HomeMy WebLinkAbout0081 TURTLEBACK ROAD - Health >�
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COMMONWEALTH OF MASSACHUSETTS
::.:EXECUTIVE;OFFICE OF:ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
1 RECEt D-
APR 2.7 2003
TOWN OF BARNSTABLE
TITLES _ HEALTH,DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
" 81 Turtleback Rd . . 1 (�
Property Address: Mars tons Mills MAP " 1
Noreen a a an
Owner's Name: PARCEL
Owner's Address: SOY
Date of Inspection:
Name of Inspector:(please print) Wi 1 1 i am E_ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P .0.-130x 1089
Centerville. MA`
Telephone Number: (508) 775-8776
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
trainingand experience in the proper function and maintenance of on site sewage disposal systems.1 am a DEP
approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000} The system:
/ Passes -
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Zv 1 Date:
- T
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heattltlor'
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 6/15/2000 page 1
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Page 2 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY`ASSESSMENTS`
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 81 Turtleback Rd
ons i is _
reen a ahan � III
Owner.
Date of Inspection
Inspection Summary::Check A,B,C,D or E I ALWAYS completesll of Seaton D
A. YYs
m Passes:
►ave not found any information which indicates that any of the failure
indicatedo is described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
Comments: _ .. ;
B. Sys emFdionPasses:
O components as described in the"Conditional .ass"section need to be replaced or
repaired. completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yemined(Y,N,ND)m the for the following statements..if"not determined"please
explain.
'The septic tank is metal and over 20 years old*or the septic tank(whether metal'or not)it structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is immment System will pass inspection if the
existing tank i replaced with a complying septic tank as approved by the Board`ofHealth:
'A metal septi tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that a tank is less than 20 years old is available.
I
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):, aced
broken pipe(s)are repl.
obstruction is removed
distribution box is leveled or replaced
ND explain:
The sys em required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspectio if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
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Page 3 of I I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM
PART`A
CERTIFICATION(continued)
Property Address: 81 Turtleback
Owner:
Date of Inspection:
`C. urther Evaluation is Required by the Board of Health. x T ' .
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
4 .Cesspool or privy is wtthin 50.feef 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:fun�koning 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 front a
p 'vate water supply well'•.Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for colifotm
..bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and,
the plesence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failUe criteria are triggered.A copy of the analysis must be attached to this form.
I .
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
•PART A
CERTIFICATION(continued)
Property Address:
Owner. _._.
Date of Inspection: /. �9—0 `.
D. System Failure Criteria applicable to all systems:.
You 4 t 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 cesspoo
tscharge'or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
logged SAS or cesspool .-
Static liquid level in the distribution box above outlet invert due to orclogged SAS or'
an overloaded
cesspool tha '/:day flow.
Liquid depth in cesspool is less than 6",below invert or available volume us less n
R:quired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s)_Number
of times pumped high ground water elevation.
• Any portion of the,SAS,cesspool or privy is below h
any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
ater supply.
_ '6y portion of a cesspool or privy is within a Zone 1 of a public well.
y,p,rtion 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[orm.]
(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. LargerSystems:
To be considered a large system the system must serve a facility with a design now of 10;000 gpd to I5,000
gpd.
You must Licate either"yes"or"no"to each of the following: ,
(The following criteria apply to large systems in addition to the criteriaabove)
yes no
thhe 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►s located
in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
_ _
Zo a II of a public water supply well .
If you have answered"yes"to any question in Section E the system is can a significant threat,id answered
"yes"in Section D above the large system kas failed.The owner or operator of any large system considered a
significant t eat 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: 81 Turtleback Rd
Marstons Mills
Owner: Noreen Callahan
Date of Inspection: U `.._
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? , .
tl_ Has the system received normal flows in'the previous two week period?
_ _✓Nave large volumes of water been introduced to the system recently or as part of this inspection 71.
✓— Were as built plans of the system obtained and examined?(If they were not available note as N/A)-
V — 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 differentfrom owner)provided with information on the proper
maintenance of subsurface sewage disposal systems.?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes ,no
l./— Existing information.For example,a plan at the Board of Health.
