpansion Attic � l Garbage,Grinder )
p,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ............................
Design Flow..................67. ...............gallons per person per day. Total daily flow........... _S.52•--------....._._.---gaf lgns.
WSeptic Tank Liquid capac>ty_1Q2�_gallons Length............... Width_.—.__._..... Diameter_____--__--_. De th..........._q✓!p I'
x Disposal Trench—No. .................... Et
Disposal Total Length.._................. Total leaching area. .....sq. ft.
Seepage Pit No..._....___f Diameter_6..._r aFl� t�' te`to� inlet....... Total leaching area_���_.s ft
P I------ - g q
Z Other Distribution box (x) Dosing tank ( ) ] '= � L170AX
~' Percolation Test Results Performed by.............................................................. .......... Date....................._7 -----
1.4� Test Pit No. 1... 2".....minutes.per inch Depth of Test Pit._.13�......_. Depth to ground water. !p"!E_._ 'v�
Test Pit No. 2......�..minutes per inch Depth of Test Pit._� .�._...... Depth to ground water._ 4 ........
a -------------- -----..........-•-••••-•-•---•---........-----•......._..--••--•-••------- ._..._....._.....--
0 Description of Soil.... 1__t / _._ .c , .-.- ® -------------------------•----....----------------......•...............-•••--•----.----•-
v --------.1. _... r r�s. ....... p- 'g-' .....z--------------------------------------------------------------
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
-- ,.isuby board o h esig �_ . . ... 1c
.............
_ Dat /
Application Approved By..... ................. . .. . ._. •-•-•---------------•----•---•------ ..... -�ZD - �....
e
Application Disapproved for the f ollowin easons-------------------------•--...--••-----•----------------------•-------------•--•-----------••-•----------...._..
•----......-•-•------------•-•--------------------------------------------------------------•---------------...........•-------------------•-------•-•-•----••-•--•--•-•...-••--•--------------...•--•-
Date
PermitNo......................................................... Issued........................................................
Date
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
I A-
m /�- C-- A -IL
DATA
No........----_....... FRs..........................._ ti.
THE COMMONWEALTH OF MASSACHUSETTS 4-9
BOARD OF HEALTH ,) 7
c --- .................OF..... /2N S 7........
Appliratiun for Uiupuuttl Works Tunutrurtion rrrntit
Application is hereby made for a Permit to Construct (A or Repair ( ) an Individual Sewage Disposal
System at:
....:L:v-T ZC�'(-I},1.j3 c- �....� �G H4/45Te)NS
._.._.......... ...................•--•--•-•-- •-•---...-•••-........--•••-•--...---•.----. ..-------•-....__......_..........--.-•--•
tion-Address
o
/4 ............. .....•.. ..vo w1 4N ' .I
1'V pn // Address �1 ................
...................................................re
� Installer ress
U Type of Building Size Lot ....7.3_..Sq. f t
Dwelling_\1o. of Bedrooms.2...(&SL46 t_U/L-3 xpansion Attic (f1lG) Garbage Grinder ( �
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ---------------•---------•-----------------------------------------•-----------------------••-------------------------------•---------------------•-.
Design Flow................. ._...............gallons per person per day. Total daily flow--- 3_.�-'_U........_.........._ 1gqns.
W Septic TankC M4OLiquid"capacity_. gallons Length...--_-- Width.._--......... Diameter____-"'"..._. De . ....... �P
x Disposal Trench—No. .................... Widt .................... Total Length.................... Total leaching area_: i- 6..sq. ft.
Seepage Pit No------------I-------- Diameter.L..-..�_-__•---- DeptFi'`��o� inlet.......4........ Total leaching area.•Z_.._.-_-__.sq. ft
Z Other Distribution box (� Dosing tank `-�OAy
Percolation Test Results Performed by-•••••-•••••••---•-••--••••....-•-•----•--•-------•••.................. Date...................
Test Pit No. 1....'L-.....minutes per inch Depth of Test Pit...13'............. Depth to ground water.._._._" ....._....�._.
�� ' f�.UE &A)L
GL, Test Pit No. 2.......?/:.minutes per inch Depth of Test Pit....
................ Depth to ground water.__....:....•......__._
QI' ---------------------------------------------------•---.....----.....---------------•--......•....-•.........................................................
