HomeMy WebLinkAbout0779 WAKEBY ROAD - Health WLA
WAKEBY RD.
RSTONS MILLS
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O LOCAT N '-) AL SEWAGE
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VILLAGE � ` ASSESSOR'S MAP &
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: 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 M feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
Feet
Furnished by CJ
within 300 feet of leaching facility) �� �
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VILLAGE
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Town of Barnstable Health Inspector
pp Tp� Office Hours
Regulatory Services 8:30-9:30
Thomas F.Geiler,Director 1:00—2:00
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�$ 16 9. ,e� Public Health Division
QED s Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
AMNESTY PROGRAM APPLICANT-SEPTIC QUESTIONNAIRE
1. General Information: Size-of Property: a(/
Address: Map .Parcel
Name: Phone#: a24• q�s�o
2a. How many bedrooms exist at your property now?
2b. Are you planning to add any bedrooms? Q If yes, how many?
2c. How many bedrooms total are prdposed at this property(including the amnesty unit)?
2d. Please include a copy of the floor plans for the entire property- showing the existing
rooms in the home plus the proposed amnesty apartment and/or addition. Please label .
each room clearly on the plans.
3. Is the dwelling connected to public sewer? YES or N0
` �I1_tttewdwe}ing is connected to �eEuer=,sl�tlons##4 tluougl�ow
4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells?(!�/V
5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER?
6. Is a disposal works construction permit on file? YES or NO
6a. If yes,how many bedrooms were approved according to this permit? Bedrooms.
7. Were any building permits obtained for construction of additional bedrooms? YES or NO
.8. Is there an engineered septic system plan on file at the Health Division? YES or NO
9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
----- ---------------------------------------------------------------------------------------------
�� FOR OFFICE USE ONLY
The Public Health Division has no objection to bedrooms at this property.
Special Conditions:
Signed: --- Date:
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FTHET°�� OWN ';F BARINSTABLE
The Town of Barn � le2 AN 8: 40
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Office of Community and Economic evelopment
TFD"'P�p 230 South Street
Hyannis, MA 02601I`JESIOM
Office:508-862-4678 Fax:508-862-4782
May 31,2005
Mr.John C. Klimm, Town Manager
GaryR. Brown, Town Council President
Barnstable Town Hall
367 Main Street
Hyannis,MA 02601
Re:
Lois Skinner- 576 Mariner Circle, Cotuit- a single-family accessory unit
Lee Burrill- 779 Wakeby Road,Marstons Mills - a single-family accessory unit
Sara Benson- 170 Woodside Road,Marston Mills - a single-family accessory unit
Lisbeth Florestal- 125 Woodside Road,Marston Mills - a single-family accessory unit
Gentlemen:
This letter is to inform you that the Accessory Affordable Housing (Amnesty) Program has received
requests for a project eligibility letter under the Community Development Block Grant ((DBG)
Fund and under Article II of Chapter Nine of the Code of the Town of Barnstable and the Criteria
for the Local Chapter 40B Program.
The Program Coordinator is reviewing the requests. If the Town has any comments on the projects
please forward them to me so that they can be addressed in the site approval letter. This letter gives
you official notice of our receipt of the above application(s). We will issue a decision as to the
acceptability of the sites and the consistency of this development within the guidelines of CDBG.
cerely,
tabeth�DMfflen,Program Coordinator
y&Economic Development
cc: Town Attorneys Office
Building Department
Public Health Department!/
:�Op.=%5-01 14 : 27 BARNSTABLE HEALTH DEPT 5087906304 P.06
��� ► "� Town of Barnstable
Regulatory Services
• BA RNSlA2
9 MUSS. g Thomas F.Geder,Director
AIFo Y. Public Health Division
Thomas McKean,Director
367 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
DACE: 7 I3 0 I
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The Barnstable Health Division has reviewed the Title 5 septic inspection form for the
above referenced property. The following comments listed below are deficiencies
accordir.g to 310 CMR 15.300 and the Town of Bamstable Health regulations. Please re-
inspect the system, if necessary, complete a new report form or revise the pages pertinent
to the deficiencies listed and resubmit the report to this office within fourteen (14) days:
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P'9ge 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 779 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LEE BURRILL
Date of Inspection: 5/7/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
BOX 1S STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 779 WAKEBY RD MARSTONS MILLS,MA 02648
Owner's Name: LEE BURRILL
Owner's Address: 779 WAKEBY RD MARSTONS MILLS,MA 02648
RECEIVED
Date of Inspection: 5/7/01
Name of Inspector: (please print) JOHN GRACI MAy 15 2001
Company Name: SEPTIC INSPECTIONS gTAB►E
Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 -TOWN�A�H DEPT.