_L/ 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))
5
Page 6 of I 1 >
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
81 Turtleback Rd
Property Address: T4 :34;1 -
Owner:
tioreen
Date of Inspection: !�-5—U 3
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(desrgn):. Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedroomso U
Number of current residents:
Does residence have a garbage grinder(yes or no): /f�-G?-
Is laundry on a separate sewage system(yes or no):JLU [if yes separate inspection required)
Laundry system inspected(yes or no): a
Seasonal use:(yes or no)/v O 2 0 0 2 85,000 g 1 s
Water meter readings,if available(last 2 years usage(gpd)): 2001 84, 000 g 1 s
Sump pump(yes or no):A-U
Last date of occupancy: 0 3
COMMERCIAIA USTRIAL
Type of establishment:
Design flow(based on 10 CMR 15.203): Rd '
Basis of design now(s ats/persons/sgft,etc.):
Grease trap present(y s or no):_
Industrial waste hold g tank present(yes or no):—
Non-sanitary waste di charged to the Title 5 system(yes or no):
Water meter readings if available:
Last date of occupan y/user
OTHER(describe
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as prof the inspection(yes or no):_
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
eptic 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/Altemative 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 installed(if known)and source of information:
/C; 9 6
Were sewage odors detected when arriving at the site(yes or no):d�U
6
Page 7 of I l
OFFICIAL INSPECTI.ON FORM NOT-FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
SYSTEM INFORMATION(continued);:
Property Address: 81 Turtleback. RdMarstens--P44: s
Noreen eall
Owner: an
...... . .....
Date of Inspection: -/-� —C�'3
BUILDING WER(locate on site plan)
f'X
e Depth blow a'de
P
Materials of con tructiori_cast iron —40 PVC_other(explain):
Distance from p ivate water supply well or suction line:
Comments(on ondition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade: (�
Material of construction: .✓.concrete—metal_fiberglass_polyethylene
other(explain)
If tank is metal list age:_ Is age confumed•by a Certificate of Compliance(yes or no):_(attach a copy of
certificate) - ,
Dimensions: , G +' to �a
Sludge depth: L/- S•
Distance fiom top of sludge to bottom of outlet tee or baffle: Z 6
Scum thickness: V' ' e
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 49,
How were dimensions determined:_(>
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liqu`idlevels
as related to outlet invert,evidence of-leakage,etc.):
use/
GREAS TRAP:_(Iodate on site plan).
Depth belo grade:_
Material of construction:_concrete_metal—fiberglass—polyethylene_other.
(explain):
Dimensions
Scum thic ess:
Distance Win top of scum to top of outlet tee or baffle:
Distance fr m bottom of scum to bottom of outlet tee or baffle:
Date of las pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related l outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION`FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM-INFORMATION(continued)
Property Address• 81 Turtleback Rd
Marstons Mills
Owner: Noreen Callahan
Date of Inspection: `7—g'�d -
TIGHT o OLDING TANK: (tank must be pumped at time of inspection)(locate on.site plan)
Depth belo grade: g
Material of nstruction: concrete. metal fiber lass_ p ofy ethy lene other(explarn):
Dimensions:
Capaciq: _________gallons
Design Flow: gallons/day
Alarm presen (yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last p roping--
Comments(c ndition of alarm and float switches,etc.):
DISTRIBUTION BOX: �f present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: atlets equal,any evidence of solids carryover,any evidence of
Comments(note if box is level and distribution to ou
.,`
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working or r(yes or no):
Alarms in working or er(yes or no):
Comments(note con it
of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 Turtleback Rd
.,,_r_tens Mill„
Owner: ------__ eailah n _
Date of Inspection: /— �G /
SOIL ABSORPTION SYSTEM(SAS):2/ (locate on site plan,ezcavation'not required)
If SAS not located explain why:
Type
leaching pits,number:
reaching chambers,number: ,3
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,
etc.):
CESSPOOLS: (cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and con guration:
Depth—top of liq id to inlet invert:
Depth of solids]a ``er:
Depth of scum laydr.
Dimensions of ccsslpool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note cot dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
I
PRIVY: (locate on site plan)
Materials of con truction:
Dimensions:
Depth of solids:
Comments(note ondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 81 Turtleback
rrtzr_a tvrra rixza—
Owner• o e
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.
r g
J
10
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Page 11 of I]
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
81 Turtleback Rd
Property Address: MRr-Rtn.,_ ,,,,; i s
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
'10
inbtained from system design plans on record•If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within ISO feet of SAS_)
+�hecked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentati )
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
'Y
11
� s
f
,{ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 7u2-/-/4P_l
Owner's name
Date of Inspection `�
I ? 95 ,P
PART A 4
CHECKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of
Health.
one of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
L____'The facility or dwelling was inspected for signs of sewage back-up.