0 Description of Soil....4a.:_
..................I ••----•.....•-•-••---•-••..........................•---••......---
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 Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issue. by the board of health:
Si n� ems~ f
° g d. =,..... i�t r� 1/ !_.:. fir
... . •-••--. ••••• ..__.
. � Date
Application Approved By............. .____._. ......_ L J .��
�,�
Da e
Application Disapproved for the f ollowin easons:•--------------•-------..._..-------------------------•---•--------.....------------------------...-••••-•-••-
••....--•-------•-•-----•........--•--....---•-••--•--••......-•••-.....-•••-•••••-----•-•--•--••••-•-...._...----•-------•...•---••---•••---•-----•-•••••-•-•••-••---•••••••-•------•---•••.._.....---•-
Date
PermitNo......................................................._ Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
� 1
{ ........ ..(?w. ............0F...... .1`)2 SiLc
(Irrtifiratr of Toutplittnrr-
THJS IS TO CERTIFY, That the Individual Sewage Dilpos 1l System constructed (� or Repaired ( )
by............._.:�' t>1.1.���:�.<.... ;a r'7G..-----•---•--•--- `--- ------=----------•-•----•--------•----..........-----...-----•-•----••-•---•---
-� / Installer 1 1I
...... -
-----------------------------------•----........................•--•-
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................•. dated--------z�_.r_---------------------------
._._.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. - - -�
DATE... , r--- ---•-------- Inspector / °...........................................................
THE COMMONWEALTH OF MASSACHUSETTS, l.
BOARD OF HEALTH
........, ..�?icl�J..............OF.....EZ 2 :?. .f3�-.
No....�..w.....4...... FEE........................
a
Disposal Works Tonstrurtion Vermit
Permission is hereby granted...... Z723=721t& _...__._ ...---•-----•-•-----•-----•---•--•---•.......................••---.........................
to Construct ( or Repair ( )_an Individual Sewage Disposal System
at No........
1...i. \\\. Nj ..
± J
Street ..
as shown on the application for Disposal Works Construction Permit No_._.� __� _ �_ D ted. • ................. ................�
I� L ..........
-•.• •
f
DATE..................... .........tL... .......... � BoHelth
_
�
FORM 1255 A. M. SULKIN. INC.. BOSTON
UP�I,, Department of Environmental Management/Division of Water Resources
WATER .WELL COMPLETION REPORT
WELL LOCATION
Address La7 rah. �oaft��/ 4 —)
a
City/Town -fralC7n naS n r
G.S.Quadrangle Map
Grid Location /VIU�
Owner 461 J - r—iu %J (A j %,f
Address I'! Rrx
WELL USE CONSOLIDATED WELL
Domestic[B' Public ❑ Industrial ❑
Type of Water-bearing Rock
Other
Water-bearing Zones
Method Drilled QU 4, P t) From To
2) From. To
Date Drilled / � 3) From—To-
4) From To
CASING Depth to Bedrock
Length C3 Diameter
Type Po " UNCONSOLIDATED WELL
STATIC WATER LEVEL Water-bearing Materials
Sand: fine medium A-"coarse p�
Feet below land surface �t -� � ❑. ❑ ❑
I� Date measured�F �� Gravel: fine❑ medium❑ coarse❑
Screen:
GRAVEL PACK WELL Slot# A length X from Yrl to "/;
Yes ❑ No ❑
Split Screen (or 2nd screen)
WATER QUALITY TESTS MADE._ Slog length from to
Chemical ❑ Biological Depth To Bedrock
PUMP TEST
Drawdown feet after pumping days 4 hours at IQ GPM.
How measured Recovery feet after hours.
LOG of FORMATIONS COMMENTS: (On well or water)
Materials From To
Cb
ci
wP ^ ( DRILLER m
/.1.
r ,. /i; Firm A .J(fin .,_,e
Address
Registration Not -�
Operator's Signature
Please Print firmly BOARD OF HEALTH COPY 25M.10-85•807101
Log Number: 6432 Bottle # E476 Date: August 19, 1986
$a4tis� BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT
't �p SUPERIOR COURT HOUSE
7
v BARNSTABLE, MASSACHUSETTS 02630
A1ASO DRINKING DATER LABORATORY ANALYSIS PHONE:.362.2511
_90. 337
Client: Ai-V L.' Gady Collector: Dennis A. . Scannell
Mailing Address: Box 159 ' Affiliation:' well driller
Marstons 'Mills, MA 02648' Time & Date of
Collection: - 8/18/86 ' 9:15 a.m,
Telephone: 8818-5727 Type of Supply: __well
Sample Location: Lot 26 TimberLane Well -Depth: 43'
Barnstable, hIA Date of Analysis: 10.30 a.m.
