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Home My WebLink About0057 TURTLEBACK ROAD - Health 57 Turtl ackyyeC��:�� -is i � A= 047-075 — Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address , Wayne Mahannah Owner ' Owner's Name 4, information is Marstons Mills Ma 02648 8/7/2019 required for every r;. 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. Inspector Information / . filling out forms on the computer, _Sean M. Jones use only the tab key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane ay Company Address Centerville Ma 02632 City/Town W State Zip Code Fn�_ A 774-248-4850 smjonestitle5@gmail.com, SI4522 ......... Sean@smjonestitle5.com License Number.µ B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails gip.,._..,.. 8/712019 Inspector's Signatu Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of Inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev 712612010 Title 5 Official Inspection Form,Subsutraae Sewage Disposal System•Page 1 of 1e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owner's Name information is for every rewired Marstons Mills Ma 02648 8/7/2019 4 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1 y System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 57 Turtleback Rd Marstons Mills is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box, 1000 gallon precast leach pit and 6 Infiltrators. The system was found to be in proper working condition at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or``not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. •A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y 0 N ❑ ND(Explain below): t5irrsp,due•rev.7W20I$ Title 5 Official Inspeclion Form,Subsurface Serape Oimsal System•Pogo 2 of 18 I t ' Commonwealth of Massachusetts -- Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Garner Owner's Name information is required for every Marstons Mills Ma 02648 8/7/2019 _ page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cunt.): El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below) ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: 15inspAx•rev..7IM2018 Tille 5 Official Inspection Form,Subsurfaces Sawaga Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Font-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owners Name information is Marstons Mills Ma 02648 8/7/2019 required for every ._�_. age. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cost.) ❑` Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, If any) determines that the system is functioning In a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS Is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all Inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5irtap.dcG•rev.70812018 Title 5 Official Insp"tun form:Subsurface Sewage Olsrosal System•Pap 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments = 57 Turtleback.Road Property Address Wayne Mahannah Owner Owners{dame information is Marstons Mills Ma 02648 8/7/2019 required for every _ page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (coat.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000'gpd- 10,000 gpd. ❑ ® The system faits. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area--IWPA)or a mapped Zone 11 of a public water supply well t5irsp,doc•rev.712 O18 Title 5 Oftal Inspection Form;Subsurteoe Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments us 57 Turtleback Road Property Address i Wane Mahannah Owner owners Name requiretifore Marstons Mills Ma_ 02648 8/7/2019 required for every Rage. CityfTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6_ You must Indicate"yes"or"no"for each of the following for ad inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received 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? ® El available as built plans of the system obtained and examined?(if they were not available note as NIA) ® ❑ 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)] tsuW:doc•rev.:712612018 Title 5 official MsWion Form:SUMnlaes Sewage Disposal system.Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owner's Name information is required for every Marstons Mills Ma 02648 8/7/2019 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes 0 No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes [0 No Water meter readings, if available (last 2 years usage(gpd)): -- Detail: Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Mrtsp.doc•rev.MA2010 Title 9 oMUW Inspection Form,Suosunace Sewage uiapoael System-Page 7 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owner's Name information is required for®very. Marstons Mills Ma 02648 8/7/2019 page. Citirrown State Zip Code Date of Inspection D. System Information (cont.) 2. CommerciaUlndustrial Flow Conditions: Type of Establishment: -- - - Design flow(based on 310 CMR 15203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t6trsp•doo'rev.7/2612018 Tills 5 Official Inspection Form:SuDsurrate Sewage Dtspoael System-page a of 18 Commonwealth of Massachusetts -- Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owner's Name information is Marstons Mills Ma 02648 8/7/2019 required for®very page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: Tank, d-box and pit original 1972, Infiltrators added 1997 Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): 1.5 Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints in good condition, no leakage, vented through roof. Mrlsp.doc rev:7/Yt 018 Title 5 official Inspection Form;Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owner's Name information is required for every Marstons Mills Ma 02648 8/7/2019 : page, CityLTown State Zip Code Date of Inspection D. System Information (cunt.