The site was inspected for signs of breakout.
�11 system components, excluding the SAS, have been located on the
site.
./�The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
�he facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
S EP 1995MWOF
N
t
p
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B Ilk
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
number of bedrooms
n number of current residents
garbage grinder, yes or no
laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential , calculated flow:
Water meter readings, if available:
Last date of occupancy
GENERAL INFORMATION
Pumping re,Ford and source information:
/V System pumped as part of inspection, yes or no
if yes, volume pumped
Reason for umping: .
Type of system
Septic tank/distribution box/soil absorption system
Single cesspool
_L,::,--Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of al_`l components. Date installed, if known. Source of
informati P
-
♦.a f`Sti.iiV].
Sewage od jsldetected when arriving at the site, yes or no
V
SUBSURFACE SEWAGE DISPOSAL SYSTEM ' INSPECTION FORK
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain:
Type.
leaching pits and number
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions
overflow cesspool , number 2 o uo �
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegptation, r c dations for -ma,19tenance or repairs, c. )
r
CESSPOOLS (locate on site )
lan :
P
number and configuration 04
depth-top of liquid to inlet invert O
depth of solids layer a
depth of scum layer O
dimensions of cesspool r.
materials of construction y
indication of groundwater
inflow (cesspool must be pumped as
part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of ve etat-ion, recommendations for. maintenance or repairs,etc. )
PRIVY:
(locate on site an)
materials of constructs
dimensions
depth of solids
Comments: '
(note conditio of soil , signs of hydraulic failure, el of ponding,
condition o vegetation, recommendations for maintenance o e airs,etc. )
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site plan)
depth below grade:�_
material of construction: concrete meta �lFRP other(explain)
dimensions:
f�
sludge depth
distance from top of sl ge t bottom of outlet tee or baffle
scum thickness
distance from top scum to top outlet tee or baffle
distance from b tom of scum to bot of outleL tee or baffle
Comments:
(recommendati for pumping, condition of inlet nd outlet tees or baffles,
depth of li id level in relation to outlet inver structural integrity,
evidence o leakage, recommendations for repairs, etc. )
DISTRIBUTI N BOX:
(locate on to plan)
dept of liquid level outlet invert
Comments:
(note if level and ributi is equal, evidence of solids carryover,
evidence of le ge into or out -o ox, recommendation for repairs, etc. )
PUMP CHAMBER:
(locate on site plan)
pumps in working order, or no
Comments:
(note condition of pu chamber, con 'tion of pumps and appurtenances,
recommendations for aintenance or rep irs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of .
determination in all instances. If "not determined" , explain why not)
Backup of sewage into facility?
Discharge or ponding of effl ent to the surface of the ground or
surface waters?
aL/ Static liquid level in the distribution box above outlet invert?
At/ Liquid depth in g&sspool <6" below invert or available volume< 1/2 di
flow?
Required pumping 4 times or more in the last year?
number of times pumped 4f,__1
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
-,L11/ within 50 feet of a surface water?
within 100 feet of a surface water s pply or tributary to a surface
water supply?
'7�2
�
� G2�within a Zone I of a public well? /���,,.,
,?ithln 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
within 50 feet of a private water supply well? '
less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water ane
.for coliform bacteria, volatile organic compounds, ammonia nitrog J
and nitrate nitrogen. jk ,
'Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE SPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all well within 100 '
� 3
o L
T7
Z 33
DEPTH TO GROUNDWATER
depth to groundwater
method of cletermination or approximati IS 6 S
TOWN OF f BOARD OF HEALTH
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
��---=
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS ( (UIL41 -
ASSESSORS MAP, BLOCK AND PARCEL
OWNER' s NAME
- v �
—� PART D - CERTIFICATION
NAME OF INSPECTOR )cl�f US P M6fz.;V
COMPANY NAME 1 f 'WI2IY� 1.J�� l l� �{S''�2(/�-5
COMPANY ADDRESS 775 r - '`b`�� �4 �SEf ��
Street Town or City State ZIP
COMPANY TELEPHONE ( 568 ) 36 Z- '3 a �-a FAX
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposa`1 system a
this address and that the information reported is true , accurate , and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check on
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system fails tc
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this i s ction form.