PARAMETER SAMPLE RESULT RECOMMENDED LIMITS'
Total Coliform Bacteria/100 ml 0 0
Conductivity micromhos/cm 500.0
Iron m) 0.3
Nitrate-Nitro en pm 10.0
Sodium m 20.0
I . Water sample meets the recommended limits for drinking of all above tested parameter!
II .XX Based only on results of the parameters tested for this sample; the water is
suitable for drinking but may present the problems checked below:
A. Water sample has higher than average levels of Nitrate. Future monitoring is
recommended (2-3 times per year) to establish any upward trends.
B. X The low pH of. the water may shorten the useful life of the house's plumbing.
C. Water may present"aesthetic problems (taste, odor,- staining) due to
D. Water sample has high levels of sodium. Persons on low sodium diets should
consult their doctor.
III. Due to one or ,more of the reasons checked below, this water sample .is 'unfit for
human consumption: A. High Bacteria' B.' High Nitrates
REMARKS:
CC: Barnstable Boardof Health
CC: Scannell Well Drilling �, r
r
WILLIAM LIEBERMAN
REGISTERED PROFESSIONAL ENGINEER
LICENSED REAL ESTATE BROKER
235 TIMBER LANE(MARSTONS MILLSI
W. BARNSTABLE, MA 0266E
1617)42B-2592
February 6, 1987
Board of Health
Town of Barnstable
Hyannis, Y-a. 02601
Re: Lot 26 Timber Lan.
Sewage Permit 86-881
Gentlemen:
1
?lease be advised that I have inspected the
on site disposal system on the referenced property
after excavation and also prior to back filling.
The system as constructed conforms to Title
Five, Town of Barnstable regulations and the plans.
It is to be noted that the septic tank is
more than 10' from the building and there is more than
150' between the well and the leaching pit .
Very truly you ,
ZN OF A
ti W lliam Lie rman RPE
/ WILLIAM G
WL/el t� LIEBERMAN N
.o\p Flo. 2397i
-r F
o\GIs-rEI I�`�
FSSlONAL E��G
;
Ilk
.� �
� V� �Q 5
r
COMMONWEALTH
� ALTH OF MASSACHUS)✓TI'S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
r
v
I
i
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM j
PART A
CERTIFICATION
Property Address: /�r ( �-e/L-
Owner's Name: J
L. fe .J
owner's Address:
n
Date of Inspection:
Name of InspectoA(pleaeprint), IJ/4.<-/-4/�fCompany Name:MailingAddress: '�` �Telephone Numb :
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 orr 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:
--<-Ses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
4Fails
Inspector's Signature: Date: S
The system inspector shall submihis 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 or 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.
Page 2 of 1 I..'
` OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESS
MENTS NTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: / 'TrM a /I �,�• _
G
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System sses:
have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 C M R 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Condi ' nally Passes:
One or more syste components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon co letion of the replacement or repair,as approved by the Board of Health, wi I I pass.
Answer yes,no or not determined(Y,N,ND the explain. for the following statements. "not determined"please
The septic tank is metal and over 20 years old* or th ank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or fa a is imminent. System will pass inspection i f'the
existing tank is replaced with a complying septic t s approved by Board of Health.
*A metal septic tank will pass inspection if it i ucturally sound, not lea ' and if a Certificate of Compliance
indicating that the tank is less than 20 ye- old is available.
