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HomeMy WebLinkAbout0170 WOODSIDE ROAD UNIT #A - Health 170 Woodside Road _ - - 127-009. T®0 .CALar3� s MMS TOWN OF ARNST LE l LOCATION 0(G44 $SWAGE# VILLAGE (, ASSESSOR'S MAP&PARCEL lor7 009—GJ 0 SEPTIC TANK CAPACITYI— QDO LEACHING FACILTTY:.(type) e) :c NO.OF BEDROOMS l —46nol r r-wc41 OWNER &4 a: PERMIT DATE: COMPLIANCE.DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet op JYIG.Cn rl��� �� \ � 00, .000, DATE V/26/06 PROPERTY ADDRESS 170 Woodside Road West Barnstable /off -'�'�g Woo MA 02668 jq-00 On the above date, the septic system at the address above was Inspected. This system consists of the following: Apaatment Main Hou'3e 1., 1-1000 gaiiorz tank.i 1.: 1-6 ' 8 cez,s/Zo o i 2., 1-Diztbz.igut.ion Box., 2.1 1- 1000 gaiion ieach.ing pit., 3.1 1-1000 gaiion .eeach.ing pit Based on inspection, I certify the following conditions: Apaatment Oa.in Houze 4., 7h.iz .ins a 7.itie rive zept.ic zyztem (78Code) 3o 7hiz .ins a sewage zyztem., 5., Septic zyztem .iz .in paopea woak.ing oade2., 4o Oatea .in pit .i4 14" �2om flipe. yztem .iz .in paopea oak.ing oade.¢., SIGNATURE 1/ A-'�"� =_ Name: Robert A. Paolini Company: Joseph P. Macomber & Son Inc . Address: P. 0. Box 66 CJ �y Centerville. Mass 02632 ` Phone: 508-775-3338 or 508-775-6412 ` s CinupH P: ,MACOMBER & SON, INC. Tanks-Cesspools-Leachflelds Pumped & Installed h Town Sewer Connections Box 66 Centerville, MA 026.32-0066 775-3338 775-6412 i � T .F COMMONWEALTH OF MASSACHUSETTS JD- j EXECUTIVE OFFICE OF ENVIRONMEN'I'AL AFFAIRS .DEPARTMENT:OF ENVIRONMENTAL PROTECTION a TITLE 5 OFFICIAL INSPECTION FORM-,.NOT:FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART-A -- CERTIFICATION - Property Address: .. 170 Woodside Road West Barnstable MA 02668 Owner's Name: Sara Benson Owner's Address: Same Date of Inspection: ?�/0 h Name of Inspector:(please print)__�Rol � A Pao.l'ini Company Name: g. P_ 8a a o'm on Inc. Mailing Address: Cen eavc e, uzz, 02632 Telephone Number: 5 0 8-7 7 5-3 3 3 8 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.13:340 of Title 5(310 CMR 15:000). The system: XXX Passes Conditionally Passes Beds Further Evaluation by the Local Approving Authority ils Inspector's Signature: Date: .$r-Z,6j)k 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 shaved system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to-the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that '�. time.This inspection does not address how the system will perform in the future under the same or different conditions of use. i Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION:FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM r" PART A CERTIFI.CATION(continued) Property Address: 170 Woodside Road - West Barnstable MA 02668 Owner: Sara Benson Date of Inspection: Q,/2 6/0 6 Inspection Summary: Check A,B,C,D or.E/ALW..AYS-completetall of Section:D A. System Passes:l,ES NO I have not found any information which indicates that-any of the failure criteria describeTjn,310 CMR 15.303.or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: SeR.t.ic zurtemz ate .in p/topea w62k.ing oacdea a.t ;the /22e.3en.t time. B. System Conditionally Passes: NO One or more system components as described in the"Conditional Pass",:section need tote.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. NO 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:9as 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: NO 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: NO 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: 2 f - Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTI.FICATION continued Property Address: 170 Woodside Road West Barnstable MA 02668 Owner: Sara Benson Date of Inspection: %/2 6 f 0 6 C. Further Evaluation is Required by the Board of Health: No Conditions exist which.require•further evaluation by the Board.of Health:in order to determine ifthe 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: 0 o Cesspool