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally Passes
_ Needs Further aluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 5/7/01
The system inspector shall submit aticopy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
Notes and Comments
THE SYSTEM PASSES TITLE V INPECTION. RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO YEARS,
TO PROLONG THE SYSTEM'S USEFULL LIFE.
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 779 WAKEBY RD MARSTONS MILLS, MA 02648
Owner: LEE BURRILL
Date of Inspection: 5/7/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY ONE TO TWO
YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
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.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain.
n/a 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.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 779 WAKEBY RD MARSTONS MILLS, MA 02648
Owner: LEE BURRILL
Date of Inspection: 5/7/01
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of 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 I 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 n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 779 WAKEBY RD MARSTONS MILLS, MA 02648
Owner: LEE BURRILL
Date of Inspection: 5/7/01
D. System Failure Criteria applicable to all systems: .
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than'/2 day flow
X Required pumping more than 4 times in the last year NOMdue to clogged or obstructed pipe(s).Number of times
pumped nla.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. ]This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
_ X the system is within 200 feet"of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
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.
r
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 779 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LEE BURRILL
Date of Inspection: 5/7/01
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period ?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection'>
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site'?
X _ 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 ?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems`?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X Existing information. For example,a plan at the Board of Health.
X _ 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)]
Page 6,of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 779 WAKEBY RD MARSTONS MILLS, MA 02648
Owner: LEE BURRILL
Date of Inspection: 5/7/01
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 C.MR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 2
Does residence have a garbage-grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO {if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR.15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1988
Were sewage odors detected when arriving at the site(yes or no): NO
Page 7'of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 779 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LEE BURRILL
Date of Inspection: 5/7/01
BUILDING SEWER(locate on site plan)
Depth below grade: 22"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 16"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W 4' 10""
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING
SEPTIC SYSTEM EVERY ONE TO WO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
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
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 779 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LEE BURRILL
Date of Inspection: 5/7/01
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level:N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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.):
n/a
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
Page 9 of 1 l
. g
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 779 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LEE BURRILL
Date of Inspection: 5/7/01
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: nla
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF
FAILURE.SOIL PROBED DRY.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
Page I G of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 779 WAKEBY RD MARSTONS MILLS,MA 02648
Owner: LEE BURRILL
Date of Inspection: 5/7/01
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.
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Page,1 L of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 779 WAKEBY RD MARSTONS MILLS, MA 02648
Owner: LEE BURIhILL
Date of Inspection: 5/7/01
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
YES Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
USGS MAPS AND CHARTS- 12+FEET
I
Town of Barnstable
a�atvsrest.E,
Department of Health, Safety, and Environmental Services
059. Public Health Division
" 367 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas A McKean,RS,CHO
FAX: 508-790.6304 Director of Public Health
TO: LEE E. BURRILL DATE: JAN. 20, 2000
779 WAKEBY ROAD.
MARSTONS MILLS, MA. 02648
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 779 WAKEBY ROAD was inspected on 09/11/97
by ALBERT R. RIVET a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of
1995 TITLE 5 (310 CMR 15.00) due to the following:
(� BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN
OVERLOADED OR CLOGGED SAS OR CESSPOOL.''
The above system, according to our records has been in a failed state for more than two years.
Therefore, you are directed to hire a licensed Town of Barnstable septic system installer to sketch
a proposed system that will bring the septic system into compliance with 310 CMR 15.00, The
State Environmental.Code, Title 5 within(14) fourteen days of receipt of this notice.
The septic system must be brought into compliance within (30) thirty days of your receipt of this
directive.
You are also directed to maintain the system by hiring a licensed septage hauler to pump the septic
system to prevent discharge of sewage or effluent into buildings, onto the surface of the ground, or
into surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to any court
of competent jurisdiction as provided for by the laws of the Commonwealth.
