HomeMy WebLinkAbout0026 WEATHERVANE WAY - Health yllpatheryane Way
Marstons Mills P
--- - 147 048
r
I
I
i
.- — T(?`N OF BARNSTABLE
SEWAGE #
V7i Ir WE.A'&654Da& 1�'lc�� S ASSESSOR'S MAP & LOT `17-
Cv� �c.
I' -L�R'S NAME&PHONE NO. NAtc �,t E"t� 8Uk-e 3 8 5- 7 6 O S
SEPTIC TANK CAPACITY O G�i1
LEACHING FACILITY: (type) (size) lkg
NO.OF BEDROOMS
BUILDER OR OWNF,R
PERMTTDATE: COMPLIANCE DATE:_2 ( l /c,70
4
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility —� _ Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Fudge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by l ZC2t)
r _ �._..,, _ _ _ _ _
��
S
� �i
a
, .
� �
�. � � � � � -
.,� Commonwealth of Massachusetts
Title 5 Official Inspection Form
ti1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Weathervane Way
Property Address
Richard Demerjian
Owner
Owner's Name
information is
required for every Marstons Mills Ma. 02648 11730-20
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information �� 5b��
filling out forms #"
on the computer,
use only the tab _Michael Sears
key to.move your Name of Inspector
cursor-do not Jim The Inspector Man
use the return - -- ---- ---- -_ --
key. Company Name
P.O.Box 784 -- -- _�--
r� Company Address
West Yarmouth Ma. 02673
City/Town State Zip Code
508-364-4398 S114430
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® 'Passes ,pH OF'4f,4
2. ❑ Conditionally Passes
MICHAEL '.N
3. ❑ Needs Further Evaluation b the Local Approving Authority
o: SEARS
y pp g y = No.SI14430
4. ElFails -. 'r' FRTIF�`�
INS
11-30-20
Inspector's Sign re Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
ut&nsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l
26 Weathervane Way
Property Address
Richard Demerjian
Owner Owner's Name
information is Marstons Mills Ma. 02648 11-30-20
required for every _ __.
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
1000 gal tank, D Box, Pit and a trench
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N FIND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
I
Commonwealth of Massachusetts
�x Title 5 Official Inspection Form
- ��� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Weathervane Way ----__^----------__——_
Property Address
Richard Demerjian
Owner Owner's Name -- ------------------------------------- —
information is Marstons Mills Ma. 02648 11-30-20
required for every -- _ _
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2I System Conditional) Passes (Cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Weathervane Way
Property Address
Richard Demerjian
Owner
Owner's Name
informatrequired lforon levery Marstons Mills Ma._ 02648� 11-30-20
page.. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health and Public Water li r y ( cSupplier, 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 fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Weathervane Way
Property Address
Richard Demerjian
Owner Owner's Name
information is Marstons Mills Ma. 02648 11-30-20
required for every _
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4 System Failure Criteria
a Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
_ or clogged SAS or cesspool I
❑ ® 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 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
❑ ® p P Y pp Y
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system 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.
5) 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 CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Weathervane Way T
Property Address
Richard Demerjian
Owner Owner's Name — -- - ——__
information is Marstons Mills Ma. 02648 11-30-20
required for every _ _ ._._—
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ 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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Weathervane Way
u Property Address
Richard Demedian
Owner — ----- - ----
Owner's Name
information is Marstons Mills Ma. 02648 11-30-20
required for every _
Page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 C M R 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
Number of current residents: 2 --
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report,)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage 2018-82000 gal
g ( y g (gpd)) 2019-65000 gal
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
I ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!� 26 Weathervane Way
Property Address
Richard Demerjian_ _
Owner Owner's Name
information is Marstons Mills Ma. 02648 11-30-20
required for every -._ __.. _.
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2- Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): --—
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): - -
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: --
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: ---
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: NA - - --
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? - -
Reason for pumping:
------------------ -------
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
I
Commonwealth of Massachusetts
Irp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
l
c / 26 Weathervane Way
Property Address
Richard Demerjian _
Owner Owner's Name
information is Marstons Mills Ma. 02648 11-30-20
required for every _ —- - ----- - -- - -State Zip Code Date of Inspection
City/Town S p P
page. .
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and-a copy of latest
inspection of the I/A system by system operator under contract
❑
Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
NA — -- -
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
3711 Depth below grade:
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet-
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 9 of 16
I
?� Commonwealth of Massachusetts
p Title 5 Official Inspection Form
�J� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!' 26 Weathervane Way
Property Address
Richard Demerjian
Owner Owner's Name
information is
to arsns MillsMa. 02648 11-30-20
required for every M _. -- - —— ---- r_page. Y --
Cit (Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
27"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 gal
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
litSludge depth: -
Distance from top of sludge to bottom of outlet tee or baffle 29" -
0
Scum thickness
8"
Distance from top of scum to top of outlet tee or baffle —
Distance from bottom of scum to bottom of outlet tee or baffle 18" --
How were dimensions determined? Sludge 'ul dge' ta_�e _
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000 gal tank with inlet baffle and outlet tee in place, inlet cover at grade outlet cover 27" below grade
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
f
Commonwealth of Massachusetts
+� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I
26 Weathervane Way
Property Address
Richard Demerjian
Owner Owner's Name
information is Marstons Mills Ma. 02648 11-30-20
required for every - — — —
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness — -
Distance from top of scum to top of outlet tee or baffle -
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: -
Capacity: gallons _
Design Flow: gallons per day
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Weathervane Way
Property Address
Richard Demer_jian
Owner Owner's Name
information is Marstons Mills Ma. 02648 11-30-20
required for every -- -- - --
page. City/Town State Zip Code Date of Inspection
D. System Information.(cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: - — Alarm in working order: ❑ Yes ❑ No
t.
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16x12 with 1 outlet pipe, cover at 32" below grade in brick walkway
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
- � 26 Weathervane _-
�� Property Address
Richard Deme:jian —
Owner Owner's Name
information is required for every Marstons Mills Ma. 02648 11-30-20
--- - - — -- — — _ - — --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
1
® leaching pits number: —
❑ leaching chambers number:
1
❑ leaching galleries number: —
® leaching trenches number, length: 1-25 -
❑ leaching fields number, dimensions:
❑ overflow cesspool number: — -
❑ innovative/alternative system
Type/name of technology: — — - -—
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
I
Commonwealth of Massachusetts
,P` Title 5 Official Inspection. Form
iI i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Weathervane Way
Property Address
Richard_Demeriian --
Owner Owner's Name
information is Marstons Mills _Ma. 02648 _ 11-30-20
required for every — -page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS is a 1000 gal pit with a 25'trench off of pit, SAS is in proper.working corder with no sign of failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth -top of liquid to inlet invert — - - -—
Depth of solids layer
Depth of scum layer ---
Dimensions of cesspool
Materials of construction — -
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
l� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Weathervane Way
Property Address
_Richard Demerjian
Owner Owner's Name
information is
required for every Marstons Mills _Ma. 02648 11-30-20 _
page. City/Town State Zip Code Date of Inspection
D. System Information.(cont.)
13. Privy (locate on site plan):
Materials of construction: - -
Dimensions —
Depth of solids — - --- -
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
i
Commonwealth of Massachusetts
�� - Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`cc 26 Weathervane Wad _ _ —
�� Property Address
Richard Demerjian —
Owner Owner's Name
information is Marstons Mills _Ma. 02648 11-30-20
required for every -- - - --
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the.boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A From f
l;
l
B
peck ,
3 �r►�k 1
a
A(
N OF MqS//i,,�i
o SEARS
SO'-. No.SI14430 co_
✓ [ "44, Sf iN StP,�G�������
—q
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
(- 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
26 Weathervane Way —
�� Property Address
Richard Demerjian --
Owner Owner's Name
information is Ma. 02648 11-30-20
required for every Marstons Mills _ - -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
depth to high round water: 121+
Estimated de
p g g 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:
local excavators installers- attach documentation
❑ Checked with o ( )
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Hand augured 12' no ground water
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
' Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
�1� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r;
u—
26 Weathervane Way
Property Address
Richard Demerjian
Owner Owner's Name
information is
required for every Marstons Mills Ma. 02648 11-30-20
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Cie
_� a® 4 S
f �l
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
a� z3(0 to
COMMONWEALTH OF MA,SSACHUSETTS
ExECUTNE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP DID
� 0
PARCEL, D
TITLE 5
F
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 2( RECEIVED
Owner's Name: .;4=cjr1t'aL Goa--- AUG 2 4 2004
Owner's Address: s'a,-n—c— - yy3y
TOWN OF BARNSTABLE
Date of Inspection: T// O y HEALTH.DEPT.
