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HomeMy WebLinkAbout0431 WAKEBY ROAD - Health 431 Wakeby Road Marstons Mills P A = 028 100 -- y t I i I vy �4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. Cityrrown 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 filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Raymond Dumas cursor-do not use the return Name of Inspector ' y _ key. Dumas Landscape Const. Inc. Company Name w � 564 Old Stage Rd. Company AddressAlf - Centerville Ma. 02632 teem City town State Zip Code 508-778-0249 S1437 t"' Telephone Number License Number aj. B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority C2..' L 1/20/2011 Inspecto s Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. 2)11 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Di g spo ystem•Page 1 of 1 Commonwealth of Massachusetts AM" Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which.indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): , ❑ broken pipe(s)are replaced ❑ Y ' ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool,or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•''r 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface,water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ `the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 TiBe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. City/town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components.pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons.Mills Ma. 02648 1/20/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage private well 9 ( Y 9 (9pd))� Detail: well Sump pump? ❑ Yes ® No Last date of occupancy: 9/10 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons r day y(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: none available Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons • How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑' Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1977 house built leach field upgraded 9/6/97 R&H Const. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 12" 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.): good Septic Tank(locate on site plan): Depth below grade: 12"feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth: all water t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 i every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle all water Scum thickness none Distance from top of scum to top of outlet tee or baffle n/a Distance from bottom of scum to bottom of outlet tee or baffle n/a How were dimensions determined? dip stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend 2-3 year interval on septic tank but not needed at this time 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees good liquids at level 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 day Alarm present: ❑ Yes ❑ No Alarm level: = Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w u Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert at level 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.): no evidence of leakage or carryover 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.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: as per as built on record t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s ' 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number, dimensions: 32x11 ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology. 4 Infilltrators/4'of stone as per as built Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): no signs of hydro failure 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 t5ins-OWN Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): none 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.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f� Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 431 Wakeby Road Property Address Larry Linnell Owner Owner's Name information is Marstons Mills Ma. 02648, 1/20/2011 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cost.) 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 t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 431 Wakeby Road Property Address Larry Linnell Owner Owner's-Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to.high.ground water: 37.3 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: Ground water contour map 50'+2.3 adjustment SDW253 well=52.3 iopo elevation 89'-52.3=37.3 ft Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Tide 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 431 Wakeby Road Property Address Larry Linnell - Owner Owner's Name information is required for Marstons Mills Ma. 02648 1/20/2011 every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARXSTABLE �- LOCATION `f 1 Oi4 KCl)�c l' SEWAGE# f ASSESSOR'S MAP &LOT VZ:CAGE /�/,c?