PER QRDER OF THE BOARD OF HEALTH
'�Zas McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
q:halth\&ti1altWe52y.&c
I
77
Town of B le R� }� -^-fir=�
Department of Health,Safety and En egtal Services A �eZ 'X
Public Health Division,367 Street s Z. 23 499 187 J /s, . �,S P t
/o UST.�_ AGE
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P.O.Box 534,' �- _:±. � JAN24*00 � �
Hyannis,MA 0j 2 .� 8 t
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613 84 4 3
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' 1st NOTIC17 2000--.._
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" 2nd NOTiC
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ai SENDER: I also wish to receive the
■Complete items 1 and/or 2 for additional services. f011OWing services(for an
w ■Complete items 3,4a,and 4b.
a) ■Print your name and address on the reverse of this form so that we can return this extra fee):
card to you.
ar ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address
permit. of
■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery m
tom. ■The Return Receipt will show to whom the article was delivered and the date Consult postmaster for fee.. a
c delivered. Id
4a.Article Number d
3.Article Addressed to: Z �9,
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cc ❑ Return Receipt for Merchandise ❑ COD $
7.Date of Delivery
of
/ Addressee's Address(Only if requested
MM 5.Received By: (Print Name) 8.Add ( Y c
W and fee is paid)
g 6.Signature: (Addressee or Agent)
X
9 102595-9�-e-0n9 Domestic Return Receipt
PS Form 3811, December 1994 i`
Z 203 499 187
US Postal Service '3a
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not use for International Mail See reverse
Sent to f /> >
STs,8y,slumbe X_�)�,Q�
P / ce,,Stat &ZIP .�pje(�
Postage $
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
LO
Return Receipt Showing to
Whom&Date Delivered
a Return Receipt Showing to Whom,
Q Date,&Addressee's Address
0 TOTAL Postage&Fees $ 2.
Postmark or Date
0
LL
/y�/ �
Stick postage stamps to article to cover First-Class postage,certified mail fee,and`'•
charges for any selected optional services(See front).
1.If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service !N'
window or hand it to your rural carrier(no extra charge). m
Q)
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q)
return address of the article,date,detach,and retain the receipt,and mail the article. �-
Ln
3. If you want a return receipt,write the certified mail number and your name and address rn
on a return receipt card,Form 3811,and attach it to the front of the article by means of the
gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a
RETURN RECEIPT REQUESTED adjacent to the number. Q
4. If you want delivery restricted to the addressee, or to an authorized agent of the O
O
addressee,endorse RESTRICTED DELIVERY on the front of the article. M
5. Enter fees for the services requested in the appropriate spaces on the front of this
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ti
6. Save this receipt and present it if you make an inquiry. 102595-97-13-0145 a
f
Town of Barnstable
snxtvsrnsi.$,
Department of Health, Safety, and Environmental Services
'""M Public Health Division
367 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO: LEE E. BURRILL DATE: JAN. 20, 2000
779 WAKEBY ROAD.
MARSTONS MILLS, MA. 02648
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 779 WAKEBY ROAD was inspected on 09/11/97
by ALBERT R RIVET a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of
1995 TITLE 5 (310 CMR 15.00) due to the following:
BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN
OVERLOADED OR CLOGGED SAS OR CESSPOOL.''
The above system, according to our records has been in a failed state for more than two years.
Therefore, you are directed to hire a licensed Town of Barnstable septic system installer to sketch
a proposed system that will bring the septic system into compliance with 310 CMR 15.00, The
State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice.
The septic system must be brought into compliance within (30) thirty days of your receipt of this
directive.
You are also directed to maintain the system by hiring a licensed septage hauler to pump the septic
system to prevent discharge of sewage or effluent into buildings, onto the surface of the ground, or
into surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to any court
of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ER OF THE BOARD OF HEALTH
'-Z7 -
as McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
gJdih�tileakiUdry.doe
e
Please see accompanying complete prescribing information.
r
cC,C'q
FAMVIR® Time to be
famadovir Proactive
No. / (D Fee y�70
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpphratton for Migogal *pgtem Cougtrurtion Verna
Application for a Permit to Construct( )RepairkUpgrade( )Abandon( ) ❑Complete System ❑Individual Components
d Location- dress qr Lot ,,, /f yJn // Owner'sNape,Address and Te.No.
v �`Y
Assessor' Map/Parcel
- =o-7
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
6/0
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size 1/9 Ag-sq. ft. Garbage Grinder( )
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
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) aj_ee�L&Z,
cc 2�
Date last inspected: '
Agreement:
The undersigned agrees to ens construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions 'Title of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been iss d by th' azd o alt .
Signed Date
Application Approved by Date
Application Disapproved for the Mowing reasons
Permit No. Date Issued
No. 7 (O - s Fee ��
THE COMMONWEALTH OF'MASSACHUSETTS Entered in computer:
• Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppricatiou for Mi5pont *pztem Construction Permit
Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Lo-ion dress of Lot o., ,,, /f �/J� Owner's Name,Address and Te.LNo.