Name of Inspector: (please print)
HENRY J . LEARY
Company Name: ,SUPERIOR HOME INSPECTIONS
Mailing Address: P.n BOX 544 3 Z-i% WIES � c�-�-
rARVFR , MA =O
Telephone Number: Rnn 44F,=33I1
CERTIFICATION STATEMENT
1 certify that 1 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:
A.,�;asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's.Signature: of- L., , 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.
Notes and Comments
/q'•T
Ci0.✓7+Z�✓d E /JUyrr P�j�lG- f>'w,� C1.�� ivG- 7-H %L
"This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address bow the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/1 512 000 page 1
'Page 2 of 1 1
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFICATION(continued)
Property Address: .7ts wCi4ra4Ejc--�fr...6: .✓.aY
�d TD•y w-�t�C
Owner:
Date of Inspection: 7,i/ o y
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
YIE5 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:
fiifT3 2hr�r`c"7�i...� � NOT. A !� �' d� Qu.4nt_v�alTFT A c To
�1tf� �LeirJ6-F.TT�1 e•� �,F S✓t?�i.� �T ow./L�./ ��SC�.:z��s 'TNE
Co+v�TTolvt iF 7-He vF
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 es no or not determined e the following y e (Y,N,ND)in the for statements.If"not hetermined"please
explain.
t44kThe septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is strucnirally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will passmspa== 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:
OV�S—Mcted
Observation of sewage backup or break out or high static water level m the disvibudm box due to broken or
o pipe(s)or due to a broken,settled or uneven distribution box. System will pass mspoction if(with-
approval of Board of Health):
broken pipe(s)rice ezplactd
obstruction is removed
distribution box is leveled or rgAaced
ND explain:
44-- The system required pumping more than 4 dimes 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:
2
'Page 3 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:e2&.�* t_�,4.v� ��y
Owner:
Date of Inspection: 7/Z/60 V
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(lxb)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
"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.
AI)14 3. Other:
3
'Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM 1NSPEM- ON FORK
PART A
CERTIFICATION(continued)
Property Address:o2(c
,/�j.O/yffbw� rrtTG.[�S
Owner: e G
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
NOBackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
&0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
b4,.0 Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
cesspool
Np Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
,NU:7 Required pumping more than 4 times in the.last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
&0 Any portion of the SAS,cesspool or privy is below high ground water elevation.
pip Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
A�o Any portion of a cesspool or privy is within a Zone 1 of a public well.
,tSt0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
/�fo 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 fftbeweHwater 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 fle"t 107000 gpd to I5,000
gPd•
You must indicate either"yes"or"no"to each�ofthe falbwiag:
(The following criteria apply to large systems al addition to theailaa above)
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`eater 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:o26 L✓C-AT/d�iLVaw� Lt/is�J
INAI&SMUL." tom
Owner: jimcAdime
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 th caner cupant, Board of Health
146 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,m4terial 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:
Yes no
_ Existing information. For example, a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
1�z'r' l�i9S .Lvc.4TL'a� Cv��ic /t-E�+o vC-iJ �•v[J e21�&Yz�rr
r9�✓O rn Er9ly 2.�r»�wTS ry o�a
F
r
Page 6 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:jb 6)6 7t�_~e 4(J,9y
Owner: _
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):__3 _ Number of bedrooms(actual): _
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):,330 p,�
Number of current residents:_1�
Does residence have a garbage grinder(yes or no): Avo
Is laundry on a separate sewage system(yes or no):&o [if yes separate inspection required]
Laundry system inspected(yes or no):Ld4 aoe,t - .zod ~ G,p�
Seasonal use: (yes or no):.So ,1 m e 3 - ,
Water meter readings, if available(last 2 years usage(gpd)):A oo Y - �[y - �/y _ 7y
Sump pump(yes or no): nto
Last date of occupancy:agg& 6=i
COMMERCI UA"USTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): ipd
Basis of design flow(seats/persons/sgf,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: YEA�Zt_y .6`/ ownJ�.c�
Was system pumped as part of the inspection(yes or no): L-yo
If yes, volume pumped:_gallons-How was quantity pumped dea mined?
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)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Appr xin)ate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):&0
f
Page 7ofll
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:.,?
(8AAa of
Owner: h N tiT
Date of Inspection: 7 "12 S/
BUILDING SEWER(locate on site plan)
Depth below grade: jai!
Materials of construction:_cast iron &-'40 PVC_other(explain):
Distance from private water supply well or suction line: .//i4
Comments(on condition of joints,venting,evidence of leakage,etc.):
vt rt 2=211ZD
SEPTIC TANK:` (locate on site plan)
Depth below grade: "a
Material of construction: L,�concrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): —(attach a copy of
certificate) , , -
Dimensions: 6 xQ>gl-�
Sludge depth:
Distance from top of sludge to bottom of outl ee baffle:,q/9V X A3�r
Scum thickness: �i
.Distance from top of scum to top of outl or baffle:,gtoX.
Distance from bottom of scum to bottom of outl�r baffle�r�,/3
How were dimensions determined: a^=S•e- '779peE
commendations, inlet and outlet tee or baffle condition, structural integrity,liquid levels
Comments(on pumping re
as related to outlet invert,evidence of leakage, etc.):
pl>A'1� F C[,�fiKJ 1/ER2L`� TEE
Ar �r-w �T
Q rrr/ i rY.[v6lL 1� ll2"A�/VL" /EB1
py1�-
GREASE TRAP44/glocate 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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
- i
I
Page 8 of 1 1
OFFICIAL INSPECTION FORM—RIOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address;,24), g,�E s!tl¢y
/_n4r-g7VA/
Owner:
Date of Inspection:Mai/AV
TIGHT or HOLDING TANK: (tank must be pumped at time of inspectionxlocate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: IDS (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distribution to outlets equal,any evidence of soiids carryover,any evidence of
leakage into or out of box,etc.):
-D2s 7— 02=02z�as a �a��xo v� �.n� --y�l]E.vCIE-
LE'A.r.4Q�
PUMP CHAMBER:/(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber 000rlievn of pumps aadappurtenances,etc.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM.—NOT VOLUNTARY ASSESSMENTS
O FOR
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:,?(,2 0EATziETA(&AziC w.9V
1&'e' 22V MX-L Ls
Owner: ,��;
Date of Inspection: :ZGi 2 Lf
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_jZleaching pits,number: y, Aiuy Tv AX,0= of
leaching chambers,number:
leaching galleries,number:
Teaching trenches,number, length: d&Mmt. Yw x
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
rt1rf-2 HY/0 . �m'Z-,0o•- T s3
.3�CET BELOtw.2 S'NLET' �NVEi2T �(fYv�OSCA�lJ�Cr' ✓SMCS, F404✓6/CJ C`TG . OIIK.S
PEE s -./_
CESSPOOLS: N19(cesspool must be pumped as part of inspection)(locate on site plan)
N.umber and configuratibh:
Depth—top of liquid to inlet inverts:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY:4(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.):
9
Page 10 of 11
- ARY ASSESSMENT
OFFICIAL INSPECTION FORM SOT FOR�rOLtTNT S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(coatimxd)
Property Address;(& WEi9TN5CV.4A/E 4JA V
/AgSTDi1/l A�12LLS
Owner: T
Date of Inspection: 7/ o
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.