�'���r S � INSTALLER'S NAME&PHONE NO. f�S G G�� SEPTIC TANK CAPACITY " j :G. � ,��,�.=, LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR QWNER' PERMIT`DATE: l t- : :/ J COMPLIANCE DATE: Separation Distance Between the: Feet Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well andleaching Facility (if any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet­o\aching facility) Furnished by r�W n 14° t' K� ✓ _ r K.Ta 'rJ j�tw� JA�- ' � i AsBuilt Page 1 of 1 TOWN OF BARNS JTABLE f/ LdGATION SEWAGE# - Vr.LAGE rr/ ASSESSOR'S MAP&LOT S INSTALLER'S NAME&PHONE NO. E[ ,e'AJ zuG SEPTIC TANK CAPACITY LEACHING FACII.I'TY: (type) L!1• - cz,%,dze, (size) NO.OF BEDROOMS BUILDER ORIWNEIji A21 PERMTTDATE: COMPLIANCE DATE: - Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and- Caching 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 Y uL, G n Jiro �_ M� -6 s. http://issgl2/intranet/propdata/prebuilt.aspx?mappar=028100&seq=1 5/31/2011 COMMONWEALTH OF lOIMASSACHUSETTS zoo EXECUTIvE OFFICE OF ENviR0NT+ ENTAL AFFAIRS _ DFPARTmFNT OF E+ RECEIVED ONm7 MAY 0 4 2004 TOWN OF BARNSTABLE M HEALTH DEPT. OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSNIENTS SUMURFACE SEWAG2 DISPOSAL SAL SYSTMM-FORM PART A +CERTI MATIION Owner's-1�anne: .F_r� r F_ "r�. c� a� jV1,4P r �� Owner's Address: FARCE Date of Inspection: ` -a- %r LOT _NzMzGff M5PMts ;<p_!was pa=t) s9yrvc ✓� �/ ✓-s. Company Name: 41""405� Tebphow Number. -9✓6- CERTUICATION STATEMENT I certify that I`have personally inspected the sewage disposal system at-this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and;experitnce n tLe proper.fimcfion.and.maintenanee of.on sits:s-_mge disposal systems..:[aura a DEEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: Basses Conditionally Passes bleeds Further Evaluation by the Local Approving Authority ails Inspector's Signature: ��21� �'�/"� Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP).within.3€4 days trf completing this:inspection.If the system is a shared system or has a design flow of 101M gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The.original shouldbe.sent.to.tlre.systean owner and copies sera to the buyer,if applicable,and the approving authority.. Notes-and Comments: ""This nPN ty q�es bes..f ftloias at the#sane of:bmpec. iou and tnmmdeir Vie cond dims of use at that time.This inspection does not address how the system will perform in the future under the same or different condidow of age. Title-5 htspeation.Fornr 8/15f2UE)El% page l Page 2 of It OFMCUL MPXC ON FOR —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECZ$' ON FOR PART A 1l �,,{,� 'A. . NN y CE�d'li MCAT ON(continued) Irate-of hspeetion• Ba:$ S: -_-airy: C4--m—ft:A%,BCD w I C AL,.Afif = sill of Se">h re IA',. A. Systm Passes: I ham not fond any informfien which indticaes tmt as of the hilaare•csiterm rabed in 310 CMA 15.303 or in 310 CN1R 15:304 exist Any failure criteria not evaluated"are indicated below. 'Comments: B. System Conditionally Passes: Q�-- One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system Won c ompletiom of the replacement,or repair,as approved by the Board:of Health,will.pass. Answer yes,no or not determined(Y;N;N D)•in tie for the following statements.If-not-determiwX'please explain. --The.septic tank is metal and over 20 years old*or the septic.tank(whether metal or not)is structurally msmmd,cddwts subgauw ISTItmooft or exftalml orlwk,ft AITe is:'1111HUMnL System will Pawmspechon if the existing tank is replaced with-a complying septic tank as approved by the Board of Health A:ntdal.septic ink will:pass inspedi -ff it is.structurally sound,M lead and if a.Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: 'Q_ Observation of sewage backup or break out or high static water level In the distn-butionbox 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 ofHe p broken pipe(s)are replaced obstruction is;removed distribution box is leveled or replaced ND explain: The system required pimping more than 4 times.a year due to broken or obstructed pipe(s).The system will pass uLqpwaon if(with approval of the Board of health} broken-pipe(s)are replaced obstruction is removed ND explain: Page 3 of-1.1 0MCM ,IISIMMO VO -NOT FOR VOLUNTARY ASSESSWAM SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPE ON FORM PAIR''A CERTM CATIO 1(contm ) pWTV 113/ lit y.fir /W- Owner: n-ottc� Date of`Inspettlow. Conditions exist which-r .fire.fiuthen Auagion�y the Board of Hv4th in order to detenlnine of:the.system is g to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310€CMM 15.303(l)(b)that the of foncetioaniaa in a manner whkh will ubMe health safer and the environment: �y�e.�a�� � e pr®te�p � y Cesspool or privy is within 50 feet of a surface water gU Usspool or privy is wig 54D feet of a l ordering vegetated wetland or.a salt mars L :ftden wM-Thil wlmtheftwdaf HeAth(aud Dick dater S.n"Mer;if any)detenn%es that the . system is functioning in a manner that protects the public health,safety.and environment: _ The system has a septic aaal soil absorp8ion system(SAS)and the SAS is witlaih 100 feet of a surface.water supply.or tributary. o.a.surface water supply. The system has a septic tank SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank an SAS and the SAS is within 50 feet of a private water supply well. The system has aseptic tank and AS and the SAS is less than 100 feet but 50 fat or more from a, private waW-supply wen'**-Method to deft^r . **'Phis system passes if the well water sis,performed at..a.DEP.ceatified.laburator for coliform bacteria and volatile organic compounds' cues that the we3�is free'faom poRution from hat facility and the presence of ammonuia nitrogen and nits nitrogen is equal to or less than 5 ppm,provided that no other Bore criteria am triggered:A copy of the his must.be attacbed,.to-this. -;. 3. Other: Page 4 of I I OFF�IeCIL III PI„CTION FORM—NOT FOR VOLUNTARY ASSESSMNTS SUBSURFACE SEWAGE]DISPOSAL SYSTEM INSPECTION FORM. PART A CEIIBTIM.4TI<rON(continued) Property Address: %131 '-Jf _C13,k Rc� Owaner: her" Date of Inspection:. D. System Failure Criteria applicable to all systems: You most:inldlicate�es"or`ne to each-of the followiang for.a�.moons: Yes No. _Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool p/Discharge:or.ponding of effluent to the surface-of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid.level in-the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool /Liquid depth in cesspool is less than b"blow invert or available volume is less than'/z day flow ��—Re4wred-pumpmg:.than 4 times.in the last year NQ dqe to clogged or obstructed.pipe(s)-Number of times pumped. -Any.portion of the SAS,cesspool or privy is belowhigh g-rorancd water elevation Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. -Z'Any,portion of a cesspool or privyy is within 50 fit of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater th sa 50 feet front a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, perffonaedl at a DZ?cen hied laboratory,for cd fornt bacteaaa a3md vanatile.ergaide ,roads indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen.and:a torte Wirogen is egdal to arr kss than 5 p9m,..provided1hat no other famaTe cafteu ia. are triggered.A copy of the analysis must be attached to this form.] IV 0 (Yes1No)The system fails.I have determined that one or more of the above failure criteria exist as desuibed in 310 CN%15.303,therefore the system fails.'lie system owner should contact the Hoard of Health to determine what will be necessary to correct the failure. Large Systems. To be commddemtz hov system ae symm=ad Bern a facility.,,is al di m:: of_10, gpddi-tRa-15,000 gpd. You must indicate either"Yes":.or"oo"to of die following: (The following criteria apply to large sy in addition to the criteria above) yes no _ the.system.-is>within.400 of a surface Ong water suPPly the system.,is.within.296 feet of a tributary to a surface drinking.water supply _ — the system is locat4 in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped ?one li of a publ" water supply well If you have arise"y(s"to ariy question in Section,E the system is:consideavd.:a si at threat.or amwered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a sigcii ficant threat under Section E:or,feed under Sea tion 1)shall.upgrade the systerra.in-aw"dance with.3:10 G1+At 15.304.The.system owner should contact the appropriate regional office of the Department. Pale S of 11 OMCU L INSPECTION FOR—NOT FOR'YOLUN`I'ARY ASSESSMNTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Ply Date of inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following_ Yes No: Pumping information was provided by the owner,occupant,or Board of Health t/Were any of the system comments pumped out m the previous two weeks _4e-- 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 bf this inspection Were as built plans-of the system obtained and examined?