ND explain:
Observation o" ewage backup or break out or high static water level in the distribution',bgx due to broken or
obstructed pipe r due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of and 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
i
ND explain:
Page 3 of 11-
~- OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: V
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 determin
is failing to protect public health, safety or the environment, e if the system
1• System will pass unless Board of Health determine ' ceordance with 310 CMR 15.303(1)(b) that the
� , tem is not functioning in a manner whic protect public health,safety and the environment:
_ Cesspool or privy is with' eet o as ace_ Cesspool or privy is 50 feet of a bordering vegetated wet lan_d o a salfmarsh
2• yytem will fail unless the Board of Health (and Public Water Supplier,if any)determines that the
stem is functioning in a manner that protects the public health,safety and environ\\ rr;eut:
— The system has a septic tan
soil absorption system (SAS)and the SAS is within
surface water supply or tributa a surface water supply. 100 feet of a
— The system has a septic tank and S and the SAS is wi --_ -
, n-a-Zurt l of a public water supply.
The system has a septic tank and S the SAS is within 50 feet of a private water supply well,
_ The system has a s tank and SAS and the S is less than 100 feet but 50 feet or more from a
private water su well". Method used to determine istance
**Thi stem passes if the well water analysis,performed at EP certified laboratory, for coliform
b eria and volatile organic compounds indicates that the well is ee from pollution from e presence of ammonia nitrogen and nitrate nitrogen is equal to or that facility and
s than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this�form.
3. Other:
Page 4 of 1 I '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
� llf
Owner: 1
Date of Inspection: C`
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
p 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
_,jogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due io an overloaded or clogged SAS or
spool
uid depth in cesspool is less than 6"below invert or available volume is less than '/, day flow
]::�-required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
times pumped
y 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
wvater supply.
_ _ ny portion of a cesspool or privy is within a Zone 1 of a public well.
ny 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.]
(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 Systems:
To be considered a large sy 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 e f the following:
(The following criteria apply to large systems in a to the criteria above)
yes no
— , the system is within 400 feet of a surface d ' tng water supply
— the system is within 200 feet tributary to a surface drinking water supply
_ — the system is 1 a et d�trt a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA).or a mapped
Zone II public water supply well
If you h e answered"yes"to any question in Section E the system is considered a significant threat, or answered
"ye ' to Section D above the large system has failed. The owner or operator of any large system considered a
gnificant 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.
Page 5 of 11 '
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: L) r—
Date of Inspection:
Check if the following have been done. You m ust indicate"yes"or"no"as to each of the followin :
Yes a
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 ?
1ZWere as built plans of the system obtained and examined? f they y were not available note as N/A)
as the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out ?
Were all sy
stem components, excluding the SAS, located on site ?
Were the septic tank manholes
of the baffles or tees,material of construction,dimensions,tdepth of liquid,depth of led,and the interior of the u genand depth of scum?spected for the d�tion
Was the facility owner(and occupants if different from owner)provided with informatio,
maintenance of subsurface sewage disposal systems'? r on the proper
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes
r — 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)J
Page 6 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMEN'CS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: tHld l
Owner:
Date of Inspection: %1:WCf0NDIT1ONS*
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 3 10 C� 15.203 (for example: I I O,gpd x a of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no)/-0
Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required]
Laundry system inspected(yes r no):LDA i
Seasonal use: (yes or no):_P
Wafer meter readings, if av ilable(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy: — C ?
COMMERCIAIANDUSTRIAL
Type of egt lishment:
Design flow(base CMR 15.203): d
Basis of design flow(seats/perso C.
Grease trap present(yes or no):
Industrial waste holding tank present(yes _
Non-sanitary waste discharged t • itle 5 system(yes or no):—
Water meter readings, - i able:
Last date of cy/use:
O R(describe):
GENERAL INFORMATION
Pumping Records
Source of information:--a dA i ifoa(l_4 v
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped: 1 Ct�allons—How was gylan ' pumped determined?
Reason for pumping: JI-41AJ r�.ur�! o
TYPF SYSTEM
epttc 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
_Other(describe):
Approximate age of all components,date in galled(if known)and source of informati n:
Were sewage odors detected when arriving at the site (yes or no): /�d P`Q,
Page 7 of l 1 F .