7 �llf/ �7 AA
Assessor' Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size . /0 AL sq.ft. Garbage Grinder( )
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 '
J Size of Septic Tank G v ca Type of S.A.S.
Description of Soil-
Nature of Repairs or Alterations(Answer when applicable) f C .
u 2•
Date last inspected' y
Agreement:
The undersigned agrees toath',
ruction and maintenance of the afore described on-site sewage disposal system /
in accordance with the provisione Environmental Code and not to place the system in operation until a Certifi- j
Cate of Compltiance has been issZdalt
.
Signed Date
Application Approved by Date
Application Disapproved for the owing reasons
Permit No. �o V V Date Issued
.`
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(�)Upgraded( )
Abandoned( )by
at 7 has been constructed in accordance
with the provisions of Title 5 and th for Disposal System Construction Permit No. 7- 6 dated / G 7
Installer J 0.&off,_. Designer
The issuance of this permit shall not be construed as a guarantee that the syste will function as designed.
Date —�1 Inspector
11
--------------------------------------
No. V41
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
1=igpo5a1 *p.Otem Cou!6truction Permit
Permission is hereby granted to Construct( )R pair*)nUpggrade( )Abandon
System located at - 7 yl�, / Al
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.
,r
Provided:Construction must be completed within three years of the date of this permit.
Date: Approved by_�
s . .
J
1019/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPL MIT WITHOUT
N FOR A
DISPOSAL WORKS CONSTRUCTION PER
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated 0 c;6- 6 l M ,concerning the
property located at �"7 �� meets all of the
following criteria:
a There are no wetlands located within t00 feet of the proposed leaching facility
a There are no private wells within 150 feet of the proposed septic system
a There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
a If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will I>Q.t be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map) S
2—
SIGNED:
DATE: l f
LICENSED SEPTIC YSTEM 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).
q:health folder:cert
V
`f V
- 3
4.
r
coplwown of Barnstable Health Inspector
�optt�rp�� Office Hours
yP o� Regulatory Services 8:30-9:30
s. Thomas F.Geiler,Director 1:00—2:00
Brrsrasre.
9� MASS. Public Health Division
RFD �A Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 5084624644 Pax: 508-790-6104
A Pi ESTY PROGRAM[ APPLICANT-SEPTIC QUESTIONNAIRE
1. General Information: Size-of Property: fie am
Address: i Map c0M— .Parcel 0D7-00/
Name: Phone #: 0264, ?15
2a. How many bedrooms exist at your property now?
2b. Are you planning to add any bedrooms? o If yes, how many?
2c. How many bedrooms total are proposed at this property(including the amnesty unit)? t"
2d. Please include a copy of the floor plans for the entire property- showing the existing
rooms in the home plus the proposed amnesty apartment and/or addition. Please label .
each room clearly on the plans.
3. Is the dwelling connected to public sewer? YES or NO
- z
���ewdwe��2�s cbnaeci�cl�to�pu`b'I�c-se�verxs`)�,que h@IIs4s'.tlrr '� }F - -
,Y
4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution to public supply wells?C;rl
5. Is the dwelling connected to an ONSITE WELL or to PUBLIC WATER?
6. Is a disposal works construction permit on file? YES or NO
6a. If yes,how many bedrooms were approved according to this permit? Bedrooms.
7. Were any building permits obtained for construction of additional bedrooms? YES or NO
.8. Is there an engineered septic system plan.on file at the Health Division? YES or NO
9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO
FOR OFFICE USE ONLY
The Public Health Division has no objection to bedrooms at this property.
Special Conditions:
Signed: Date:
O;/health1.pf:les/amnestyapp.
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LOT 1
BURRILL,LEE E 101 . ......
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779 WAKEBY RD
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MARSTONS MILLS MA 02648 0-000
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WAKEBY�ROAD
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COMMONWEALTH OF MASSACHUSETTS �
/T
I " EXECUTIVE OFFICE OF ENVIRONMENTAL AF I S FP 1 S 19
DEPARTMENT OF ENVIRONMENTAL PRO IONk4o e gNST 9� �
> y q
ONE R'INTER STREET. BOSTON. MA 02108 617-292.5500 y0fplgB(F
9
WILLIAM F.VELD TRUDY CORE
Governor Sccrctarp
ARGEO PAUL CELLUCCI DAVID H.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 7�/ ' c- Address of Owner:
Date of Inspection: ��_9��p. f (If different) 75�
Name of Inspector:
I am a DEP appre A incrwcU r-myiyyantln 5ertion 15.340 of Title 5 (310 CMR 15.000)
Company Name: AL ,IL. saan
Mailing Address: _4331CR®SS R
Telephone Number: _ N. ®AF'
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 inspection: The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes -
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: .� ^� Date:
—��—
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or, D• / C,) -gyp;Ti()/V
D-Q�X l r
AJ SYSTEM PASSES: FA/4 ir✓U-
1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
NO 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.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or .