(If they were not-available note as N/A) Was the.facility:or dwelling inspoded:for:sigus.af;sem. ge_back up Was the siteinspected.for,Signs of @"Ten"k out Were,all sy em components,..exclud g.the:SAS,located on site _ We=the septic tmk moles uncovemd,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dianensions,depth'ofEquid,depth of sludge and depth of scum Was the facility owner(and oecupants iNi ferent from owner).proyide 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: Y �ofHealtb Existing info�iation.For example,aplan at th Bi 'Determined m the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)PIG CUR 15.302(3)(b)) Page 6 of 11 I ` tC TAIL WSPF'Cno (D -NOT]FOR VOLUN7ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'nON FORM PART C :SYSTEM,WFOPMATION 6�1rz�I5T�5 �„it pia Owner: C Ili' c aS,_- "D -off Inspection- f y FLOW CONDITIONS Number of bedrooms(design): y Number of bedrooms(actual): DESIGN-flow:based on 310.CNIR-15103.(for.e e:1.10 x#:ofbedrooms): VV0 Number of current residents: Dow residence have a.gartow Winder(yes or no): Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection requiredl Law dry system.inspacted(yens©r no): Seasonal use: (yes or no): Water meter readings,if available(last 2 years &a- 0 ..�a�t.�cce3t.� zig'Ar , well Sump pump(yes or na):� ~'� Last date of occupancy: COMMERCUM"USTRUL Type of esmblishmem. Design flow(based on 310 CMR 15. 03): apd Basis-of.design.flow{semis/ - etc.): Grease trap present(yes or kdwmg wasw holdmmg t o n0l_ Non-sanitary waste discharged to the klle5l system(yes or no): Water a wler readings,if available: Last date of occupancy/use: OTHER(describey �KNIERAL WFORMATION Pumping Records _ S0urC,aofiaaff0ranati0n4] �. .�1 Was system pumped as part of the inspection(yes or no):-AID If yes,volume.purrtped: pilons—How was quantity..pumped.deten ined? Reason for pumping: TYPE Q, SYSTEM eptic tank,distribution box,soil absorption system Stng)e cessps�l Overflow cesspool —privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _lanovahwMlteaaative technology.Amch:a+cpff.ofthe-mot:opmation--ml,maiWenance;act(to be obtained from system owner) _Tight tank _attach a copy of the DEP approval. r Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at-the site(yes or no): _ .� i Page T of I 1 0MCL4L INSPECTION F® —NOT FOR'VtbWNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM.li)4T B AT ON(continued) Date df-Inspection: V-a- v.y BUILDING SEWER(locate on site plan) Depth below grade: �� Mated&of.constructiow cast iron .PVC�o (expla.i a): Distance from private water suppl 11 r suction line: sv — Comments On cxuulit on of;als,ventizcg,evidence of leakage,:etc.): �4yl SEPTIC TANK: ✓ (locate on site plan) Depth below grade: /_2 � Material of conouctim,. .—metal— fiberglass._.-Polyethylene —other(explain) Iftamk ismetal:list:age: :ls:age es►ntgmaed by a Certificate of Compliance(des or no): (attach a:copy of certificate) Dimensions. X Sludge depth: 2'`' Distance from top of sl�rdge to bottom of outlet tee or baffle: _ Scum thickness: f Distance from top of scum to top of outlet tee or bale: Distance-from bottom of seam,to bottom of outlet tee or baffle:�_ How were dimensions determined: Uri e!` PP M v 0A-C n*= _"fiefs Comments(on.pumping recommiendations,'inlct and-outlet tee for baffle condition,structural imegrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �co..ry•.e.rt ���� 1=u�r►�e .2 — ::� �:S 'Fo� y►M r�-}'� ° GRFASE TRAP:_(locate on site plan) .Depth belowgrade: Material of construction: txuacrete=metal fiberglass_polyethylene otter (explain): Dimensions: Scum thickness: Distance-from top of scum to top o et tee or baffle: Distance from bottom of scum to botto of outlet tee or baffle: Date of last per. Comments(on pumping recommendations,Niel and outlet tee or baffie condition,structurd integrity,liquid levels ,as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 0M_ CLkLINSPECT'ON FORM'NOT FOR VOLUNTA 'ASSESSPv1ENT'S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM MFORMATION(con*ww) Property Address: Q 3 I tn1 A-x E V RA. Owner:�a�oli"a -r ycE pd�F I t to of fhgc6non:. 