or privy is within.50 feet of a surface water n-n 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: no 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. no The system has aseptic tank and SAS and the SAS is within a Zone I of a public water supply. no The system has aseptic tank and.SAS and the SAS is within 50 feet of a private water supply well. no The system has aseptic.tank and SAS and the SAS is less than 100 feet.but 50 feet or more front a private water supply well". Method used to determine distance vizug.y "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: r^ i 3 Page.4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 170 Woodside Road West Barnstable MA 02668 Owner: Sara Benson Date of Inspection: %/?6 f 0 6 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the.followingrfor 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:w.aters 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 NOT due to clogged or obstructed pipe(s).Number of times_pumped 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... _ 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.] NO (Yes/No)The system fails.I have determined that one or mom,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 1.0,000 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 70 Woodside Road West Barnstable MA 02668 Owner: Sara Benson Date of Inspection: ch/9 F/w; 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? 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. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 170 Woodside Road West Barnstable MA 02668 Owner: Sara Benson Date of Inspection: mob/2 6/0 6. FLOW CONDITIONS RESIDENTIAL Apa2.tmen.t Main Kouza Number of bedrooms(design): 3 Number of.bedrooms(actual): I #9 e d 3 #d e z i gn 3 DESIGN flow based on 310 CMR 15.203 (for example: 116 gpd x#of bedrooms)`. 3 3 0 Number of current residents: 2 Does residence have a garbage grinder(yes or no): qez in h o u.6 e Is laundry on a separate sewage.system(yes or no):n o [if yes separate inspection required] S �.13 Laundry system inspected(yes or no): no Seasonal use:(yes or no): a oo ff O J. Water meter readings,if available(last 2 years usage(gpd)): cS—�3 f/ 6 �%. g Sump pump(yes or no): n o had " ����� Last date of occupancy:�z a e e n t` J COMMERCIALdPODUSTRIAL NSA Type of estab4 ment: Design flow(based on 310 CMR 15.203): gpd Basis of desigp'flow(seats/persons/sgft,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: N/A Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system a R a 2 t me rz t _Single cesspool m a n . h o u z e Overflow cesspool main h o u z e _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): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): n o i 6 I Page 7 pf 11 OFFICIAL INSPECTION FORM—NOT FOR:VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 170 Woodside Road West Barnstable MA 02668 Owner: Sara. Benson Date of Inspection: 2 6 7 0 6 BUILDING SEWER(locate on site plan) Depth below grade: 3 6" a R t 2 4" main h o u z e Materials of construction:_cast iron _ff 40 PVC_other(explain): m a•.i n house o iz a a ge u a g Distance from private water supply well or suction line: 20 t Comments(on condition of joints,venting,evidence of leakage,etc.): ,�o into a�Reaa t iaht. No Zaakage.i Veale / f hnnii� hniiAo 7zent SEPTIC TANK: ,.(locate on site plan) 1000 ga i o n a a 12 a 2.t m e n.t Depth below grade: 24" Material of construction:_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: 8.' 