� FZi:K1K- of t-1 oc�SC
C649400m)
®TeS7- i-(o(,C &-))GAca4-1aE' To /.2
No cwe ou sv1:� N O ENCovA-?7-C"
3 D-C3o><
RZT HA s RMScn-- To GR-4Dc
wl STEEL C.OvEit. v+✓4N62. PfCrV£c.WH y TFI►2K-- /} -;2 = 3`1 C -3 = YS
A o ^l orr DiexvE He q v y 7x vG/GS
04- L-Q✓SP, o VG'R. i HZ'S i9 2 Grlt
DEs�►v�n Fo.G cAA-S o,v c,y
W C pr7 k+ -v r9 ry E �.iJ/��{ P12;S'�v►� �-L S /� ,A
en
i
Page 1 1 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:,2/s064TNE ywAw 469Y
17]AC_t7h&1 Mzl1.,S
Owner .rscar 4�L_ Caaq'
Date of Inspection: ZZ/z If)4
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater],a 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:1
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:
�S"7" Ha!F ce.'�l3A�NoE ��Q�.n„ •fin �.0 .4^�-F �c?
11
I
SUPERIOR HOME INSPECTIONS
P.O. BOX 544
CARVER, MA 02330
DATE
TWO YEAR WATER USAGE READOUT
TOWN OF
o,2� ` CCJ ��� / �`UTHROUGH 4 S
oC d C� i 6�-- �f c�-00
THROUGH =
D l
ADDRESS OF USAGE,
06/30/04 22:41 FAX 781 934 2417 DAHLEN CO INC 10In
�� L(1L�erw'i{�-• yamhiL SEWAGE#
MAU ASSUSOR5 MAP LOT 117. G i
{a sc - 0
>�i�'f"WS NAME dt PHONE NO,
saMc TANK CAFACITY
I
� LCACi'AN0 F
NO OF BEDROOMS
f B;&R OR OWNER
`` pERMTrDA1E: COMPLIANCE DATE:_---,�, f
Sgmmdiott Distance Betwa40 tho: o r Feat
Marc M=MuatAd Groundwater Table and Bottom of Leaching FscWty
PriYVA War Supply Well and Lmelb $Facility (If any waUs exist Feet
on site of within 200 fe4t of laachiM facility)
I Edge of Wetland and L.CACWag Facility(U any wetlands exist Sect
4 within 300 feet of leaching facility) Z Oo d
Furnished by
o �
t
s F
COMMONWEALTH OF MMI SACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPART cNT OF ENVIS[INMENTAL PROTECTION
ONE WINTER STREET, BOSTON IdA 02106 (617) 292.6500
TRUDY GORE
Iiscm"
ARG20 PAUL C£LLUCCI DA''J.ID B..STRUHS
Ooretteor :SUBSURFACE SEWAGE DIBPOSAI SXSTEIIII INSPECTION FORM Commissioner
PART A
CM 119WAT(ON
4 Addrerse; Na�rra of Owisar G ft /?:t M
Z
r S of Osrna►: Vav,e
DNa s! tX� A,l'S tb b , S� CaSs
Mawrs d rtss�ae-1e � Ll
!sae•DE! edPs rt► a/psasos tip Seatlon 10.340*11111s 9(310 CMR I S.000)
fegl NnIM:
Bls/irt Aiwa: d.-A6c r
TdsPMM*AIO : ollS Cf7g
I aWWV that I have personally lydpectsd Nee sewage disposal system at this address and that the information reported below i:r true,acem-orto
OW complete as of the time of inspeotton. The Inspection was performed based on my training and experience In the proper hirx ti an and
rtaimenonco of on-aft sewage disposal-:systems. The system:
Pearce
Conditionally Pa+aae
,+ Needs FuWw Ev4gustion By the local Approving Authmlty
Fab Der � W
Insprsslsr's llptrlur.:
The System Inspector*hall submit a cowl of this Inspection report to the Approving Authority (Board of Health or DEPlwithin+this %- (301 days of
coftwArting this Inspection. If the systenn Is a shared system or has s design flow of 10.000 gpd or greater.the impactor and tie 4ysttnn neMaar
shall stubmit the report to the spp►oprisu.regional office of tM Department of Environmental Ptotection. The original should be seal:to the
system owner and copies&art to the bul4K,if applicable,end the OPProvine authority.
NOTEit AND COMMENTS -
�'*7 PtAvr j
AR
� 1 l 200oop 0
k%&Drr .
revised 9/2/98 lsgriofu
0 PftkW en Rtcydnd Paver
lUf UIWACE SEwAAE DOURO$"SYSTW flIOPECTION FO11M
PART A
f f f17111 `.ATION fonMarssidl
PtaMrty Adlioes: ,,?Ei w eoTf4va•i,,-{
lease a� l4rAeC �
ff T9on ftYiI�ART: fo A. Z C, dr D
A. IIISM PA7 ;
=4- i have not found any information which htdicsas that any of ilea faiWs conditions described in 310 CMR 16..303 aid.et, Any fsAure
— a Ito net evaluated we htdiceted below.
CONKS i ffi: _ ----
IL IMSM CO Mo"KNAur PAft S:
one or more system components as described in the "Conditional Pasta,' action noel to be replaced or repaired. The ii1vtom, L.pan
completion of the rsplecemem,,M repair,an approved by the board saieh,w)d pass_
indiaste yes,no, or not determined IV, W,or ND). Describe basis of ornlnation in all Instances. if"not determined", exalslln why net.
The septic tank is metal,unless the owner or rotor has provided the system inspector with a copy of s!(.1utiflcete of
Compliance lattechad)indicaft that the was installed within twenty(20)bears prior to the date of ft i+mtpeclon:ce
the septic tank,whether m not metal,i rocked,structurally unsound,shows wbatarstial lnflltration or oa�t4htnt+)on, a turdC
faNure b imminent. The system will ea Inspection if the existing septic tank Is replaced with a compN)nI<sap tic bank all
approved by the Owed of Health.
sewsoe backup or break t or high static rester level observed in the distribution box is due to broken or olDxtructral i>rpe(s)
m due to a broken,ni ed or uneven distribution box. The system wol pass Inspection if(with approval cA the board of
ltaalth).
token pipets)we rspleced
alistmelon Is removed
dlttribuden box Is levelled or replaced
_ The syets roouirod ioumpins mere then four times a year d6w to broken or obstructed pipets). The system will pass
If(wish approval of the Board of Hooth):
Woken pipe(s)am replaced
obstruction is removed
revised 9/2/98 nee:era
SPACE SEWAGE DISPOSAL SYST7AA NMSPECTIDN FORMi
PART A
C0 91WATIM Iowwameda
PiaparayAdAwa: Imax (J(A
OtrrMc 0/tc3/`q 0-
OVA 14 InupaeAatt:
C. FURTIMSI EVALUATiOIM 0 RAMPED BY THE BOARD OF HEALTH:
CwWhtidr w exist which require further evaluation by the Board of HeaM in order to d*ti,r,`n*M the system is felOnS to pmteclz iht
puWk heltd,selsty and tie erMA/onment.