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7-/ Je4lZ (*dRJ e
Owner: d y
Date of Inspection:
BUILDING SEWER(locate on site plan)
Depth below gra --
Materials of constrL
ion: _cast iron _40
Distance from privwater su r s c ion line:
Comments(on con joints, venting, evidence of leakage, etc.):
SEPTIC TANK:!(locate on site plan)
Depth below grade: �a
Material of construction: vebncrete_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)
Dimensions: V-1 �t P1W 10
Sludge depth:
Distance from top of sJu ge to bottom of outlet tee or baffle: y
Scum thickness: r
Distance from top of scum to top of outlet tee or baffle: 3 t,
Distance from bottom of scum to botto f outlet tee or baffle:
How were dimensions determined: _ p��� t _��y�_
Comments(on pumping recommendations, inlet and outlet tee or ba etll conditionp structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
Li No Of k �
GREASE TRAP:_(1 site plan)
Depth below grade:_
Material of construction:_concrete metal_ i ass--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 ou e or baffle:
Date of Fast pumping:
Comments(on pumping recon ations, inlet and outlet tee or baffle condition, structural integr' liquid levels
as related to outlet inve vidence of leakage, etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INF QRMATION'(continued)
Property Address:�j� ,
&*�
f"
Owner: U
Date of Inspection: . C7
TIGHT or HOLDIN C: (tank must be pumped at time of ins
pectionxlocate on site plan)
Depth below grader
Material of construction: concrete metal fiberglass__po
other(explain):
Dimensions''" —
Capacity: gallons
Design Flow: all ay
Alarm present(yes or no):
Alarm level: in working order(yes or no):
Date of last p g;
Comment ondition of alarm and float switches, etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:"_
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of
leakage- into or out of box,etc.):
Ur L !V
d � d
�.
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 chamb of-pumps and appurtenances,etc.):
Page 9 of I 1 ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: ,,,p
Owner: ✓(/
Date,of Inspection: Q T Q
L
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not locate explain why:
7- `�+ / -d
Type
leaching pits, number:
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
etc.): , damp soil,condition of vegetation,
S 'A-2J
vJ ,-)
CA s G4 d//vd 1,j 70 O�
CESSPOOLS:., (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configura
Depth—top of liquid to inlet Inver:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of constru
Indication undwater inflow(yes or Cc is(note condition of soil, signs of h a_ulic failure, level of ponding,condition of vegetation,etc.):
PRIM': (locate on site plan)
IMaterials of construction: i
Dimensions: —
Depth of so
Co nts(note condition of soil; signs of hydraulic failure, level of ponding,conditio f vegetation,etc.):
.Page 10 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner•
Date of Inspection: , Q
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 buildinggl
• 'i
Q
Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:- =ff/v),J �,
Owner:
Date of Inspection: v
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to p ground wate-Ji feet
Please Indic to(check)all methods used to determine tho high ground water elevation:
Obtained from s l ystem design plans on record- If checked, date of design plan reviewed:
Checked with local Board of Health-explain:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
,i
^
� �S|GN|� ����` �'`U� ��''���^ ]� *�__ �
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���K���� ��� ���o��4 ������ ��������on ��m�
�~v-v--~~--- � �
Ann1icubuo is hereby made for u Permit to Construct /A or Repair ( ) an Individual Sewage Diuy000}
~n /
LOT - ��� �� � �
--^--=--_'-------~-'^-~-_~----_--.-_----------_' '^'^-------------_.-'------_-'---_-_-----_-__'-
Add
_.. ������. _ ________._______
Installer Add ess
Type of Building Size Lot-. S q.;f�t
I)weliog1�1�o. o� B�drouo�o.��-(.�6��b.7 A.4xpansion Attic Garbage GrinderOr6cr_�Typo of Building ... No. of persons----_----- Showers ( ) -- Cafeteria ( )
04
w Other fixtures --''-''---'-.--.--'--------.--------_-------------
' ...........gallons per person per day. Total 6uJv8o��
Septic �< ' lA��-gu} VVib6 Diu D �t�A4/�v/ ~!
Other Distribution box (X) Dosing tank ( ) 5-*f aA
~~ Percolation Icot Results Performed by.......................................................................... Dutc.--.---. ._-�
Test Pit No. l-.'�^--..miuu�s�perinch Depth of Test Pb.. .--- Depth to ground ~otcr
~44~ Test Pit No. 2---.Z~~~..niiouhaper inch Depth of Test 9d-/.............. Depth to ground vvutcr' ..��/��
_- ---_-_- . ''-' ''.........................................................
/-''
-------'� ---r .............................................................
-_----'''-----__'---''-------_-..--.-.-._---_--_-.._-'_--'-.----_---_-'.-__-..