6'X5 ' 8"X4' 10" Sludge depth:_t 2 a c e Distance from top of sludge to bottom of outlet tee or baffle: _n a r v Scum thickness: .tea ce Distance from top of scum to top of outlet tee or baffler tea ce Distance from bottom of scum to bottom of outlet tee or baffle:ice How were dimensions determined: m e a,3 u2 ed Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage, etc.): 10umn Innk n»vn,q 2 40nn.t_1 TnOof •R aul Pof loo6 ngo agars Tank iz �t2uctu2aPQy �ounrL. GREASE TRAP: N0(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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): k2eabe btaf? .ib a o t 2/Le6Rn#_ 7 Page 8 of I 1 .OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 170 Woodside Road --WesE BarnstabIe MA 02668 Owner: Sara Benson... Date of Inspection: 1/2 6/0 6 TIGHT or HOLDING TANK: NO (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_.polyethylene othei(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. Tight o2 hoid.ing tankz ate no /2aeZent. DISTRIBUTION BOX:�.s(if present must be opened)(locate on site plan) RRaa;men; 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.): 13nx a.A Poop-P hn.s 9 a.Po 2n.P i No zj2tid ca2avove2 oa ieakaue .in oa PUMP CHAMBER: NO (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.): Puma rhagge2 .iz not �2ehent I . I 8 ;J Page.9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _SYSTEM INFORMATION(continued) Property Address: 170 Woodside Road West Barnstable MA 02668 Owner: Sara Denson Date of Inspection: 512 6/0 6 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Located see page 90 - T pe leaching pits,number: 2 1- Apaatment 1-hla.in house leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,r_umber,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.): Loamy to medium -6and i No.s e.ignb o� &.ieuae oa /?ond.ing 6o.iez ate day., Ve etat.ion �e noamaio CESSPOOLS:y.eh (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: )eo2 ma.in._houze with oveal-eow eeach.ing 12it Depth-top of liquid to inlet invert: 0 Depth of solids layer: 0 Depth of scum layer: 0 Dimensions of cesspool: 6'X 811 Materials of construction: c o-n c c e t e . g i o c k'3 Indication of groundwater inflow(yes`or no):n o Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Loamy to medium .sand no .6.eng,3 o� �a-i&ae oa pond.ing .zo.iiz ate day vegetation .cis noama o PRIVY: N0 (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.): l a ivu is not Rae.ben - 9 I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS j SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C \. SYSTEM INFORMATION(continued) Property Address: 170 Wood8 de Road West Barnstable MA 02668 Owner: Sara Benson Date of Inspection: %12 h/0 6 SKETCH OF SEWAGE DISPOSAL SYSTEM Provi4ee a sketch of the sewage disposal system including ties to at least two permanent refer-eiice landmarks or benchmarks.Locate all wells within 100 feet. Locate where public water supply enters the building. main oe 10 �I Page 11 Af 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'Property Address: 170 Woodside Road West Barnstable MA 02668 Owner: Sara Benson Date of Inspection: $/2 6/0 6 SITE EXAM . Slope Surface water Check cellar Shallow wells Estimated depth to ground water ?y feet Please indicate(check)all methods used to determine the high ground water elevation: ,NO Obtained from system design plans on record-If checked,date of design plan reviewed: y e.3 Observed site(abutting property/observation hole within 150.feet of SAS) Checked with local Board of Health-explain:a A g u i- f 1 no Checked'with local excavators,installers-(attach documentation) ye,�Accessed.USGSdatabase-explainAt;�/?:tOwn.'9aanzi—a9E?e.,ma.,uz You must describe how you established the high ground water elevation: 11.6ed • Cape Cool Comm.i,3.ion ldate2 7aaie Con.tou2z And %ugiic ldate2 Supply Veii head 122otec.tzoa a/zeaz map., Sept 1995 ldatea 2ehouacez o�-.ice cage cod comm.iz.ion , Top of Grouml Leaching Pit 1 feet Groundwatepo Feetel B ow Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method ' f nerefore,the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is h feet. .� 11 ., .,. .,,..-.., .,.,,,*..�..�,..ToiN..'.,P, BAR.$TABLE. 130ARD QF URAITH " TOWN. OP y ,9UBSURPACR SVAUR nlSl'OSAtr AYSTRM INSPECTI•QN FORM - PART D.•r.CERTIFICATION ~��"V" among 9 no mow -TYPE OR PRINT CLEARLY- PItO.PERTY ZNSPZCTEJ7 STRECT ADDRESS 170 .Woodside Road West Barnstable. 02668 , hSS•ESSORS MAP BLOCK AND OWNSR's NAME Sara Be2ss�n PARr'.