1i SYSTM WSi PASS tiM JM BOARD OF HEALTH DETU M NO N At CE WITH xi cMR 1S.m timbi THAT mE SysTE1111
IS NOT FUNCTIONSIO M A MIAAINM WHICH WILL PROTECT THE HEALTH AND SAFETY AND THE EIMY )MMI'NT:
_ Ceespoal or privy IS aftMn 60 feet of surface water
Caespooi privy is eidslre 60 tort of bbordar" sted rwedland or a soft marsh.
29 SYSIM WILL FA`W-US 114E RD OF HEALTH IAND PUKIC WATER SUPPL�A,F ANY)DETIiIfiSAM THJIX 7111E SYSTEMI IS
PUNt:T1ONSMO W A B{AIiiMER 1 PROTECTS THE PUSUC NSALTH AND SAFETY AND TILE®IViRONMIEMT:
The System hex is tic tank and a*absorption system ISAISI and the SAS is within 100 foot of a surface low siter e�y;ay or
tributary to a of water supply.
The system ku septic tank and soM absorption system and the SAS is within a Zone I of a public water IMMA y wee.
The system a so0tk tank and ea absorption system and the SAS is within 60 fart of a pAvate water Suplily watt.
The system a septic flank and soil absorption system and the SAS Is lose then 100 feat but 60 test or m®du from is
prlvato we supply ivell,unless a well water analysis for coliform becte s and voleft organic compounds iirelicetls dM the
well is fr from peBatlan bom*at fecNity and dw presence of ammonia nitrogen and nitrift nitrogen is siIwil to of lass
Own 6 4tAetlral used to determine drstancs IapproaAtoalien net val6di.
,h OTHER
revised 9/2/98 Pw3of11
&USSURFACE SEWAt3E QIMOSAL SYST111111111/M PTCTHM FO M
MITT A
CERTM1CATkt11111(vord WoM
r�•.•ra A'` `: .2(o (.Jeep VXK1 Wear
0wttwr:
Dori sit bnpstNhK 3(f (CID
D. lfflr 3rlt PAL::
you"Not W410a slow "Yes"or"No" in each of the followMg:
I have dgW mined that one at ff at*of the following failure conditions oxist as described In 310 CMR 15.303. The basin for Wi;
dearmknotiom is idsofled below. The Board of Health should be contacted to determine what will be necessary to c orrar:t the?Velure.
Yee No
. Backup of sewage irt')facility ar system o a to an overloaded at slogged SAS or coespeal.
Diacherge or pondinil of affluent to the suM a of the ground or surface waters due to an overloaded or clogliudl SAS or
sesapool.
Stale liquid level in 1*o dFstributi box above outlet lnvwt due to an overloaded at dogged SAS or cesspool.
l.Iqukd depth in*ss lwal is a then S" below Invert or available volume is loss than 112 day flow.
Required pumping m than 4 times in the last yar JW due to dogged or obstructed pipofsl.
Number of times ped_
Any por0on o Sol Absorption System.cesspool or privy is below the high groundwater elevation.
Any of a oesepool o privy Is within 100 foot of a surface water supply or tributary to a surface wstw:H;ipply.
_ Any rdon of a a**spool or privy is within a Zone I of a public well.
.r y portion of a***:spool or privy is within 50 foot of a private wet&Supply wall.
_ Any portion of a cesspool or privy Is less-then 100 feet but grostor than 60 feet from a private water suppy wall with no
acceptable water qu+bIty analysis. If the well has bson.sNo2ed to be acceptable,attach copy of w*U*star srislytas f*r
ooUform bactetls,vaa�tkla o►gardc compounds, •nitrogen and mltrata nitrogen.
L l sZ1/sIM FAIV:
you elwst indli*ew alth&"Yes"or"No" to each of following:
The following critoria apply to 1;1rgs eye a in addition to the crltorie obove:
The System Serves a facility wNh design flow of 10,000 fiPd a greater lLarpa System?and the ryetam is a signffi�:arn 9ihraat 6a public
heath end oa%ty and th*envl ment because one or more of the follow".Conditions exist:
Vas No
tM* within 4tD0 foot of a euthca Orinkimg water eul3ply
the is within.WO foot of a tributary to a surface drinking water supply
system Is located in a nitrogen sensitive eta(Into"WeR oad Protection Ara IWPA)or a mapped Zone It of a pabIle
sat supply wa)
The owner or of any such system show upgrade tM system In occarden*e with 310 CMR 16.304(2). Ploau consuh:the t,ocd rsl!ionai
oMca of the Depart"ant for further Informstlon.
revised 9/2/98 per 4of11
11PI l 86/Z/6 jaaatna�
•auaeisA;3 N�sIO es
#c,eaummoupe u iadoid a41 uo uopouuo;W%Mm p*Woid eisM►(mmme wolf lueigtlp tl '*iusdnaoo hwl AUMo AI#P%VU r
tlgNtt>:Ot'9�1 _
(slclaa.dsa:uwm,01 aawtalp to uopewlsoidde'anal le al 0 wed of paieNa a(u1Na sinpt a4i to Am*tl)ppg 041 ul paW AU8400
wo'l is meld 'eldlu o,ios. •uoptw%Ul Ou(ialsp
:ue peseq peu(wialop Uasq s94 file e4l uo ws&"g uolldiosgr ila3 44l is uo(itaol pun 0=1s a41 '
•wnas to 44dsp '•"nis to 4tdep'pl^b!I to Wdop 'suolowewlp'mogsr4mbao to p oeuw ISM so
0104144 to w*1vpu0a joi powedsul so**m%OWN$No to iolaual a41 put'peuedo'pole^ooun ejam 0e104ntw Vm apdoe o41 7
s>!s sip uo pole**,useq eAa4'weisAS uopdiosgd llal @416ulpnlase 'c;iuouodwoe waisAs gv
. pvip*A to eulip sot 1pnaodsW eaM wile e41
,mop sissm plasnpul io Aieilws•uou SAIaasi iou swop wepAs 041
,dn-4."wq e6eMos to w6p iot peisadsul asa SKpMP s,A40%041
'WIN 4t1AR 01"116ne IOU eq A041 tl aloN •PsulUM9 PUG PaUpigo uag ane4 scald M"q sd —
•wpaadsal
ut41 p ivied am•o Apoeaei we;"*mg o1W peonpoitul uwicl iou ewe4 mom to sewrgoA aml •Peusd Mm 6uww aasss
a.ay PUMIu&44e34u.Ueaq 694 welsAa SW put 91106M oMi 90001 t9 aot Pedwnd Uesq sue4 sluouodwoo w4s"S acp to sue"
'446014 to prioq io'iuedn000'ieuma eW Aq pWCMd 0e-10 Uoliawi%ul&AldUmd
ON A
:6ulmOM 00 to 4aee 01 IN ON,.ao ..10A.as{N1a aieaSW linty"A;eueP Ueag aAe4*UMOltat e4i t1 A3040
10080
�lipvl
WYOd MOLt.03dltM MIlLVAB WlMdNG lbrMll 30M 1111811E
BIASURFACE SEWAGE DISMAL SYSTW WSPECZ10111 FORM
PART C
SVSTW irF01MIlATtt]M
w.,.a AAte�........ �6 Ct1{ .1 Cc ao-�
/ /`ZL
Flow CONDrnOIt
g.p.d.