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
t)EP on the World Wide Web: http:Hwww.magnet.staW ma.usldep
Cej Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 779
Owner: F/e j)'o;'.5
Date of Inspection: 9-//-9"7 f
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed,
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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 replacedf :- s]� 1,. , +� ya-"J'
obstruction is removed - '� '
C]hFURTHER 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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE'SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil.,,absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
_ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) OTHER
(revimed 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 779 WAX 8�r!F
Owner: F"rd119O1'E Ht1e
Date of Inspection: g_/X_7 9-%�- 9 7
D] SYSTEM FAILS:
You mu indicate ewer "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
L-"- Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
�/. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
v- Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(zevixed 04/25/97) Page 3 of 1D
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 7 7r U)A'ke Q R rlr� S �5 1141 2 t
Owner: n"Y1 C_,
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No '
Pumping information was provided by the owner, occupant, or Board of Health.
None 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.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
v~ The site was °nspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
f/ _ 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 Soil Absorption System on the site has been determined based on:
f _ The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b)J
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7 )/✓ �t1e'�,r`^ {�( /�° / ? 'c' fv,+: .t C'
Owner: FoP 749t91-I? M/KjC;
Date of Inspection: 7—//-q--7 9— 7-ia-9-7
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 4��O a.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):_VO.
Laundry connected to system (yes or no):If�
Seasonal use (yes or no):
Water meter readings, if available (last two (2)year usage (gpd): P z '/A?-°`' I/ll r,=L
'Sump Pump (yes or no): AA)
Last date of occupancy: T~J 7-q1 -7
COMMERCIAUI NDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the,Title S.system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_
If yes, volume-pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
1,-"'Septictank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no (if yes,attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: ���� '' Sod /l 1it"�/s'0
Sewage odors detected when arriving at the site: (yes or no) �w
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77CI
Date of Inspection:q—P-97
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron L"'40 PVC—other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition 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 confirmed by Certificate of Compliance _(Yes/No)
i �-�( � w t'r�tZ x S`
Dimensions:
Sludge depth: /o - - 4
Distance from top of sludge to bottom of outlet tee or baffle: �✓ 114 f3;
Scum thickness: l "
Distance from top of scum to top of outlet tee or baffle: iD
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined: Nt G",4�3 u R I
sa
Comments: t'
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
GREASE TRAP: A1/A
(locate on site plan)
Depth below grade:
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
• SUBSURFACE SEWAGE DISPOSAL SYSTEM-INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -7?9 VJ'A'CF"et-T 610,
Owner: 01f1 C'.
Date of Inspection: �' 9_Ia_q 7
TIGHT OR HOLDING TANK:W A (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order _ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: (� -
(locate on site plan)
G
Depth,of liquid level above outlet invert:
Comments:,
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_/V��7`
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
i
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7 79 VVA
Owner: Fxe DA%tF 1-qe
Date of Inspection: GJ/>_9 -7 .¢.
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: 1
leaching pits, numbe,*:_
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:.
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) =
/�-_ hl 0 i►-/ Pr7^ f)i'/r// '01Ati?iP N1ily'fK "30 d/' 0 QvR;w/r-
�L
CESSPOOLS:
(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 (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:VIA '
(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.)
I
(revised 04/25/97) Page a of 10
SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 77c% 1, 1qX K 6 y_rF P), 1%6ef70,m� /"I/Z L--S
Owner:
Date of Inspection: ,•_/)-9--7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
wwi, `L/ 1Qz6 y
Y%
w1'l` FA0��
q„r^P
Iq
i
ji
\ D-OOX
� P,r
(revised 04/25/97) Page 9 of 10
r �
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -7 7q W 11,C g Ii 4. `1711R -rOA--S M
Owner: PR/P'0m'rf
Date of Inspection: q -7
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
��Obtained,from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
6--` etermine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
Ai0 5�,�p e /T- /l .
C /?;i PK O F 5 1,5,, vas G ��t 010 iQ F y
e t-Jr;P/C .vS
prar►? (�ri.vr`-1 71757` 4d Lr?' Div (�S/'G'n� ('�/r^� �J,Q• �/
i
(revised 04/25/97) Page 10 of 10
r
t
No.. '.._..�.. :� Fxs... ..��•.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HE LT
_. .