* D 0HJ?rIFI0AT30N ; Robert A 'Paoli , . NAME 'OF •INSPECTOR - - - -- COMPANY NAME J n "r-jar . A I ok .65:-Ce-,n r-vi]3 M14;: rs32-006� COMPANY ADDUSS ` To •or City. •st&44• tip • str• k; :. . COMPANY TEG$PHONE .t 508• Y�73 3338 FAX (' 508•1--190 f578 CZRTI•FICATION. STATEMENT I certify that I • eivo persotial-ly .i,ns•peotea .-the Qewage 'digpopal. system at this nddress and that• :tife" information reported .is true,. a.00Ura•te-, grid omplete as of the time .aif *�inspeoOony The in0pe¢tion was per-formed and any recommendations regarding •upgrade•, .ma•inte.nitnoe ,-. abd repair .a.te• con0stent with my trainilig and exP.erience in thq proper futToti,nn• and maintenance of on- site sewage 48POsai. systems, Check one: ' SysteM PAS D The inspection whic.h J. have .conducted has .,n•ot• round any information . which indicateg that the system• lals to adequately,, protest .public health or the envi,.ropment as defined in- .310 CMR. 15';30.3•, -Any foilure criteria U of :evalunted are as stated in the .FAI•Lura CRI•TMUA •s+eetion o•f this form. System FAIL•EU* The inspection which I have aon'ted 'has- found that the gystem fails to protec.� the public 11ej%ith Rnd tho enV.ronmen•t ' in acaoxdanoe with Title 61 310 CMR 15 . 3Q3 , and as • specifically noted -on -PART C FAILURE CRITERIA of this inspects, `:for ' �. .. nay$ Ins.pector Signature' )n6, copy of this oertI f i..oat•iat� trust •be rovi'ded 'to : the .QWNEIt•, tho BUYER where appi oab10• and h!t DPARD OP H8A TH, * If the inspection FAIL•Eb•, 'thb .owne"'.o�r "operator a:hall, . upgz"?ade'•the system. wV hin o'n.s-��'6ar-Qf the t Cia' •e of the inepeotion, unless. allowed Qr• regiti.•re�, d AthAr,at9e as urovided iri �3,IU CMR 15 , 306 ,. L - - Town of Barnstable r Health Inspector oF1HE t Office Hours Regulatory Services 8:30—9:30" Thomas F.Geiler,Director 1:00—2:00 9� BAINSrnst.e.,�� Public Health Division 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: Address: F Map V Parcel_a�L_ �5 a Name: Phone #: 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms? If yes, how many? 2c. How many bedrooms total are proposed 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 NO Iftce dwellmg LS connected toxpubtc sewer,tslagquesti©ns#4 through #9 beFow' _ l .. 4. Location of dwelling is INSIDE or OUTSIDE a Zone of Contribution t public Su ells? 5. Is the dwelling connected to an, ONSITE WELL or to PUBLIC WA-�- '' �o UJ Gn 00 s 6. Is a disposal works construction permit on file? o -YES-o or ENO 6a. If yes,how many bedrooms were approved according to this permit? �`$edrobms. Cl r 7. Were any building permits obtained for construction of additional bedrooms? YES171or NO .8. Is there an engineered septic system plan.on file at the Health Division? YES or NO Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO FOR OFFICE USE ONLY objection t � Th ublic Health Division has no obj o bedrooms at this property. ecial Conditions: Signed: Date: 2 Z O;/heal th/wpfil es/amnestyapp Yre. i � i i J r V � 1� Vi 1 /' WIN • "IS ep Aga IZ Building Sketch 3v • � �9a'E-tT/��9.CiilfE.v� 36 scc�✓�cE�cL FE 3c-� 1 /'TKST LL—riGL t3�2w'y Lr✓ •%G L-ratL1G c7�� 36 :G Spa sera F !•7 Si�r-.2.va�E a :3grEz,�✓7' .. tCL•i�.'L1-7 iS6•�•���.� 3G - Address: IN- M4 ". �l %t:., "k4 a .•?a`y� i:. yy;rr.stf �3a= i• ` 00 s �I. rt. -- «ji:f.:`�J.f.'•'•.�n�,y� �[ - � •2. a't .�. 3{�p'�c.• S{;� MY a. .s<.s ii v'^ _ s,ti,. .tea`.;, N :,I�" y:` •.• A t n- �, 3C�fir; �+,•`�atr} ,f'yitil'9• :. n�' :`�.A -a.,.. - zVl ? i ",! • '�':-�"- •:�',:�,.,.. yF- �.," fT r a . 1:t. , : ,rye - :-:yy.�, � a:.:'i:' n:,.:i?"'::. �..a6 r}�ir i::+' .dr., ':il'„ ..:�,. �. :,�1R �i.:i'.:•._' _ ,P:i alb,. i:a7bi V t�:/�'t''° y vi :'•'7 ? y. R -' !.�•, : F:ij:_, ` _ m r TO 'wa,.,o . , , 00 a t. .k '�: :r,.Try+'/Y.: �•4. ... .. _ - ��s - 's� _ ._. . - : �✓ CVO �e , n f4 °; Ibis cetlificaalidicafesacstptable.iiiinrnuiiU-bitabltxegoimmidntsperMa&t=huseU:StatdBuil�irig'.Gotle` an '{ooirn.of Baiiistablesoning inaricts in d CO a+l7t}le q. Ul OD 4 yI,_ j . n ,y s 's M1 ', 'it �•� . , , Vw 2 n ' M ti "a de'�toaf,-1'�Iatsto .