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: Z concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes. ❑ No Dimensions: 1000 gallons Sludge depth: 54" ------ Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2° Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements 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 does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. tsinsp.dog•rev.7f2&wi a tale 5 Off dat Inspection Form.Suhsudace Sewage 01spasw System•Psge 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owner's Name information is Marstons Mills Ma 02648 8/7/2019 required for every page City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design flow: gallons per daym_.____ � — t5insp.dac�mv,7126018 Trite 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusett Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner owner's Name regUired information e Marstons Mills Ma 02648 8/7/2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: - _-- - - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" - Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Distribution box was video inspected and wa found level and in good condition with no rot.Water level was even with outlet inverts with no signs of past backup. MnspAoc-.rav;7t2&2048 Title 5 Omael hispection Fwm:Subsurface Sewage Dispoo System•Page 12 of tB Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owner's Name information is Ma required rstons Mills Ma 02648 8/7/2019 for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: ® leaching chambers number: 6 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: El leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5in�-dac:'rev,7I28t2018 Title 5 Off aal trepeclion form'Subsurface Sewage Disposal System-Pago 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Foam-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owner's Name information is required for®very Marstons Mills Ma 02648 8/7/2018 . CitytTown _�._.... page. State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of past overloading.Vegetation was normal, soil was probed and found dry with no signs of past saturation. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): fta..doc•rev.7P18I2010 Title 5 Official Inspection Farm•Subsurface Sewage Disposal System Pop 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owner's Name Information dfo Is r every required f Marstons Mills Ma 02648 8/7/2019 C /Yawn page. 4 state Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions.. Depth of solids Comments ;note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 1565p;doc•rev.746010 Title 6 Official Inspection Form:subsurface Sewage Mgmsel System•Pap 16 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owner's Name lrtfonnation is Marstons Mills Ma 02648 8/7/2019 required for every page. CityfTown State Zip Code Date of Inspection D. System Information (cunt.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below drawing attached separately P� A3 L(7 131 '16 AH iyk 6 6q 5,, A� 5L' PrLIG'G 14( 7 2 t5insp,doc-rev.7I2 O18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 18 Commonwealth of Massachusetts -- - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address Wayne Mahannah Owner Owner's Name information is Marstons Mills Ma 02648 8/7/2019 required for every -- ................. page. City/Town State Zip Code Date of Inspection D. System information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 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: 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: Groundwater was established by accessing town of Barnstable groundwater contour maps.. Before filing this Inspection Report,please see Report Completeness Checklist on next page. tSEnsp:doe-rev.TPLSl2018 rlle 5 Ofhdal Inspection form:Subsurface Sawage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 57 Turtleback Road Property Address _ Wayne Mahannah Owner Owners Nameinformat required ie Marstons Mills Ma 02648 8/7/2019 required for every page. cityrrown State Zip Code Date of inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked Z C. Inspection Summary: 1, 2,,3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed D. System information: For 8: Tight/Molding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included 15insp.doc rev.Pl26WS Tidy 5 official lnsp eciion Taut,Subsurface Sewage Disposed System•Page I of p I TOWN OF BARNSTABLE LOCATION 57 jHr�� ack /�o( SEWAGE # 97—/0"1 VILLAGE ASSESSOR'S MAP& LOT_CJJ. d INSTALLER'S NAME&PHONE NO. JVAH Nct A y �- 95 5 f` SEPTIC TANK CAPACITY /G'OO ia�� li° �y/jam•.y- LEACHING FACILITY: (type) (size) `!