G4/............OF.......... -G�v� . .........................
/,2 �Vv iratiou for Ui ipasal Workii Corm rnrtion thrmit
Applicati �s�hereby m de for aZeit to Construct (�or epair ( ) an Individual Sewage Disposal
System t:
.../ Z/J r.`
.......... ,1.. ---•---
-•-----------....... --• -••-•• ••n-Address
_.. r/ ... .... ._ ......-. ...1 ..... ...... ....... ........
i O er Addr ss
------•--• _..... ...................... .. ..
Installer Address -. 2 ry
Type of Building Size Lot___��.�._l.a�.1_Q____Sq. feet
U Dwelling—No. of Bedrooms. ____ ..._ Expansion Attic (l7 Garbage Grinder
►i —
a
p, Other—Type of Building __._l ......�"'� . No. of persons___.__.3................. Showers ( ) Cafeteria ( )
Q' Other fixtures ------------------------•------- -
d
W Design Flow.......... . gallons per person per day. Total daily flow.:__ _________________________gall s.
W Septic Tank—Liquid capacitlr�,eVZ-gallons Length....
'�P Width._._ 06> eter________________ Depth_s,]'_ ..
x Disposal Trench—No. ......... Width.................... Total Length.................... Total leaching area_W'0? ¢....sq. ft.
Seepage Pit No......__ ..._ Diameter.___.._�0... Depth below inlet____lP........... Total leaching areac�. ---sq. ft.
Z Other Distribution box ( V/ Dosing to )�
Percolation Test Results Performed by............................. ..... Date._.._._. .___.... ....._____..........
Test Pit No. 1......._____....minutes per inch Depth of Test Pit.................... Depth to ground water......l...............
Test Pit No. 2......CK7-.___minutes per inch Depth of Test Pit........1_________. Depth to ground water...... ..............
P4 ••--••--•_...................................................... .............................-•......._..--•--•••-•-----•----••-•-••-••--•-•-------••.
ODescription of Soil--------•---....0--___s3----------------72040....-_--_.....StGI(S�Q/. ................................................................................---1.1_-'�� '.............. c.�. �------ rLtvel ..................................
w
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance.with..
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until Compliance dn'sen iss.>!red by the board o iealth.04, ned.._....L'� ...---•--- -...._•--•--•-,�-' ........' b.y _...
1
Date
Application Approved BY �� --- ----- .- - .. a.-.--�=4-`
Date
Application Disapproved for the follow• g reasons----------------------------------------------------------------------------•-•-•----------:__-___...--..-....•..
.................................•-••-------•----...----------•-•--......-•-----•--•-•--•-••-•---------...---•-•--•----------------------------------------------...-----------------•-••-•••----••-••---
Date
PermitNo........... •----�.��. .............- Issued.......................................................
Date
_ - --------- --- ----- --------- --- ---- ---_--- - - _....�4..�►.�� - -__-.
r
a
No................--....... � � � FEs:..�...`'.........T
THE COMMONWEALTH OF MASSACHUSETTS
,�- BOARD OF HE�ALT ,
..: ......' .t'�p`,+v�.}r �- C' .:_: ......... ................_
.........OF
Appliration for Eliipbiitt1 Work.5 Tonitrnrtion omit
Application is hereby made for a Permit to.Construct or -Repair ( ) an Individual. Sewage Disposal
System at:
.......... .........1.1�........ { Wv...........
j
..... ..................
Address r� o Lo f It1o��
-•[ j✓°t: /t:'... r ✓r; 1 __ ja :i
Owner i Address
._ '_i_zl......... ....... /f � "-..... Z. I.�...�C_O'.e.' ...... r_t^...
Installer \ Address
d Type/of Building Size Lot............................Sq. feet
U Dwelling—No. of..Bedrooms_.:c^,��_.�..............................Expansion�Attic Garbage Grinder ,(i r)
a -—Type of Building __/ _'z'?_� No. of persons..:�_.T. _................. Showers ( ) — Cafeteria ( )
� Other fixtures .....................................................................\:..............................................................................
W Design Flow............................................gallons per person per day. Total,daily flow ----------................gallons.
WSeptic Tank—Liquid capacity,CA/� gallons Length........_: _' Width._�ti' /,176iaketer................ Depth
x Disposal Trench—No. .._.:' `-...._. Width.................... Total Length............. ..... Total leaching area.,--- % .....sq. ft.
Seepage Pit No-------_=..,.f.�__._ Diameter.......✓ .... Depth below inlet...- ..... .... Total leaching area.-.... ...sq. ft.