�.I�Ils�'.'aiViA . .. L _ Uill#C Gl ..:_.. .: e , .. _ .. .- _ a Cam. edro" �n�#'toy.. °c�e� -��.�_. - 1 .::.4!.��y/('�A,'Rur 1 v.:....... , , .. .. ♦ r - -- r.�-[u r J v.. 4. �l {�:�WO' e0 W , ti •-u .,:•..r.tkp9r.<n::z.::Sx:•ny::'"7n am e� .. u 'v; � ; :_ .. .• ... �. .:.. : 'r ;:`is.} - - - • u ' � ti — P. 1 COMMUNICATION RESULT REPORT ( JUN.22.2005 2:50PM ) TTI BARNSTABLE BOARD OF HEALTH FILE MODE OPTION ADDRESS (GROUP) RESULT PAGE ---------------------------------------------------------------------------------------------------- 446 MEMORY TX ECNMC DEV OK P. 1/1 ---------------------------------------------------------------------------------------------------- REASON FOR ERROR E-1) HANG UP OR LINE FAIL E-2) BUSY E-3) NO ANSWER E-4) NO FACSIMILE CONNECTION Town of Barnstable Health.Inspector Office Hours Regulatory Services 8.30—9:30 - a • Thomas F',Geller,Director 1:00—2:00 ut 16TA tom, a XM Public Health Division Thomas XeKean,Director 200 K*Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMESTY ROG'R.AM APPLICANT—SEPTIC UEST10 1. General Information: Size-of Property:. Address: MapW ,Parcel �d Name: A phonek: 2a. How m my bedrooms exist at your property now? 2b, Are you planning to add any bedrooms? If yes,how many? 2c. How nmy bedrooms total are proposed 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. - ASSESSORS MAP NO: 1 Z 2 ~' PARCEL NO.: C-)o-I- No... 6.�. �'� _ - - FH$.......................... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH .................OF................................_......--------------------------..............---........ � Iix�a#ilau for Uiqvuii al 19orkii Tomitrurtivit rprutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systems at: .......... 4 ..�!.._ . ------------------- Location-Address or Lot No. k........................................ ..................... .. dd�.. .. ....- . .................. ._.... .. ►"� Installer . Address r Type of Building Size Lot-1 _�.P_.Sq. feet Dwelling pNo. 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 ( ) Percolation Test Results Performed by---------------------------------------- •----•-----•--------------------- Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ G Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ri - --------------------- Descriptionof Soil....: _...._,_C ---------------••------------------------------------ -----• --------•--------------------.....-- x W ---------------------------- - ------------------------ ----------------------------------------------------;-------------- ----- ........... UNature of Repairs or Alterations—Answer when applicable__._ •----------------------------------------------------------•------------------------•--•----......------•---...----:-------------------------------------------------------------------..._......-----. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iIHE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance hasrbeernued by the oa- of health. Signed. -'�� = /// . _A lication A roved B tPP PP y---------------------------------- .......--- JDate Application Disapproved for the following rea --------------------------•---------------------•-------------------------------------•------------....._ ....-•--------•--•---•----------------------------••-----------------.......---------------••-----.....--------------....-------•---------------...------------------------...-------------------------- Date PermitNo--------------------------------------------------------- Issued_--r::4 ------.!� ...................... Date Fxs............................. THE COMMONWEALTH OF MASSACHUSETTS " BOARD OF HEALTH ...................I...........O F.........................------.........----------.......-................................ ApplirFatinn for Disposal Iforks Tnnitrnrtinn Vrrmit . Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .../. .... Location-Address or Lot No. ...................... ­­w 4..................... ... �C� ....................