/,s �X 7 x 2'yr& NO.OF BEDROOMS BUILDER OR OWNER. -d All R .►•�r c. PERMITDATE: 11— J7— 17 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of.Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by If ,7/7 ti X� /7 ,9h, ,,.h £ �s opo� TOWN OF BARN STABLE LOCATION 5-7 134CA- AV SEWAGE # VILLAGE 1W4-'7#_"s �W/$ _ASSESSOR'S MAP &LOT . d INSTALLER'S NAME&PHONE NO. R 41 A' SEPTIC TANK CAPACITY l0019 C;.0 41. / i i LEACHING FACILITY: (type) tv �:� %�I+G �` (size) �/•S vt& NO.OF BEDROOMS BUILDER OR OWNER �g;4`l A1�u PERMITDATE: r7— 17 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist . within 300 feet of leaching facility) Feet Furnished by j�v✓af" L�� . L9 No. [ �t� 7 w Fee 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for �Digogar *potent Conotruction Vermit Application for a Permit to Construct( )Repair(L-51u1pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �y Owner's Name,Address and d Tel.No. / .4,.7 '%kv/[v Assessor'sMap/PazcelS77, �-1�v�4��Cf?�P Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flows 8 gallons per day. Calculated daily flow 3 U gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) A s/ems /j /_5-00 s � a�y R/ ///4 � S.0_S. /%e3 • ?C 7 `w y[ :2 s I-J—4r-A "h�// yam f 1./4' 5f4.e :tea ,Jc 9- / ' ,bal®tom l��,d��c.i.,� 2 ZosSdoals l Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by alth. Signed �— Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued 07 7— �� 7 ` Fee No. 9 4, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLICAEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 0(ppYitation for Miquar *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(L Upgrade( )Abandon( ) ❑Complete System ❑Individual Components i Location Address or Lot No. .J 1 Owner's Name,Address Band/Tel.No. J-7 7i, /!o �4.�1��C�� y �jl/ h.� i+�14 4 4.47 A-.of 4 Assessor's Map/Parcel 'S S7 7A I- r Roe�r i?W Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3S gallons per day. Calculated daily flow 3 3 y gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. i Description of Soil 2 """` O s~1 Nature of Repairs or Alterations(Answer when applicable) ,AS/4 7 j /Syo S t R9, -3 S- �O _-e 7 A�/9' sfi•.� rwc% t / ' ,bs�or.�.•- / t* �.�cipa— �SS✓laa/c* Date last inspected: Agreement: j The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by th` azd Health.. Signed ri'l Date 'ir 17- 9 7 Application Approved by Date Application Disapproved for the following reasons } Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( ) Abandoned( )by at 5-L:7 :Tjtz has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2,7- /J s dated 5/- / 7--�7 . Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 1 / 1 (-/ Inspector 1 --------------------------------------- No. ,� ,�X Fee �0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigpooal *pgtem ngtruction Permit Permission is hereby granted to Construct( )Repair( U grade Abandon( ) System located at . 7 U P r' and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to f comply with Title 5 and the following local provisions or special conditions. Provided:Construction/must be completed within three years of the date of this permit. fj Date: Approved by �I a j t f NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated 4,17_ 7 , concerning the property located at S-7 1�� 10 �` �l< meets all of the following criteria: There are no wetlands within 300 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system •` The observed groundwater table is 14 feet or greater below the bottom of the leaching facility •—There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: LICENSED SE TIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. jxcrt N.� Y F, .: .r, ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ 1v&.f.............OF.........../Y ;t10U4*//96/ ----------------------------------- Appltration for Rapviittl Marks Cnnnitrnrttun Prrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �1y/�s roc. fGLS b _ Q .• vl�7LE ....................q --------- - ------••--•- ................. Locat n-Address or Lot ••• ...... ------ 00 U r ----------•-••--•...........................Address Installer Address `� d Type of Building Size Lot.. ...... ................Sq. feet Dwelling—No. of Bedrooms___.__. ...............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building •........................... No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ...................................................... W Design Flow..... ................._ allons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width..........-..... Diameter................ Depth--_-_------__--. x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. 3 Seepage Pit No.._/d_00__ "Y�)idmeter.................... Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date---------------------------------------- aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water__-___________________-. rX, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_______--______-__--.__. a ----------•-•-----..... ...