U Nature of Repairs or Alterations--Answer when applicable�-------_------------------'--_-'
--.-_-.-_._'---__.---._---..'^.-.---''-'_.-._-----.---_.----------------''----
Agccnouzz :
I The undersigned agrees to install the ufo,edeacribed Individual Sewage Disposal System ioaccordance with
the provisions ofIlI1E 5 of the State Sanitary Code The undersigned further agrees not to place the in
operation until a Certificate of Compliance hpLs been ssu by=the board o�he*h,,,
-
- ---'--' - '-
Date
pplication Approved Bv-_-'� --0�����~_�_����__
. u**
Awlication Disapproved for the follouin easons:..............................................................................................................
'
_ --__--.------.----._
Date
�
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. 0
y
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
M /� -'L�
DATA
Application Approved By.......... .......
Application Disapproved for the followinueasons:...........................
I ...........................................................................
................................................................................................................... Date
Issued....................................................
PermitNo....................................................... Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............0F......... .........................................................
Tatifiratr of Tompliana-
THJS- IS TO CERTIFY, That the Individual Sewar.,Dhpoial System constructed (X) or Repaired
by......... ................I.nsta.fler............ ..........................................................................
.....................................................
. ........... .................
at'..................................................................... .... ............................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------------------------------ ---------- dated........-/...r....................;...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM 1lY1 F T
UN. ON SATISFACTORY.
..............
............. J................................................
DATE...... .. ................... ........ .................... Inspector.
THE COMMONWEALTH OF MASSACHUSETTS,
BOARD OF HEALTH
....................
........ -��A)..............OF...... .................. ......N o....�..O... ......
FEE........................
.
Permissionis hereby granted...... .. ....... ...........................................................................................
to Construct or Repair ( Lan Individual Se:%&Yage Di oral Systqn
`L L., -6 ............(............................................)............ ...............
at No.........LY.-L!........2J�................... Street D ted -2
as shown on the application for Disposal Works Construction Permit No .................
t...................................
......................................................
....................
%of Health
DATE...............................................................................
FORM 1255 A. M. SULKIN, INC., BOSTON
sOIL LOG
[�0. 2 L z 3
r NO.
7Z
4
617
y�
_ q4 t 13
13 S2
• 9 - �; 12 S� � 3
Lvv`F-fL '�2� Ag• W��Hav �3
v Z„ Rio A R- 4d 1
10
14 i
15
pERC T EST RESULTS
3la z
. - PERC RATE
T 1
ES S ED BY : T— o
WHITNARD of HEALTHBO
3
� _ DATE: _ -- ?�S�Vr
OCT. 4.2005 :OEM,''I Bi1F;rI;_?r;_.i E EX:}ARD OF H_�LTH E ..
�r,0.c1i F'.1!1
Town of Barnstable
g , Board of Health.
MAU�o P-0.Box 534,I3yamds M4,02601
u�x: aun.gba 11err15 A.,AQCTAR,YJ,CHO
FAX 505.790.630; Dinsetetorp6lioRaft
l bfAL.10:TOW,410F BARNSTA.BLR `
PUBLIC%MALT`.DIVISION
20011vlA1,'s STABE'T
"� I3�''Al`,'ldi5,IvL4 02b01
FAX,509.7904,104
SEPTIC jXU_EZMSPECT0R GI9T
Date C I
'Same of DEP Certified bapector- /a 1,4Ad
Husiness Address
Badness"Telephono lYo, 0 �
FAX 1P9utautaee- t/ AdY5
Home Address—_,�Z/A-2 A2P Zf.&2
Rome Telephone Number� �
Thp ttndersiged a,gees to comply with;PART V]II, SECTION 14,00 of die]3oard of � �1
Health Rquiations. `The septic Sys=insp�t or shall complete every applfcabl_section of the"Titls 5 c—n
pfCxcisl IMPection pone-Not I or Vohmtary Amcss=ats,Subsurface Sewage Disposal System Farm,"
supplied by tho Mmach asetts Tleputrtaemt of Ruvironmentd protectiau� In&dditlan,at the bottom_Uihe y
:ast page of this oMPW i pection fum tho septic system inspector shall provide a siretoh diagaautihowipg
The vertical separation distance between fly bettor.of the soil absorptim sysioat and the groundwife table
slang with any high growadwater elevation 4ustsna4ts dets=jwd. IU Sapttc Mont Ins to:sl, _X
submit a copy of the completed septic system irspection report along tee resluired meals I fez ? �
Public Health Division Office v t fa 30 days of tLo iWpeeti0n d4te.