Z Other Distribution box ( . Dosing tank
'-' Percolation Test Results Performed by ` . /r.. t`/ r>'`%h' �%/'"! °Date.... ! ?_.____.._.
,`�a Test Pit No. 1..........., .._..minutes per inch Depth of Test Pit. 'L/......... Depteto ground water.-..: ...........
rZ4 Test Pit No. 2------ _....minutes per inch Depth of Test. Pit........ .......... Depth to ground water.,.-ii2...............
GG •• -------- ------------ •-•---•--•- ------••-•-----•-•••-------•-•-------••---------
0 Description of Soil............... 2....._...-•-----�r. ::>_..J`_..:= �!� 't'tf �- --------.
....................•.................... �/ --d % / ` - f! ) e-` . ! .......................,/ 's / T ��/�...................
tr-j--------••--------............._.. -
W --......-7..................................................... t----------------
...
UNature of Repairs or Alterations—Answer when applicable...:...:....................................... ...............................................
...__.F___.
t « A rc�etr'ent
g. TIie undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
thetiprovisions of T ITLE. 5 of the State Sanitary Code—The undersigned further agrees not to place the.system in
operation until a. Certificates of Compliance has been issued by the board of health.
•--..................
-- -- •••-
ate
Application Approved By.,....... •••... , .....�ti Date ....-
Application Disapproved for the f ollo g reasons
....................... •-•--._---- ...---•-------____-•-•----------------- •-••--....••--•_.. .•------------- ••.
Date
Permit No......... 1 .. Tssue(L........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
I BOARD OF HEALTH
`
Trrtifirtttr of Toutplittnre ,.
" THIS IS TO CERTIFY, That.the Individual Sewage Disposal System constructed �or Repaired ( )
x by...............
r �' " :: t' l f ✓ /r j ------.. •••.. -•-••••--•-•......•..................... ........ .......---•--............••..._._.._.....
at... ................. ; ..YY1S 1��, I ,�-------------•••--...... ••-•--•....---•-•------------•...------..._.._...----------------
has been installed. in. accordance with tl provisions of TITLE ] of The State Sanitary Code as dgscribed in the
application for Disposal.Works Construction.Permit No...... ......... dated_ .. ..................
---r°'" THE ISSUANCE OF THIS CERWICATE SHALL-NOT BE CONSTRUE® AS A GUARANTEE THAT THE
f `f SYSTEM Wjkk FUNCTION SATI, _CTORY. � Y,
DATE.......... ..7. : .: ............................... Inspector...................................
THE COMMONWEALTH OF MASSACHUSETTS t
BOARD OF HEALTH
No......................... FEE. ....................
�t,��o��tl ork� �oai�trnrtion �erntit -_
Permission is hereby granted..................R Q.6.f.:? .........p le.1^-t................._
to Construct ( ) or Repair ( )%an Individual Se rage Disposal System
at No............... `�z........ ...._.._. �... i ... `' .�`' a aY IR.? _,._... ..
............................
Street
as shown on the application for Disposal'Works Construction Permit No........:............ Dated.._.__.__._._.. .........._._..._....._..
6-K-IN.
Board of Health'
DATE. - } `�� '---•-•--•--••..-_...FORM 1255 A. INC.. BOSTON -
f
\; ,
SIC OF sy
ASS Z ®/t!r D f2 F
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Pt1IL1�
WELI�BERG So,FR*^I TACo.6
No.366