Numb K of bodroomjlJ Nwmber of bedrooms tectusi):
Tom p IGIO flew 3 ,
NW ON of cumnt residents: t
0~iMNdlef IYes or rat: ,y�
Laundry se lsepera syadm) lye*or no):.Mb If yes, separate inspection required
Loundry eygem Ytapeoted t or nol
Seawna)use IV"a no):/_„;z
Wow meter readIrW.If 708111e Qest two ""usage I®pd):
Sump"Iyee or W,„
Laot do*of 000uttsnoy: jL !
Type of estabiit ww"
0004n pow; oad (Based con 15.2031
basis-Of design flow --
tireaes trap pasari:tyos or no)—
Indeisual waste No**Tank preoant:t or not
Non."nitsry.wom dis"Oed to ds S sysdm: Iyw or no)—
wade meter reeding,if er
Last data of 00VAW eY:
OTt :l0 "raw
�R _ ----- —
'.eet mrtte of nay:
OENEFNL MIFORMATfON
pt>rlM014 men p1 end oe of arntation: V 1(
$vstani pumped a Iu of insiNrstion: It"or no)
M yes,vom"pumped:
Reomm fo+pumping:
TYNOF STSTItM
Sptlo tanhld womiion boxfsoll ebsor0on system
_ 00e coespool
_ Overflow Coweal
Inspettim records,If
I/A To rmtom fYes W no)ete.Attach copy of up tohdate epees a on nand malndnsnce env)
t!A toctanofoEy
Tied Tonle COPY of 01EP Approvel
DOW
es.+led Instalted Of known)and source of 40M.1
A}*IIOXMATE AGE of aN compor►sn '} —.—.----�---
SewW adlro detected whom Wdvkj at the she.IYes Of no)&v
reirised 9/2/.9.8
hp 6 of 11
119JUUNFACE s1 WAGE DWO=AL SYGTEM WSPECTION FORM
PART c
SYSI i Rw4)1MMATWN ileendra"
oartrr: YL
Data at! Nt too
suanno NNE:
(beats on ales Plan)
a
Depth blew aads.-m—
Matemhl of coratruction:s cost iron j.40 PVC_other(***In)
Dieum*from private pasta"Ply WON w suction one � --
Olemsbr—+F—
Commeis:foonditlo:+of)onto,venting, svldence of Ieekogs,ae.l
tI�IC T
fiocats on she pUrtI
M
Depth behw geda:z
Mewrial of construction:,-concrete_mKaf_Fiberglass _,,,Polyethylww,_,otherlexplaln}
H tank is math,list age e Is age coniimwd by CertlHcots of Compliance (Yes/Noll
Dlrrrnnslone: 1V00 Ci C3
she dePIM_ d
Distsme hour sop of sludge to bottom all outlet tes or bofflo:42k
Scum oicknesa: -3 V N
Dissel from top of eoum to top of outJ et We or baffle:�� r
Dj$Wnoe from bctten+of scum to batten o:
'i of outlet"%or botr —llm
iew dirneee(ans wen dew.. :—a.PA',D o�dt
Conrnw ts:
(recomendeden for pumping,condijon of in1I i and outist We or banes,depth of 114ulW level In relation to outit invert. strmund it lowly,
"done*of leakooe.ate. tkLUI `TrA-A it Gila�5 g—o� y.C- tom,fA& 'L,��cE
Patme an site plan)
Depth bdm wade:
Ms 04d of aonstruotion:aonereN�rnetsl_Ffborgiass �Pol _atherfexpiain)
Scum 1Aiekneea:
Obtance hem top of swan to top of oudn toe or
Diatoms from bottom of seam to bottom t tee or bane:
Ooze of lest pwnping:
cowenents:
frseannmendaden for pwnping,ffi of inlet and cutlet toss w baffles, depth of Wd level in relation to outlet invert,atnuettunul Intogrh:y.
ovlderwo of leek"".ate.}
774
revised 9/2/98 PW7oflt
1118SS MACE SEWAGE DISPOSAL SYGTW NSPECTt M FOBM
PART C
SYSTEM RMKWMATM i m"dwmoo
w.Ptar
Owt�.: raw
Dow of b-0 do t: 31 i (00 �
TMT OR MOLOM TANK: (Tank must;glass
ped prior t or at time tit,inspection)
000ate an sm plan)
Depth below Sra":e
Mat4Mi of oortapuotion:—Concrete,,,,arntal °Polyethylene _.othar(explsin)
DImmoloons
C )I:—gallons
a- 'a flow:
Alsm present
Alarm level: in wooidnil order:Yes
Dab of previous
Confronts:
(oonItlort of ktlat ,condition of a1wrr and float switches. etc.)
on)11ir rm
pooste on sae plan)
.2"*of iM+ld low above outlet Invert:
Commonts:
(note If I" dAt►f is al,e,+dance of solids carry gw► evid} f lasksys iMo or of box, etc.)_. ^
�1 —,t �`�.L /.r,✓4�5. �S�So" T. Imo- oil rk_v A lr?A �G
Ply►Cf pl
Ilooab am on sib plan)
Pumpe In working order:(Yea or _
Alarms in waift order IYes a)—,-
Comm"":
(neat centime"of mbr,co"ijon of pumps end appurtenances,atc.)
revised 9/2/98 rs�reeru
SUSSLIRFACP:UWAAE DISPOSAL SYSUM INSPECTION FORM
PART C
6"TM 9943 MATM(surAter"I
Owm : l h r
o.e.of 31 r 160
sea Afaaw�aa arsTs�hAss� ,
Iloea%an sits plan,li poSONO;excovetb)n not"Iced,location may be approximated by nondntwelvo methods)
If net beat".eaplel F:
Typrt:
pfta,nwnber:
baah)rrg Chambers.number:,—..
lead�itb geflsrlsa.nwnbor.—.
is-O ing evonch",number,%nigh:
logo"f W,ewmber,dmemilons:
overflew asaspod.number:_,_
Anemative system:
Nome of Technology:
(note sondWon of oa,siggy/p�of hydroWle fallure,I of of pondn9, damp el, eor►d�lt)gyp+�of vegat I SKg r
xe-ne Ana a 0 -I At1" ad Z Z �..._ �.,..,.,.._._.
i
Cfi &POOLS:
(locals an alb glom)
"unbar end aerNlgtIon:�,.,.M�,
"'7epU4op of"saki to bow hwart:
spin of.sods lay«:
Oeptk of seam bye►:
OhrtsnOWN of session a
Motor"of conetwation:�,.�
btdcetian of groatv/water. -
Inflow(cesspool must be pu aspacl)on)
Ca+wtverrb:
mote sondhion of am, 0 hydroulio failuro,level of pending,eondidon of vess"don, eta.)
de-
PINT:
(heats on slla plan)
MatMtds of conetwetlon:�i Ohnensierw: •-
Cornpmen":
Into corWWW of sill, sIrW of hyd a hllwe.level of pen",eondtion of vegetation. etc.)
rep -:sed 9/2/98 f►agrlaru
iltJl6ft MACE MWAQE DISPOSAL lzYlnr IM WSPEC71>A/I FORM
PART C
S1/STfEJR SOCNINRA7fON losatbulam
Hwatq►Aga..: a 6 W e�.`�,u v�.wt U�Y
rc��
sITRET C9I OF UWAGE OIBPOW SYST1 ER:
kmkWo fts to at Most two par mmm"ratwa►ea Mnemarks of tro=hrrwrks
Moats&a woNs wWn 100'il.acato whwo pu48e wow supply comas Into housal
' v
1 f
}
r
revised 9/2/98 todIt
y
. SUBSURFACE SEWAGE DISPOSAL SYSTiMA SISM WON FORM
PART C
SYSTW SSIRORMATION to FAIWOM a
wep.rh►Ad*...: 614. W t6AW ,I v—( Wcjl
N RCS Raw moms
Sag Type—
TyOW d.ptlt to g►oundws►_.