a re Epp x
ME: sz.00 pee tepa^t AlbraitM4 to the Public n alth Division Ofioe be2.!( 1,2001.
t
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SOIL LOG
SITE PLAN ,o? NO. 1 N0. 2 ` __
5-/ '
loz 'rtd�DPIT '✓ ✓ ✓5 /OZ 1
' /or Lop ;
• � gti l 1-k - c- 4 'g5
, -- - TOP OF FOUNDATION EL.: _io4 , 5 �__ �_ __.,_,
• o Ir l03•� / MAIL l � v /c2 ° !�f`o � t—{_.. / S�a
cl
Is
015
o•
e; IN.E L i 4-L8 4 13 -- 13
IN El. 1ko& b lQo,
iN El
-T' _ _ �� y 1
r c `t 2 ,
•,` 1 N.E L. A�___ 11.E AY E2 !r/j
D/B W/ 6 SUMP ��n .� r°° o.,� � 3 g
4" LIQUID LEVEL '•� �oG ' . oU�� , f 14
, �. 3 —
I I15:-T-- - a __ _ , o � � - • �' �. PERC TEST RESULTS
-t-- ice__ --a- •-' 1 r � ,; .
WITH PERC RATE
PRECAST SEPTIC TANK
CAST IN PLACE INLET
AND U ', : -- >d waL 4- WHITNESSED BY : . �To-
OUTLET T 'S PER TITLE _-- . .__ BOARD OF HEAL ! °
J .'> �..___ ------ -) �� , �T DATE . a '
SIZE . } 'J 0 � L 7 ��. L 1.._ O F `;,;i �• Q '10 r
S P rt t L w FlLo art" I
LOT•_. -.i c., ,•. _'x..w j/
7►J N ,T6L
a l I
PROFILE CIF PROPOSED SEWAGE SYSTEM li
1-0 T a i,
SYSTEM DESIGNED BY THE TOWN OF _- _ .._ . ..:__._. _ REGULATIONS AND ► i
STATE TITLE V FOR SUBSURFACE DISPOSAL OF SEWAGE . SCALE 1/4 z= V 0
N . B .
lot
E 1 . ALL PIPES SHALL BE SCHEDULE 40 P.V.C. SEWER PIPE
2. ALL PIPES SHALL BE SLOPED 1/4 " PER FOOT EXCEPT FOR I� � �� /010
t THE FIRST 2 FEET OUT OF THE D .` B WHICH SHALL. BE LEVEL `�°---
3 . DESIGN FLOW BEDROOMS AT 11O GALDAY PER BR . GAL ; DAY
SEPTIC TANK SIZE X GAL .
USE GAL W,, -:_ -: GARBAGE DISPOSAL
LEACHING SYSTEM . USE , � a. ,. .. . , r_ , F ► r, — - - ,o ,00 - A �� r
E. �L L
EFFECTIVE AREA : SIDE �►'K1�_x = _x $ 4�11__.._ ___._ .-- �n' '' ' _ — I
BOTTOM Io1.4_x w �8 _ -
T 0 T A L FLOW
--_ _..._--___.-
TOTAL REQ 'O FLOW _33 X W/sue__ GARBAGE DISPOSAL I ; '
DESERVE FLOW_ 4-cJ- 33a_�.=_z+_� GAL/DAY___ _.__ ------- ___ y�
� ) i !
� _�-t�.l_L. 4! �_tJ �_-� _..�_ - �a{� ,,t�_Zq,�-P._ ��
REFERENCE PLANS
_v. t� AtLnt TJk� Er— Ar'Pria��� t.- Mni r ?, ►`) 1__.. _
i APPROVED BY _
zF y_�. BOARD OF HEALTH - - Y--- ;
DATE
PROPERTY � �� �E c ,� � ,� R - + - - --- _ �W�'L� SEVv GL /AN
SITE
LIE �f1 M ll`( �1ntC Ll�1u G
L07-
- 35
A R'N
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ti