-•--•-•.............. . ODescription of Soil......................................mf4A e----------- ,oM.99-•------:-....--•-----------------------------------.._....------------------------. U ----------------------------------------------------------------•---- -----------••--------a.......................................................................--------------------------------- 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. g Signed._ %,, -� ---------------------_--- Date ApplicationApproved By ------••-•-• ------------------------•-------•--------•---••---------- --•----•---•--------Date-------------- Application Disapproved fort e f ollowing re ons:----•-•--•--•----------••----•------•---...-•-----------•-----------------•----------------------•-------------- --........••-••-••--------------•------•-----------•••----..---------•-•-•••-•-•-----------•----.........--------------------•-------------.....--------•---------------•------------------------•...... Dat / e Permit No.......3 �`�-__ Issued........... (o ' ?.. Date No.. = = FED.- . 't'`......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH / .-.. .-.w.. I .... ...... .......... - Appliration for 43i,ivosal Works Towitrnrtilan Vrrufit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at r,;' r __ 1 .._ ..�:_' .... ..d-'•._-•.- ;r. '' Y'c... 'r ......°rJ� �'F.�.r`:.�fr--------- ---- -^------•---•--r"-�"--�.�!..::�- X 'S�"-r ---. .. ... Location-Address .f ✓ 3 ,, �+. o Lot N 1 �` f . .`:. r': r" .'�r F..s ......................= r ,, i /ry Ownerr Address W <. {' ..,....` Installer Address UType of Building Size Lot-__..`----_______________Sq. feet Dwelling—No. of Bedrooms.._..._."...................................Expansion Attic Garbage P ( •)Showers Grinder ( ) `-1 Other—Type of Buildingr No. of persons Cafeteria 0.1 Other fixtures --------------------------------------------------•---............................................................................................... d W Design Flow____=.5._01....................rv_,__,._gallons per person per day. Total daily flow..............._............................gallons. $66P.Li WSeptic Tank—Liquid capacity............gallons Length--------_------- Width................ Diameter---------------, Depth_.--_-----__.--. Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No... 4.. Di�meter.................:.. Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box s( ) Dosing tank ( ) '-� Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---__--________-__-.---. fxq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__--_____-__-________--- a ••••--------•-----------------------------•••••••• •••••••••---•-•-•••-•-••......---•--........--•-......................................................... 0 Description of Soil----------------------- - "4==e?' f� G/C-' ,.. , U ---•------------------------------------------------------------------------------------------......--------------------•------------------------------------------------------------------------------- W UNature of Repairs or Alterations—Answer when applicable.______________________________________________________________________________________________- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health a 7 Signed # =' re a r_ Date Application A roved B ...................................._ f________________________ PP PP Y }r Date.... Application Disapproved for the following reasons:................................................................................................................ --------------------------------------------------•---------------•----•--------------------------------...................................-•----•---------------•----------------•---............... Date Permit No....... -`------------------------------------ Issued...................=.`.. = == ...... Date r THE COMMONWEALTH .OF WASSACHUSETTS - BOARD OF HEALTH (9rdifiratr of Tontpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed o(- ) or Repaired ( ) y.......... . Installer C R - y ! t s r�:------- atn .•••-•-----•E --•-�-..............••... --------- -- ' ------- ---------------•-•--- --•----- ---=••-r•-------------------- has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...... :._=....................... dated------------------------------------------...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL UNCTIO SATISFACTORY. DATE....... 'Z ------•-------•------- Inspector------ , n ----' � � A. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............................... OF.... m: -- .......................................... NO �........ FEE �i.��r��tl ork� C�oflt��rttr�i�n rrnti� Permission is hereby granted---------------- :. Jt ` ------•--------- to Construct (,_ ) or Repair ( ) an Individual Sewage Disposal System atNo..........' ----------------------- ------------- ------------------------------- Street - ...... as shown on the application for Disposal Works"Construction Permit No :'_..?_:__. Dated--------- ----------`__----____:-_--•-- r l � ,� Board of Heal�ty- DATE. ,i� .......................................... ter` t. FORM 1255 XIOBBS & WARREN. INC.. PUBLISHERS