USGS Dols w.bNto visited
Ob.wv don Walls ohsdced
oroundwater depth: SfiNbw_ _ Moderate —00"
SITE sum me"
Surhos wow
Check Coliw
Shdbw wags t
EsdMatod Depth to Ovoundw.ter-,Feet
Plows Waco"aN tM Methods used to de*'IWno High Groundwater Ebvsllon:
C*Wnod froM Design Pine on rsoa'd
Observed Sito(Abutting prsparty,coservation hole, basement sump eto.I
t),ptennined from local cOndt OM
t;oaokod with local Board of he"
r-c�•—
4:t c- od FEW Maps
i,hocksd pueM rOocrds
iDhoecked local oxosystors,WOUNero
Heed UM Dot.
00"ribe M W ycu aataMlshed the Hugh Cl-oundwater pevsdOn. (ff"be completed)I 1,r-,64 j -4
(�
t
t
revised 9/2/98 �tta<n
c, Get-At
`IO '.N "OF B�XANSTABLE
LO:CpvN °. ,,e . ,.. t� .�v�i1 . . SEWAGE # '
VILLAGE ASSESSOR'S MAP LOT -j -Q
i r
4.� �
INSTALLER'S NAME,6z PHONE' NO ,, . z
.
SEPTIC TANK CAPACITY G0-00 1.a
LEACHING FACILITY:(type) (size) 64C9
' I
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER PGL�
BUILDER OR OWNER (adVitQ,� G
DATE PERMIT ISSUED:
DATE. COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No ' ;`
1J i
� k
05,
�! -? 0
V
Fis......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration Air Disposal Works Cnnnitrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
ocation-Address or Lot No.
---.. ---------•---•-------------- .. ...__ .
Owner Address
...•.............................. ................................. .............------............................
Installer Address 4'5, �/
Type of Building /i Size Lot--------v------------------Sq. feet
V Dwelling—No. of Bedrooms.............L_f.".--.-_---_____ -__--Expansion Attic ( ) Garbage Grinder ( )
U
`4 Other—T e of Building ............................ No. of persons............................ Showers — Cafeteria
PaOther fixtures -------•-------------------------------------- ----------------------------------
W Design Flow............................................gallons per person per day. Total daily flow.___.._........_...___....................._gallons.
WSeptic Tank—Liquid'capacity.._....._...gallons Length---------------- Width................ Diameter--------------.- Depth................
x
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area........_.........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by--_---------------------- -------------------------•----------- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_____-___-___-_.._---_-.
fj Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
------------------------------------
•---••-•----.- -•---------------------•-----•----------------------------------------------
---------
O Description of Soil--------------------------------------------------- _
V .-------------------------------------------------------------------------------=---------------------•-•••----------......-----..........----------..-----------._............---------------------
------------------------------------------------•-----------------------=-------------------------------------------------------------- ------- --- ...-----
U Nature o epair or terations—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 Environm ntal Code—The undersigned further agrees not to place the
system in operation until a Certificate of Comp l e h e iss e y the board of health.
Signed ------ - -------- --- ------ ------- - -- ---------------------------------- -------------.............
..
Date
--
ApplicationApproved B ----- -------------------------------------------- ---------------- ---------------
Date
Application Disapproved for the following reasons: ------- -------- --------------------------------------------------------------------------------------------
-------------------- ------------------- ---------- .----=--------------------------------------------------------- ----- --------- ------.............
'................... ............. ...---Date
Permit No. ~ ---------------------- Issued - --o`----- .......
Date
I _
' � L/ _ 0
V
THE COMMONWEALTH OF MASSACHUSETTS
: BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration fear 11isposal 'Marks Tonstrnrtiun Permit{
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: / � l
..._... _- 7��. ................ . ....... - - ... -- . ...............
Lot No.
..- � ..�•/(�ati e -.... esil t ..... _ ..•.........or //LW� W
Ownir Address
._... .I............................................ ........... ---•--•-----...............................
v Installer Address
Type of Building l� Size Lot.....1f_5,__-J`Ekl---Sq. feet
Dwelling—No. of Bedrooms.............. .........................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures .....................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity-______-----gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.............._..... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_-___________-_____-__.
�r4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' •------
--------------------------
-----------------------
--------------------------------------------
----------------------
--------------------
---------
------
0 Description of Soil..............................................................................
x ---•---•----------------•------------•-----•-----------•---------------------•---------.....--•------------------•--•-------------------•--------................. ------------
------------
---
U Nature o pairs or Alt�erions�— ns wer 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 Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compli 11`2, h ebee tssgsj/by the board of health.
Signed/ ---....... ...... ...
f�� � Date
Application Approved BY _< G .. .�„�y ------ ------------------ ..................
Dale
Application Disapproved for the following reasons- ------------ -------------------------- -------------------------------.............................................................
................................................ ..............................--------------- ----------------------------------------------------------------------------------------
..--------
----------------------------------------
re
Permit No. .... /``~:. .. ...................... Issued ............��^-- ��---�'�------. �.
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f,TOWN OF BARNSTABLE ; -
C�ertifirak of Complinure
THIS IS TO CERT Y,, at the Individual Sewage Disposal System constructed ( ) or Repaired (
j.� ,
by �t � -------- -----
Installer
------ -----at --- . " . .� t.1 ...... . -- 19 ----
..:
has been installed in accordance with the provisiPermit
of TITLE 5 of The State Environmental Code as described in
I
application for Disposal Works Construction No. .... ..',��,.... �'"2 dated -- '.. .,`.-----�� Z?
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT Bf CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
}
DATE --------------1"— / Q .................. ......... ................... Inspector .......
...-- -------------- ------------............---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.. �...'.`''�7 FEE. .�.....
Disposal
Permit
Permission is hereby granted r .�.................... . ' .
to Construct ( ) or Repair ) an Individual Sewa a Dis osal System
Street
as shown,on the application for Disposal Works Constructs•n .'unit No��r."/Ieriated.....
---------------.--- •---- --.
or
.......
DATE.... F Boardf He th
FORM 365oa HOBBS 6 WARREN.INC..PUBLISHERS
TOWN OF BKRNSTABLE Y /�� ,.
LOCATION �U (�1� r/l SgWAGE # ✓ "
n
VILLAGE ASSESSOR'S MAP & LOT2�z�-�e
INSTALLER'S NAME & PHONE NO. /�o �r_� ,� y/dt f(-S-prij
SEPTIC TANK CAPACITY J00c)
J
LEACHING FACILITY:(type)—pp-t--- (size) 000
NO. OF BEDROOMS PRIVATE WELL BLIC WA
BUILDER OR OWNER
r
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 2 'a ,
VARIANCE GRANTED: Yes No
i
3 `
4
7-- J
A r 0
No.......-- ....
........
Fps...... ....... .......
THE COMMONWEALTH OF MASSACHUSETTS V/
BOARD OF HEALTH
------... -7-ow-1.................OF..... .....................................................
App irFation for Disposal al lark, Tnnitrnrtinn Pumit
r
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
v.�rr��.....1�r1�1. ,..Ohl.!:r-�'rr�F.-� ...P ........ ....................................................ec 7'
..........................................••--
Lo ion-Address or Lot No.
GPeC:16.4r.......-.....:: 0• P,Ca��`!�..�.�t' Le.m1r.co.iAL..---•---------•......................