'y— —v Y. TIGHT.or HOLDING TANK: (tank must be pumped at time of inspectiouXlocate on site plan) Depth below grade: Material of construction concrete metal glass___polyethylene _other(explain): Dimensions: Capacity: ons Design Flow: � __dday Alarm.Present{yes ): Alarm level: Alarm in working order(yes or no): Date of last-pumping:_�..__ Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: // (if present must be opened)(loc ate on site plan) Depth of liquid level above outlet invert:�_LF_v� Comments.(now if box is.level,and distribution-_tu outlets equal,any evidence. of solids yover; any evidence of leakage into or out of box,etc.): ._2 PAS 'ey/r-IN5Z 0 1-1,oz .,O ",yFi%PTRsH(!� PUMP CHAMBER: (Iodate on site plan) Pumps in wor)nng order(Yes or ): Alarms in working order(yes or o): Comments(note condition of p chamber,condition of pumps and appurtenances,etc,): Page•q of 11 0MCIAL INSPECnON FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPRCTION.FORM PART C SYSTEM UVFUIRMA'10N(oDrAhmed) Owner. f od�i�E t �c.E DBE e.of Inspeedw: SOM AB�1 ION S M(SAS).Ji`(Waft can sk pka,excavagem mw mgadre ). If SAS not located explain why: ^ -- Type �ching.pits,.number: leaching chambers;number leaching galleries,number leaching trenches,number,length: _Teaching fields,number,dimensions: overflow cesspool,number_ innovative/alternative system Typethame of technology: Con,meM(ate-conditionof.soil,-signs-vfhydroulichiluire,level:af.ponding,< a-soik wnditionofvegetation, etc.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth_top of liquidto-inlet invert: Depth of solids layer._ Degh of scams layer: Dimensions of cesspool: Materials of co Indication of gro ater inflow(yes or no): Cotes(note condition.of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PEb'Y: (locate on site plan) Materials-of construction: — Dimensions: Depth..of solids:. Comments(note condition qrsojL signs of hydraulic failure;lever of pondmg,condition of vegetation etc.): Page.10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.S AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYS3 A i.INFORMATION(con inaued) Property Address: 4"3 .WAA-,--&E fi1g/ (weer: Date of bispectim- Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or bent .Locate all wells vita 100 feet where ic'watex Afflya ten the bull g. . J56 • Page I 1 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SERFAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMA.'I`I N(continued) Owner:L2�41't Date of iiaspection: V 5 .1✓+7�i1� Slope Surface water Check cellar Shallow wells Estimated depth to ground water_.0 _.feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked;date of design plan_reviewed Observed site(abutting property/observation hole within 150 feet of SAS) �heckedwith local-Board offleahh-explain: x'r'SCS2 Low- aah- Checked with local excavators,installers-(attach documentation) 1-,—Accessed USGS database-explain: /Y4071-Dr AL,6_ . Pi4i%✓f n' You must describe how you established the hlo-growdmater elevators: 1 ?,01 _ s 5 :- llirf 15/2000 11 Title 5 Inspection Form 6! i TOWN OF BARN ABLE * LOCATION Ketv 7s, SEWAGE# V LLAGE A ON ��/,</�S ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. _5 SEPTIC TANK CAPACITY --er-o 6 LEACHING FACII.TTY: (type) /,N��: =�'i+a.� �> (size) NO.OF BEDROOMS BUILDER OR PERMITDATE: o =r; COMPLIANCE DATE:=C Separation Distance.Between the: ' Maximum Adjusted Groundwater.Table and Bottom of Leaching Facility Feet •Private Water Supply Well'anAeaching Facility (If any wells exist on-site or within eet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by VY '?,30 a . /74- -16 _ y TOWN OF BARN(S,�ABLE LdgATI3N 3 I 0 _ e c!� SEWAGE # - VI..LAGE /'/. Peon,!�, ///.I S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 5 I U C IdAJ TOUC, _SEPTIC TANK CAPACITY / b LEACHINGFi,FAcmrrY: (type) G: L'A'A ►,6.W2i (size) NO.OF BEDROOMS BUILDER ORI R PERMITDATE: :"; 7 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well an&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 u f� o ` ev/I�iv9 / US i� 00 �No. ? Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _// Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zippricatton for Mgooaf *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Locati9 AddEss o 5 of No, e Owner's NNag mme,Address and Tel.No. vv/�ry�( P S e#v ) ,r rk 5 E7 Assessor's Map/ParcelO Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.A-Yr" Q Aj --2,0 C, Type of Building: Dwelling No.of Bedrooms t, ,ot Size sq. ft. Garbage Grinder( ) Other Type of Building �Nj. of Persons Showers( Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 provision f th viromn ntat de and not to place the system in operation until a Certifi- cate of Compliance has be issued by th' He , Sign d Date Application Approved by Date Application Disapproved for the fo wing reasons Permit No. — Date Issued No. -.»....., Fee�� ;f tim THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS Rpprication for Oigozal bpztem Con.5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Locatio AAddress or Lot No �L(� R e Owner's Name,Address and Tel.No. �S oNs �r -1J5 nI,��P^ Assessor's Map/Parcel � Installer's Name,Address,and Tel.No. ! Designer's Name,Address and Tel.No. LQ,JS,:�rvr— T 1 0 ,U Type of Building: Dwelling No.of Bedrooms of Size sq.ft. Garbage Grinder( ) Other Type of Building L INN of Persons Showers( ) Cafeteria( ) Other Fixtures jq Design Flow gallons per day. Calculated daily flow L-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) 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 f the vironmental C de and not to place the system in operation until a Certifi- cate of Compliance has bee Issued by thi Hea Sign Date `(O — Application Approved by Date -- Application Disapproved for the fol4wing reasons Cyr r Permit No / .- �� Date Issued 7 Z -- cIT _— x--------------- --------s' 1 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS u" Certificate of Compliance THIS IS TO CERTIFY that t e On-site Se age Di posal System Constructed( )Repaired ( ) Upgraded( ) Abandon d( )by r at va Lit has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated — Installer Designer The issuance of this permit shall not be construed as a guarantee that the sys wi117function as designed. Date 27 Inspector ---G`y------------------------------------ No. / 7 Fee a THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSETTS &-gpoga[ *p9tem QCon!5truction Permit Permission is hereby gra ed to Construct( )Rep ' ( )Up rade(X)Abandon( ) t System located at � r and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: !1 to ` �tc/ Approved by :� r - 4 � CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONS'HWO]ON I'EItMF1' (W1'I'IIOU'I' DESIGNED PLANS) q/`,v® S hereby certify that the application for disposal works construction permit signed by me dated —�--�—j11 , concerning the property located at 3 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. S NED: 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). /r i 1 ® 1600 l r TOWN OP BARN ABLE I t)CATION. 0 t k e SEWAGE # - '.YILLAGE r5n, ( ASSESSOR'S MAP& LOT `INSTALLER'S NAME&PHONE N0. 5 6 v C �O�tJ 7ot1G 5 r, L'C ,SEPTIC TANK CAPACITY / e a.. . • . . . Pam/ .. iv��� , LEACHING FACILITY: (type). CIA,1,1zz) (size) 14 !2 NO>OF BEDROOMS ..BUILDER OROF �P �~ i :PETtIvITTDATE: �" �7 COMPLIANCE DATE: -Separation Distance Between the; ` M. um um Adjusted.Groundwater Table and Bottom of Leaching Facility Feet 'tivi Water Supply We11 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 .ut . nished b :� y - - - - ,off 11 i ' . x 73 LO,CATI_ON: SEWAGE PERMIT NO YT/ 1 .. � ' _ �ILLAGE INSTALLER'S NAME & ADDRESS: BUILDER'S NAME & ADDRESS: DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: Cl4CC+ ll�Qij - j Li ......... Fes$... OlJ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �ptz,cc.-._..-.--.oF..........�3 7"14`4 .. .......---.................... ........................... Appliratiun -fur Uiupuuttl Works C owdrurtiutt Vrrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: Location-Address �L L or Lot No. b /�T-----------. -,a--- - ---- . W Owner Address Installer Address dType of Building Size Lot----------------------------Sq. feet Dwelling—No. of Bedrooms.-------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building _-_--_---_--____--.-_--._ No. of persons____________________________ Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------------- r -:_..��.G..____.. Mons per person per day. Total daily flow.... �_��..................gallons. W Design Flow...... ..... .. g� P P P Y• Y WSeptic Tank—Liquid capacity j allons Length--------_------ Width................ Diameter_-_-- --------- Depth_-_--_.----. x Disposal Trench—No_�O..C� __________-_________ Widt I._....._..._........ Total Length.................... Total leaching area--------------------sq. ft. � Seepage Pit No. d---. ._.