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LEGEND L, �oacr,rs '--"� �� ftr�s_ � 'c� �, r k)
EXISTING SPOT ELEVATION OxO. CERTIFIED PLOT PLAN
_
EXISTING CONTOUR— 0 - - - rL 07- Vfi9,tl-.a am 16)
FINISHED SPOT ELEVATION ( Y K
FINISHED CONTOUR 0
APPROVED , BOARD OF HEALTH IN
DATE AGENT SCALE$ /�`=",5"0 ' DATE, 2
LDREDGE ENGINEERING CQ /N CLIENTS IMP
I CERTIFY THAT THE PROPOSED
EGISTERElAk
REGISTEREp . JOB NO. LV—O BUILDING SHOWN ON THIS PLAN
CIVIL LAND CONFORMS TO THE ZONING LAWS
ENGINEER URVEY DR. OF BARNSTABLE � MASS
712 MAIN STREET`. CH. BYsi
NYANNIS, MASS.` SHEET .- OF' -Z' ATE REG. LAND SURVEYOR
://1VG PIT A'RE MORE TN.9:V /2"BELOri/
t
/O FT. /N/A/ ' 2AOE� f1 24��/AM ETER CONC'R ETE COi�ER f
!i- St/ALL BE BOUGHT 7-0GJTAOE.CitiN ,FTRA ' l
Rwcl PIPE
CONCRETE M/N. P/TCN �. , f�+E.4Yy CA57- 1,V0 V COVER Sf/.4LL ak: USED r'
COVERS
e.. PF.Q Fr. ;
ICONC C-&r TE
Cr'i�pE CU VER CLEAN .SAND
ja` SCNEDUtbwO ' ' , a..1.i• 2 LAYER
PY.C. P/f-E OOo o GAL. a .,
MJ/V. P/TC/'/ o I • • . ♦ • • 1 •. 6 �„ WA5HFO STONE`
i4 PER ><T. SEPTIC TANK D/ST. • • •, • • • • • • e a
` BOX ,p,_.0_ A • 1 81 -• -• • • 1 !•pe9 -
314
.. Ep N/VP •':o WASNED STONE
r.:
.c•�p: /Sa,7 x2. s= -377 �s •Qo.o: • 1 / • �. • • • • • :oDo
a ,S Y/.o = /13 a .a. o., 1 • • • •. .� •• • D ov a PRECAST SEEPAGE
{ 9 o • • • • • • • • e o P/TOR WIIIV
/NVPJCT ZLEVAT/DNS t/�jo G.ac/t��-I e a 81 n
/NYERT.AT B!/ILO/NG S 'FT
i INLET SEPTIC Ti4NK •o FT. C SEE TABUL.ATJON�.
j OUTLET SEPTIC TAWH. C7 '
+J'/VLETOJ'STR/BUj/ON BOX 490 FT. SECT/ON OJT` GROvNO W,4TER TABLE
O(JTLETD/S'TJ' o4moN--BOX 87.3 FT
a INLET LEACN1Ae0 /�/T [jso Fr SEN/.4GE OlSPOSA�L SY.STE/►'I 7' &V AT/ON
L FACH11VG RJ'T
Sc�LE %v ". %=D.. DtMENS/ON -,A ma's FT. .
i DES/GN CR/TER/A eNS/ON p -4 FT.
tti Nl/MBER OF BEO.?OOMS 3 DJMENS/4N C fT. tAI�I
1 GA RCA GEO/.SPOSAL. (/NIT r!o SOIL LOG SO/1- TEST
I T TED OTAL ESTIMA FLOC-v' 33o G,44.1DAY SOIL TEST At/ SOIL TEST#2
/1(UMB�R aF --EACHIVa PITS ( �FGEI! r �ELEY, PATE Of" SOIL TEST aZ� O ( S�o
1 S/OE LEACH/NG PER P/T l SO,7 SQ FT r I� RESULTS h//TNESSED BY
OTpPf PERC0ZAT/ON RATE / rjs M N /NCHBCTTO/+f LEACH/NG F'ERPTL3' FT tS 0.65014
TOTAL LE.4Cf///YG AREA u' SQ. FT PERCOLAT/ON RATE:A2 MJN.1IJVCN
RESERVELEACN//YGAREA- Sti? FT.
t
SN OF�AS� L 07-/ y/ffK6Qy
WIuw tiN i : r sq /�( 10914E SToNS
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WEIMBERG
p No. 366 , ic. t7. >; ; / EL DREDGE ENGINEER/JVG INC.,SCO
ST. .
7/2 MAIN , .4'YAN/V19, Mrs-=
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R E/VCC)UIV7 � C4/.ENT: D,4TE% 2//0 E3 6'.
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✓OB NO. .�/O SHEET Z OF .�-
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Searcifar Map/Race! 012007 r Toyu;oj� s to sp A
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For ParcelNumbe�r 012007 IN
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� Business Name ___ one on b� Oil } "�
��, �r Area %NU�1ler � i/ (1.� ntBlTntl nt del YIN
Plion� 000 0000000 Eel Storage Tank Pe�t �� � �� tF ��
Rerc'T g � Con�tr ton
1►YeII�PRrmit �� �, � � �
a
erm�t�N 97 644 __ x
lssuanceVate � 11/06/1997lr,,I
Complet►on Date; ��� �� � 11/06/1997 ,
a
M3 �
% Slze'of Septic .. `" TYpe/Si a of SAS':
Tank * { �
2 33X2X2 5 LEACH TRENCHES
iii y r� R m 3 Apr
innov"a"�tRvelAlternatf a Tec�i�olagy Sejat�c„��y�tetns `� y�r�� SSxi g! �"�
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