O�w��n�er, Address
----•-•-------------•• •- ---• -----/.ri`WrVo A----------------•--•---•----------.-- ---•-•--•--
• Installer Address
Type of Building Size Lot....3,sto-d.......Sq. feet
Dwelling—No. of Bedrooms.__ bfrc,...........................Expansion Attic (4) Garbage Grinder
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ------------------------------------------------------•---••--•-••---•------•---------- r
W Design Flow.................................. ..gallons per person per day. Total daily flow---------•_•-_--------------. _ `...gallons.
WSeptic Tank—Liquid capacity./eao ..gallons Length y-.fin_. Width..`.-JCZ'Diameter................ Depth- ��...
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.._.........__.--._.sq. ft.
Seepage Pit No.__�ilZ�._.._... Diameter.__..Lc�.�.._... Depth below inlet_..... .�....... Total leaching area...Z��....sq. ft.
Z Other Distribution box (,K-) Dosing tank ( )
Percolation Test Results Performed ........................................ Date..?�t-Pck rPEV-...-
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to roun
Test Pit No. 1...... ------minutes per inch Depth of Test Pit___1 �=._____. Depth to ground water--- ----------.......
p-----•--•--•---------P---•--•...............................••-•-•-•----P--- g F24
R+' o v".
r
O Description of Soil------0. ;, j a y I .-tea` a�'� ► --•---•---------------------•--------------------------- �r � �
. • A66Y-Pv---•----p-----
UW --------------------------------•---•----------•--------------------••----•-•---•------•---------------•------------------------------•-----------.-•- ��S�N J ........
Nature of Repairs or Alterations—Answer when applicable.................................................... 16 No.-30216
--------•-----------------------•----------------------------------------------•--------............----••------•------------------------------•---•-••-------• ... ...----
Agreement: ilk
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste in c br"`d nce with
the provisions of TITLE 5 of the State Environmental Code—The under igned further agrees not to place the
system in operation until a Certificate of Comp, h iss by h board of�health.
Signe� �.. .. a........... ---/1-' ^--�/
Date
Application Approved By ----- --- ------ -- ------------- -0-------
Dare
Application Disapproved for the following reasons- ----- --- ........................................................
....................................... ---
Permit No. -- ... .... , �. ----------------------- Issued .......
Date.�. .....--Date -........ :_I.............................
................
J
No.--.ql.
Fizz
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
770W-rl------------......OF.....60 0!70S5 .4IG......................................................
Allp iration for Disposal Workii Tnnitriirtion Fermi#
Application is hereby made for a Permit to Construct (K) or Repair ( ) an Individual Sewage Disposal
System at:
!s zcr ll�r![G. ,fit. ¢.-rCjlvra". is J./� Lc. T ..
.. _... .--A... -------- -----
------ •-----........-•-•-----...------•-----..........................------
Lo ion-Address or Lot No.
.. ice,rbr'ic.- lcr-/�= f�?.O, cx.S 10 �cn lt_s1 ......................................
...----------................•---
Owner Address
W
Installer Address
Q Type of Building _ Size Lot._43,_5k-f-------Sq. feet
Dwelling—No. of Bedrooms... ...........................Expansion Attic (46) Garbage Grinder
`4 Other—Type of Building No. of persons............................ Showers — Cafeteria
04 ` Other fixtures ............................
W Design Flow...................................`-'_S_---gallons per person,...
day. Total daily flow.............................Z-A.0_..gallons.
WSeptic Tank—Liquid'capacityLQoa__gallons Lengthy.-6.... Width......../D... Diameter________________ Depth4``G."'...
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..--/- -------- Diameter-----GO__--___._. Depth below inlet......4.-....... Total leaching area..z�....sq. ft.
Z Other Distribution box (x-) Dosing tank ( )
aPercolation Test Results Performed by.S*04_._f J_i 14Pn........................................ �/--.--
,� Test Pit No. 1...._ ......minutes per inch Depth of Test Pit---/..S_(. .... Depth to ground water_--_"---..____.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wa erg-:=...._......._.._._.
•... • . --•-•-----•-•• ------------•--- -•----••---•----------------•••-•-.------------------.---•-
.....
O Description of Soil...... ��411, l o gic'i_.. .. vkL ?i�---------------•---------- ------.
"4 STEPHEN r
.---------------•-------•--------- 4��=l G�� ` ►�s�_..._rY19tcS)_tum.' G! t.--'-�`.. ......---........---------- . ---- .........................
U A YN
W ------------------------
•-------------------------------------------------------------------------------------------------------------------------------------- j .._.
U Nature of Repairs or Alterations—Answer when applicable.__--.................................................... ____
----------------------------•--•--------------------•---•--•-----------..._.....---•-------------------------------------------------•-•---•-•--•••--------••--•- .: .
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste inwith
the provisions of TITLE 5 of the State Environmental Code—The and rsigned further agrees not to place the
system in operation until a Certificate of Com ' ha issued b e board of health.
Sign .... ..... -- - -- .... ._-....... ..--- -.-.-...-...........---- --
Da e
ApplicationApproved By -------- ---- -- ------ - ......... --P....... . ---.. ...... .......................................... .................-----------------------
Dace
Application Disapproved for the following reasons: ..... ... .......... ................................................... ... ------------------------------
---------------------------------------------- ....
---------------------
Dare
Permit No. _ -30 - ----------------- Issued . .........f{ ....
Dale
THE COMMONWEALTH OF MASSACHUSETTS
BOARP O LTT
��Y..II..f.... OF - -E�.`-�L.:-
C�ertiftra#e of ku Onlytia cue
TH19 IS T FJ�T'IFY, That e 1,di' id 1 Sewage Disposal System constructed ( ) or Repaired ( )
by........... t/ ........ 4' k/ :: .......... ........... ...................... -rl
0 ------------------
at ...........k- r---a`?--......V11� I ue. .. W�/�he
.f�,`�-... ........ .�. ..........:...
has been installed in accordance with the provisions of TITLE t nvironmentaI b d in
the application for Disposal Works Construction Permit No. .-.--..../ ..... . ... dated --- ...THE ISSUANCE OF THIS ERTIFI ATE SHALL NOT B CONSTRUED U RAT THE
SYSTEM WILL FUNCTION SAT SFACTPRY
DATE......--. -- . --........................ �..- .�1......... Inspector ..........----------..... -- --
THE COMMONWEALTH OF MASSACHUSETTS
OARD F A TH
��.111 OF.... !-� .. . ... .. ........................ ..-
Lf
o
No...... ....... ..... FEE.__.....................
Difiv all g T V�*ifpermit
v ;---'�
Permission < hereby granted________ __ ___ ______ _____ `?._....._.._..__.._.._..._.
to Const V
) r�}tepai r vidua ,�TS
pp�a.�S-1 .em ,/In 0
t> Street
as shown on the application for Disposal Works Construction Permit NoJ"' _ ated.._.�... .1. __� .......