`�tameteSr.................... Depth below .................... Total leaching area------------------sq. ft. Z Other Distribution box ) Dosing tank ( ) `Percolation Test Results Performed bY.......................................................................... Date------------------------------------.... Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.---_--.---_--._-._.---- �14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.--_---___.--.----_-- 1:4 -----------------------------------•-------------------------------------------------------------------- ••--------•---------------------•----•----•--•-- ... 0 Description of Soil----------------- ------ -----�. •-----•-- - ----------------------- ----------------------J U ------------------------- �Q.�1/ Cll� ..: fa r--- ' G . VW -------------------------------- .................................................. ---------•-•-------=-------•...----------------•-•-•----•-••------. -�------------------- 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 NI 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 bo d of health. Signed•-- ------ ....... • - - --- ---f 3 Date Application Approved BY = �l----9-`..-7-�------- Date Application Disapproved for th7fowing reasons:................................................................................................................ ..............................................-................................................................................-.........................----------------------------------------------- Date L• PermitNo._--�,.? ---=.................................... Issued.------- /_ J/- - --- ......--------•-D *ado.-•--`�A�.---� ----. j Fi .................. ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF -HEALTH .................. , ppliration -for Bigpooa1 Works Tomitrurtioo Vrruift Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage 'Disposal System at: ----------------------------------------...• •--•••-•••-•----•-•-------•-•••--- Locatn Ad re ss L h a` o , t or Lot No. a ------------ a x ------ -•-------•------------•-----'-••-••-•-------•-•--•-•-•----------•••----•------------ W Owner Address Installer Address UType of Building r Size Lot.......... ... ...........Sq. feet Dwelling—No. of Bedrooms__________________________________ _____ Expansion Attic ( ) Garbage Grinder ( ) p, Other Typevofti Building ____ No. of persons '__ _. "............. ..__ .M6kas3( ) — Cafeteria ( ) st � 4 �' ' "^ ' 'r� w1Other fixtures d ------------------------- - ------------ ---- -------------------------------------- ---------- ------------------ Dest n Flow __ ��G Allorts er person per day. Total daily flow...:.........::.. .24________._._-. W g �°', g< P P P Y• Y "` � - - -gallons. Ra Septic+I i>tlrti Ltgtud cailltipy gallons Length---------------- Width................ Diameter.-.------------- Deptlt __-_--- Disposal Treitc'h—No z _ ��idt i____________________Total Length-------------------- Total leaching area--------------------sq. ft. Seepage Pit No.;lA64.__ __''lliametery--------.'.:......... Depth below inlet__________________ Total leaching are a------:-----------sq. ft. z Other Distribution box () *,;,..,.Dosing tank ( ) ~" Percolation Test Results Performed by__________________________________________________________________________ Date--------------_----------.-------------. Test Pit No. 1----------------tntnutes per inch Depth of Test Pit-------------------- Depth-to ground water-.------._-_-._._..--. (� Test Pit No..2____._:_:.;___minutes per inch. Depth of Test Pit____________________ Depth to��iound water........................ p... '•w : Description of,Soil-----------------------`:, ------------------------------------------------------------------••---------------------------------•----------------------------.. O •p x --------- -------- ------------• � s� _` _ c , jog �., c ----------- ------- ---- -- -- --- --= = -----------------G�.�e.#64 - V 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`S.state Sanitary Code—, The undersigned fu`rthertagrees not to place the system in operation until a Cer•'tificte:of Comphic "has been�ecdl'by the'bo d of health ,Signed.---•••. - --•- --- -------------------------------- ate Application Approved BY------------ =--- ---•---•--•--•- -•--••---•------•-••••.......... -------------------•• --------------------------------------- Date -- " Application Disapproved for tla following reasons_________________________________________________________________________________________________________________ --•-•----•-••---•._...