•.......... n Address W ---••- ..... ..... �x ........................•...... •• � ... Installer Address Q Type of Building Size Lotd.®_ ..Sq. feet U Dwelling No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria ) a d 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 ( ) Percolation Test Results Performed by..........................................------------------------------- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ra --•---- ..................................•--------.....-----•--.....................---......................................................... 0 Description of Soil---- = •......................................................... ..................................................... M W --•-----------------------------------------------•--------------------------._....•-•-------------•---------•-------- --- . .......... Nature of Repairs or Alterations—Answer when applicable_-.✓ _ �_6G'� ----------------------------•---.....--------------•-----------••--•----•----------------•-------•• ---•---•----------•------------••---------------•-------------•----•-------------------•--......._. 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 a Certificate of Compliance has been i ued y the oa health. Signed --•- -- .. ...................................... ----------J--II-.�-------•----•-•-•-- ate ApplicationApproved By..................................... ----••. -- .......... ---•-------------•------••-- .................' ' b....g-C -•--- Date Application Disapproved for the following rea o ----------------------------------------------------------------------------------------------------------------- ....-•-----------•-•---•--•---------------------------------•--------.......-----........................---•--......-------------•-------------------------------------------------------------•----•-- Date Permit No......................................................... Issued.. :1„1.--- --�! -~ ..6---•-..... ...... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF...... ............................................................... (Irr#ifiratr of TnmpliFanrr THIS IS TO CERTIFY, That the Inc v'd 1 Se age Dis ,cl ystem�constructed ( ) or Repaired ( ) by......................................................................:{. .. .......... ---- � . �'.._...:..-----------................................................ InstjIl err at---•----- ... --0.--••--••........................ c-- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code�s de cribed in the application for Disposal Works Construction Permit No........�., :-_ .F"�..-------- da.ted___..____y Ili_ rl�.............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GBJARAN EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. --------------•----..-------- Inspector DATE...----•---... ,..�`z. ..-•-- P �----------------------------------------------------------------- vs7 FAA% A ;to THE COMMONWEALTH OF MASSACHUSETTS !SO~ ►m wx BOARD OF HEALTH wCkL..........................................OF........_...................._.................._.........._............_............ No..�.ld........d.� FEE.....:..--......----.... Disposal Vnrkja nst --v�1 rrnti# ranted--------------------- ., ---I �••- .... Permission is hereby g to Construct ( ) or Repair ( ) an Individual Sewage Disposal System �- atNo.................................1-=7p..........t_t,i J.St.s. IL........ i---------- .- -•---•----......--•-•- Street �� as shown on the application for Disposal Works Construction Permit No_____6 ________..._ __ Dated------------- ...._.. ---- .............................................. ------ B r of lh DATE-------- -----•-------------------------------•--- ...... FORM 1258 HOBB & V�ARREN. INC:, PUBLISHERS - 7 ASSESSOR`S MAP NO. � i — PARCEL LOCATION SEWAGE PERMIT NQ. VILLAGE c10y—�DG' I t-N.ST LLER S 'N E A ADDflES.S & s I APr R OR OWNER DATE PERMIT 1SSUEO � 1 � ISSUED DATE COMPLIANCE i i