-------•-----------••-----_... j
y Board of Health
DATE..............f h..../_/-...................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
I
20 YIMYUM OR AS INDICATED ON PLAN NOTES,. ;
0 Y \
�1
1. WORKMANSHIP ANDMATERIALS' SHALL CO FORM: TO .E. .E.ALL NSH1 N D 0 ,Weathervane'
,. Pond
, TITLE 5 THE TOWN OF RULES AND
MASONRY.EXTENSION TO 12 ..�1CLL^3'Lz�c��.'1� ----- EL
_ r
OW GRADE p
t
BELOW f 4 ..a J
Fl WITH `BACK FILL O
REGULATIONS FOR THE _SUBSURFACE DISPOSAL OF SEWAGE
:TOP OF FOUNDATION.. ( t�`
8 IN. CLEAN - O
/O k
F
MASONRY EXTE NSION'TO f 2
, AND THE REQUIREMENTS OF HIS PLAN.Q T �a
BELOW GRADE 0 0 I
Locus
,o \
• 2. ALL...COVERS TO SANITARY:UNITS SHALL. BE BROUGHT TO o
FINISHED. . GRADE
�
o9 .5WTHIN 12OF
PIP 0
- 4 SCH. 40 PVC E
f
a1. � O
- IN V MASONRY I USED BRING COVERS T6 GRADE `
3 ALL MASON UNITS E
I IN. PITCH 1 t3 PER FT. Weathervane
SHALL BE MORTARED` IN PLACE.
wa
2 .LAYER DF Y -
4 1 m
fL 0 UlIE_,
fT _
1 S 1 Z
€ SANITARY SYSTEM AL B 'CAPABLE
f / 4 ALL COMPONENTS OF THE 5 TARY TEM SHALL E A E 1
TEE 6 t0" N WASHED STONE O -
Gi0 G _ _
r
�y A UNDER OR ,
,2
, OF WITHSTANDING H 10 .:LOADING UNLESS THEY RE DE
3' MIN. CS
2 0 a
F_ a GAL ON L
V
'[f
�' I N 0 LOADING
.7 WITHIN 1 Q FT. ;OF DRIVES OR PARKING G AREAS H 2 L D
2 MIN. _.
LEVEL LEACH I _ ,
4 0 ,
-.
T P► N 0 :' OF DRIVES OR
0
7.3
SHALL BE USED UNDER 'OR .WITHIN 1 FT a
�113 t J 4 t 2
t
MIN. 5 b / / :
Eu b
WASHED STONE
PARKING. tom '
m ert ,
"LIQUID O >_.
DISTRIBUTION
F` a ;
D .
LEVEL ,
f*: _ Pond
0 COMPLIANCE 1lVI DEED
...sox
' . 5. NO DETERMINATION HAS BEEN MADE AST COMPL CE WITH E
N R ZONING U�ATION OWNER/APPLICANT SHALL _
_RESTRICTIONS 0 ZON N REG S
9
N 'FROM THE' APPROPRIATE AUTHO
RITY.TY.
OBTAIN SUCH DETERMINATION F 0 R ,
LOCATION AP
:ao
M
l
GALLON SEP?iC :.TANK -
1.L0
/
AN VERTICAL CONTROL, SEE LEY LDREDGE
z 6. HORIZONTAL D. , , E
IASSESSORS MAP ''14-� 4S` `
L _ PARCEL
& WAGNER FIELD NOTEBOOK
W OW :.
rH w sEptic TAr+ic �EPiH ov ounFT TEE tjEl.o ft LINE
uano DEP
BOTTOMOF TEST HOLE , ,
4 FEET 14 INCHES
OR USGS PROBABLE HIGH WATER LEVEL
87r/
1 INCHES 'S FEET 9
t
6..FEET 24 INCHES
TATI
CURRENT ZONING INTERPRETATION: DESIGN CALCULATIONS
PROFILE
SEW
AGE DISPOSAL SYSTEM PR E
30 ,
MIN. FRONT SETBACK T r 0 FEE NUMBER of BEDROOMS
T SCALE
NO TO ` DISPOSAL UNIT r`
' MIN. SIDE SETBACK �. FEET
':GARBAGE S L /Ja
TOTAL ESTIMATED. FLOW
.: R SETBACK a'MIN REAR S T . FEET tD .....�
' �— X �_BR. � GAL. DAY „ >,
_ REQUIRED SEPTIC TANK CAPACITY GAL. ,
�— ,
l SEPTIC TANK
,0
GAL
ACTUAL SIZE, OF T :��
_u REQUIREMENTS
: _ LEACHING` AREA
_ .EST �3 �- ,
_ PERCOLATION -SOUL T 2 . .
goo
SIDEWALL<AREA
GPD. S F. BOTTOM AREA _ GPD S.F.
S
is
..:.DATE'. OF,`SOIL TE 7 —
W F 2' F GA AY
J
.SIDE ALL 2?T � 2 S x � GPD S L D ;
3 z
TEST BY ,�c
OT M �o ,
BOTTOM _ 7T 2 SF x (�GPD SF GAL" DAY ,
WITNESSED ES SED 8 Y .�,a�� c� , .
/ Tf 4
/
i
i ;
r
_ . PERCOLATION :RATE MIN. INCH
7 SF �Sa .`GAL' DAY
sg _
Lot 1
r
h.
'J.. �i.
t� _� CALCULATION,
_. a.�a BREAKOUT CA1..Ol.rL T
U � TEST P{T 2
TEST P1T 1
r
c
— ' —
ELEV. foo, ELEV.
v:
y
P
1
U
r � —
v
r
0.00 0 00
. C "
00_#1 1 p
r
7T
1 ,
lxq
+ f
_.1
1 s
LEGEND :
/
:...✓`�a
"1st
tJ 1
r t EXISTING SPOT ELEVATION 00 0`
X
/. EXISTING CONTOUR 0
+h No cJo r
� ELEVATION Q0.
FINAL SPOT 0 �
1
FINAL CONTOUR
100.42 1P
E:
,
/ SOIL TEST PIT LOCATION
r . $OTT M OF TEST HO BOTTOM OF TEST HOLE _
>~ W W TER W+ .., _- \ � W, V- B7, / OR; WATER ELEV. _TO N WA
101 ` 'OR WATER ELEV.
i
1 0
P C TANK :.
SE Tl
I
+
l DISTRIBUTION BOX ❑
I
r
,
1 PRIMARY ACHING PIT
P IMA LE O
V ADJUSTMENT:
T.
, . WATER LEVEL ADJUS ME
R
s u V T RESERVE .LEACHING PI ., .
99
1 i
r + ,
G WATER LEVEL
TEST DATE
,
100.86
100
f�
.. INDEX WELL
air
NDE
1 Cl1 _
/
100.33
f
.WATER LEVEL RANGE ZONE
le
6' 1 , I� r/S ✓ INITIAL ISSUE .Ss�tJ
,w : 1
Ac 8
Lot i
V FOR INDEX ' WELL 6 � DEPTH TO` WATER LEVEL I N0. DATE DESCRIPTION BY
w ►_L
-,! ti �
.. ft.f �.
43 561 s .
MONTH OF.
� FOR. 0 TH
DESIGN
SITE. FLAN AND SEPTIC
I ,
--------
WATER LEVEL ADJUSTMENT
10
_ 14 7 3
H WATER DEPTH 7o HIGH . ATE 0` 18 WEATHERVANE WAY
LOT
o IN
,
147 49 TS
z.. SSACHUSET
�ARNSTABLE MA
.w, s r
OF <,
...: .FOR
£
N£N ,
�T r� ,
LYN ..
AL ON
, GREEN BRIER CORPORATION
HEALTH �.� GREE B
147 12 , APPROVED. _ BOARD OF H .�
VVILS4N
?ra
• ..
_No.30216
1599 5
�r t 1 40 /
SCALE
JOB N0.
,
.LAN
DATE AGENT
SITE �' ,
f �
& WAGNER ASSOCIATES INC.
. / LEVY, ELDREDGE
1 I�rcw�es L m o �cl r m PLOW tam sol�e�r �
. .: PERMIT
STREET 02632
: 889 WEST MAIN STR T CENTERVIII.E MA
.:
REPROGRAPHICS SiJPPLY C
NEW ENGLAND � !,�
, ::. ..- .. .......-...�.,-..,m_..........,-..,..--.,....-,._._ - ..»....« n,....v. _....,�,.,. `'III