Z1",'���
Inspector Signature Date �l-
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partd.doc
TOWN OF BARNSTABLE
LOCATION SEWAGE #
VILLAGE 1;;1 .11-4j— ASSESSOR'S MAP& LOTS
INSTALLER'S NAME&PHONE NO. �f3/ 1'a.1�
SEPTIC TANK CAPACITY /'rT-0Z0
LEACHING FACILITY:'(type) 2 Cam % 45 � (size)
NO.OF BEDROOMS
BUL-05R OR OWNER ` la Z4Q
PERMTTDATE: P/gg: 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 leachin facility) Feet
Furnished by fs Z.f�`�,5 X
b
IT �yvs r,
1 v
s
311
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ASSESSORS MAP No:
e� n 40 .00
No.
�` s�/ PARCEL NO; Fee((
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for ;Digpooal *pgtem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
81 Tu 14e} ack Rd Marstons Mills Donald Littlefield
Assessor's ap arce
Vallf s Nfrej�I n s bannd Tg.Not i s S e r V Designer's Name,Address and Tel.No.
P.O. Box 1089
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder(n9
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil sand
Natu ogg R or Alterations(pAnnswer when applicable)) install a 1 , 500 gal tank, d-b o x
an7 3 stonepacked Cu' tex inVi ra ors
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 COO and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Vd ealth.
Signed 1e4111 I t Date JP_0� "—
Application Approved by - Dates
Application Disapproved for the following reasons
Permit No. 7 Date Issued " '"
No. 4 ta` Fee 46000
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
4
Rpplication for -Mi!5poear *raem Construction Permit
J
Application is hereby made for a Permit to Construct( )or Repair(x )an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's.Name,Address and Tel.No.
81 TItleback Rd Marstons Mills = Donald Littlefield
Assessor's ap/Parcel
I
tal,4 s N ddress and T No. Designer's Name,Address and Tel No.
�. c� 'insbn peptic Sery
P.O. Box 1089
,,Centerville
I
Type of Building: a
Dwelling No.of Bedrooms 3 Garbage Grinder(nq
Othe , Tyre of Building No.of Persons Showers( ) Cafeteria( ) !
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title r
sand s
Description of Soil p
i
Natu o R orA�terations( s er we�ee a licable) install a 1 ,500 gal tnk� d—box
an'c f3 stonepac�tec' Cube inf i era ors
i
Af i,
Date last inspected:
7
Agreement: 1
,,,,The-undeisiinea agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system i
in accordance with the provisions of Title 5 of the Environmental Co t and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this d ealth. p2 _Q
- Signed e t Date a `
'Application Approved by Date �` !k-op!4e-
Application Disapproved for the following reasons -
Permit No. 7� Date Issued �`7
———————. —————— ———————
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Dispo al System installed( )or repaired/replaced(x )on
by Installer •* Robinson Septic ..
at 8 1 Turtleback Rd Marstons Mills has been construg9d in acco;da ce
with the provisions of Title 5 and the for Disposal System Constructio Permit No. �- dated
Date Inspector
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT/THE SYS-
TEM WILL FUNCTION.SATISFACTORY.
— ----------------------------- 6.00
No. ' 4/ _ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION . BARNSTABLE, MASSACHUSETTS
3Biqu ar Opztem Con5truction Permit
W,.E. Robinson Septic Sery
Permission is hereby granted to p : '
to construct( )repair(x )an On-site Sewage System located at No.# 81 Tint teback Rd
Marstons Mills
Street
and as described in the above Application for Disposal System Construction Permit. 70
.
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below.
kAK
Date: L Approved by
Board of Health i
L
f
a
i
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
Z--, hereby certify that the application for disposal works
construction permit signed by me dated 2— , concerning the
property located at �l is R 7 G6 C l &meets all of the
following criteria:
• There are no wetlands within 300 feet Hof 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 s
• There are no variances requested or needed.
SIGNED:-- DATE: .
LICENSED SEPTIC 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].
39
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_ TOWN OF BARNSTABLE
LOCATION C v t2+f< t-7^C SEWAGE #
VILLAGE, l v \ ( (� ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) -I— .S 06 45' (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER D rl e�a-
PERMIT DATE: 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 leachi acility) Feet
Furnished by
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