---••-----•-------------------•-----•---------•-•-••-------••••--•-----•-•••-.................................................... -•----------_----•••-•---------••----------- Date PermitNo.•-'7XU----'••-----••-••--------- = ---------- Issued.---- -----•------ ----- =-,---•--•••----•- ---''--•- w"=+.-„. Date ";a�'�• �.:+ .t THE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HEALTH 6�cic 4A.• T' '............................oF. � .S................................ �� >Y t••�L•:tw ............................ Tntifirote of Toutphatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) -------------------------•-----------•-------•--------------.._-.---...---•---------••-•-•--•---- I staller has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the application for Disposal V .orks?Construction Perm itNq,__ . •:__ ____________ dated -_._�l`` .�.. .................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL`FUNCTION SATISFACTORY. ---------------------------- THE COMMONWEALTH OF ,MASSACHUSETTS BOARD OF HEALTH N Ire) o. .............. dw ............OF ...��.10.fa� FEE........................ Dinpotittt Workii Cnomitrortilin Vrrotit Permission is hereby granted------- IfAf------- ........................ ..........:....................................................... to Construct (� ) or Repair ( ) an JndIvidual Sew, ge Disposal System at No. +✓�!-/! .a�i ••• • ................................... .: / street e as shown on the application forDlsosal Works Consirtaetibrietiiit No __7S___�-�____•. Dated___.__-.__.�� j- ------------------------------------------------- J DATE �!' 13o xealth ar of fA.✓,FORM 1255 HOBBS & WARREN.kINC.. PUBLISHERS,,� THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA �./'v%•l.._-,• d'�/.� ��.�. 'l/GAL.L4:�/'.::L:J� � .. . f i3 CL,c;J r i • a 7-5 DASE9TAEL Boa c PAUL C. MURRAY HEALTH INSPECTOR BOARD OF HEALTH I TOWN OF BARNSTABLE OFFICE HOURS: - TELEPHONE 8:00 - 9:90 A.M. 1:00 - 2:00 P.M. 77S-1120 EX. 98 1 J F � 3 W, ,41rlc- 8y t3' A c Re s f -EPT) Cl IPA- 7— s / T d YD, y t � J f F \ 22 lf 3 44 • \ .. -LL ID 3 r of k�ely iF Idt r)oo w E tt J ~� J 9 /r Flaor / 4 � p G9TL•.1 Do rL-11 i { -J LOT DATA: ASSESSORS MAP: 028-100. FLOOD ZONE: XA� PLAN REFERENCE: BOOK 278 PAGE 38. ��Y DEED REFERENCE: BOOK 1292 PAGE 1069. P(jBj,IC LAND COURT REF: 38281A. ROAD THE TOPOGRAPHY SHOWN WAS LOCATED BY AN ON THE e GROUND INSTRUMENT SURVEY. \ N DATUM: ASSIGNED 06.32' BENCHMARK FIRST FLOOR ELEV. 113.05 _ I . I 1 , ` 1 It House no.: 866 k I ` ' /' ' , I ,y In co 1 T GSTINGOODED I It 'AREA 00 !!� C�co 1 1 1 u 1 1 I I `1 Proposed Riding I ' Ring House no.: 848 it II 1 1 I CART PATH II 1 s' : 10' iaER , TO BE,CREATED I 1 188.7' �� 120NCFECAP�CITY ; AROif TREES HE I , I 1 , , 141 6• � . �_ 34.8•, i i I � I i I � � II I I 1 1 !• i 6' ' /I m I I ' I \ e \` y� garden eristin ' CONCRETE ` a� � I ,I \ `\ os � bar 67i3 COVER �_ i s ` ` ` ,, \ 0 E WATER SERVIC I / ` ' Basting vel`I \\ r I ' drivewa turn out 1°1pp0 j ` i typical T I ' S � I E4�C��10Cs �O \ tip{�ao �j L O¢�� EmSTING WELL --------------- House no.: 866 ----� 3' 1?►C �E O J ,° �• r� ` `------------ ' W e -------�•\` - _''--------''_ s • o°s e 100' offset to wetland \` _ ell 5 pg \\ deck --------------------- -------------- ON pro - 5 °b W b � nds Lot 10 0 °� e�la poi 5.8f acres 0 °4-0 NOTES: o Patty's Pond THE LOCATION OF THEM EXISTING SEPTIC SYSTEM COMPONENTS � nontidal N 780 �� �~WERE PROVIDED BY THE APPLICANTS. � THE WELL IS TO GRADE. _ 43 43" ANY PORTION OF THE WATER SERVICE THAT IS WITHIN 10' 429.27, SITE PLAN OF THE SEWERAGE SYSTEM SHALL BE ENCASED. PREPARED FOR ALL LIGHTING SHALL BE DOWNCAST. THE RINGING RING WILL NOT BE LIGHTED. Paul and Susan Baudanza THE WOOD SHAVINGS AND PELLETIZED WOOD BEDDING AND MANURE SHALL BE STORED / OF FOR A MAXIMUM OF 5 DAYS. 431 Wakeby Road APPLICANT INFORMATION: BARNSTABLE, MA SUSAN BAUDANZA ZN 0 431 WAKEBY ROAD 4°' G J. E. LANDERS- CAULEY, P. E. MARSTONS MILLS, MA 02648 508-736-6950 EY CIVIL ENVIRONMENTAL ENGINEERING 508-73 � L ZONING INFORMATION: ! Gn P.O. BOX 364 WEST FALMOUTH, MA 02574 ZONING DISTRICT: RF 101 (508) 540 — 7733 ph. 0 15' 30' 45' 30' C R `�� " 508 540 — 3344 fax ASS. 028-100 DATE: 05 16 11 SCALE: 1 = 30' SCALE: 1" = 30' DRAWN BY: JDR JOB NO. 1978 SHEET: 1 OF 1