HomeMy WebLinkAbout0007 CROCKER ROAD - Health 7 CROCKER`,J"W.BARNSTABLE
i
P - b93
TROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive "-
South Dennis, MA 02660
COMMONWEALTH OF MASSACHUSETI'S
EXECUTIVE. OFFICE OF ENVIRONMENTAL AFFAIRS�0/
o DEPARTMENT OF ENVIRONMENTAL PROTI!CT10N �,7 <L?
<900®
TFFLF s .,
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMErN,
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
ProperIN Address: 7 Crocker Road
West Barnstable, NM
Owner's Name: Karen Aude
Owner's AddresN. 7 Crocker Road
West Barnstable,MA 02668 0
Date of Inspection: November 16, 2000 o
Name of Inspector: O
P Troy M. Williams
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
Telephone Number: South Dennis,MA 02660
(508) 385-1300
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. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system.
Passes
Conditionally- ('asses
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature:''S�t.,, ?��� Q Date: It/I b /oo
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. l his inspection does not address how the system will perform in the future under the saute or different
conditions of use.
Title 5 Inspection Form 6/15/2000 pace 1
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
7 Crocker Road
Property Address: West Barnstable,MA
Karen Aude
Owner: November 16, 2000
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that anv of the failure criteria described in 310 CN4R
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: /11A
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes, no or not determined(Y,N,ND)in the for the following statements. if"not determined"please
explain.
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. Svstem 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
indicatine that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box.is leveled or replaced
ND explain:
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
Page 3 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 7 Crocker Road
West Barnstable,MA
Owner: Karen Aude
Date of fnspection: November 16,2000
C. Further Evaluation is Required by the Board of Health: /v/.q
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.
L System Hill pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has.a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 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 froth 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.
3. Other:
3
Page 4 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
7 Crocker Road
Property Address: West Barnstable,MA
Karen Aude
Owner: November 16, 2000
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
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
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
,� Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
✓ 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.
_ ,v/,i/.a Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
1v19 Any portion of a cesspool or privy is within a Zone 1 of a public well.
/,./a Any portion of a cesspool or privy is within 50 feet of a private water supply well.
ti/� 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.]
N(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: /v/A
To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
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—1WPA)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 1 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: Crocker Road
West Barnstable,MA
Owner: Karen Aude
Date of Inspection: November 16,2000
Check if the following have been done. You trust indicate"yes"or"no"as to each of the following:
Yes No
_ ('.:;:-,ping information was provided by the owner. occupant, or Board of I Icalth
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?
vl Have large volumes of water been introduced to the system recently or as part of this inspection?
V _ 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:
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)]
5
Page 6 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7 Crocker Road
West Barnstable,MA
Owner: Karen Aude
Date of inspection: November 16,2000
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: I
Does residence have a garbage grinder(yes or no):^io
Is laundrN on a separate sewage system (yes or no):No [if yes separate inspection required)
Laundry system inspected(yes or no): mli
Seasonal use: (yes or no): No
Water meter readings,if available(last 2 years usage(gpd)):Pr;,,,4
Sump pump(yes or no): Alo
Last date of occupancy:
COMMERCIALANDUSTRIAL NIA
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design 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 in format ion: o y
Was system pumped as part of the inspection(yes or no): A,.
If yes, volume pumped: gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
vl 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):.
Approximate age of all components. date installed (if known)and source of information:
4 1 { p
�NYI IS 6V GI+..� -u HJM�n- �L !f /y$[) p�/3pA 4hcl� 1��,<...Mt]sif /'C!' Ih)16r�• /L �� /!0//�
�t✓ c.s- �al. �f.
Were sewage odors detected when arriving at the site(yes or no): nio
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 Crocker Road
West Barnstable,MA
Owner: Karen Aude
Date of Inspection: November 16,2000
BUILDING SEWER(locate on site plan)
Depth belo�s grade: $ "�
Materials of construction: _cast iron �40 PVC_other(explain):
Dktanci from private water supply well or suction line: /00'4-
Comments(on condition of -fro joints`,venting,evidence of leakage,etc.):
F/-s1 .,( /i s a.,.� iY. 1
SEPTIC TANK:Zoocate on site plan)
Depth below grade: 1
Material of construction: v1 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: s"xy , t�6 /oyU 2,014�
Sludge depth: 91,
Distance from top of sludge to bottom of outlet tee or baffle: .2 '6
Scum thickness: y''
Distance from top of scum to top of outlet tee or baffle: "
Distance from bottom of scum to bottom of outlet tee or baffle: /o "
How were dimensions determined: p-1,4 . _
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
CE.l.�r<,f c- Tc� /"C1! O✓'�'I<.+ 0..h✓� /�t/C.
- - ._ --.. .,..._.�'S:.'_`----T�� /"-�!_` l.c.f w t/< Tt+v.-r.l�=n _woo�{ti '•.��
r/ /mow 1•a.c�.S-�- �,..» A. 6 u r/<. .t N c�i O c,.✓ �7 c-%/y
dcot.
GREASE TRAP:!L41ocate 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
'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.. 7 Crocker Road
West Barnstable,MA
Owner: Karen Aude
Date of Inspection: November 16, 2000
TIGHT or HOLDING TANK: 'A (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 Flo% : 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: ✓ (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 solids carryover; any evidence of
leakage into or out of box,etc.):
. -- D"-1�0,1 i,.1�+5 -f+.�•.� ". r wcv� ✓ S Uv-c�1t✓
PUMP CHAMBER:A019 (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.):
8
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 7 Crocker Road
West Barnstable,MA
Owner: Karen Aude
Date of Inspection: November 16, 2000
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number: r�
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
/Vo tv. �l.vct �i.. (r it /�✓ SI r
CESSPOOLS: a�(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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: N14 (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 I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
7 Crocker Road
Property Address: West Barnstable,MA
Karen Aude
Owner: November 16, 2000
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
13a.cK.
;�s
l/
-7S'
81' 92
2-500 901- �t
10
Tate I 1 of 1 I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7 Crocker Road
West Barnstable,MA
Owner: Karen Aude
Date of Inspection: November 16,2000
SITE EXAM ✓
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater Y5 ' 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:
,v/ 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: Sbw 2 � 2 ti v i3 `1� y' 3•
You must describe how you established the high ground water elevation:
I/JtII r� 'J h S. : ; h cr< %1, w jww+ r 30'
;t C.U
/�^ , 1.L �• 4 "1 �i 4/']✓ e< (ICJ-'r<✓ L �.t V fY'�4 1.�
/ I
ll
Z 203.. 499 039
US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do t use for International Rail(See reverse
n o
40 N r
r
Post ce, ode
Postage $
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
Retunn Receipt Showing to
Whom&Date Delivered
n Return Receipt Showing to Whom,
Q Date,&Addressee's Address
0 TOTAL Postage&Fees $
C") Postmark or Date
€
u-
rn
Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1. If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service
I window or hand it to your rural carrier(no extra charge).
j2. If you do not want this receipt postmarked,stick the gummed stub to the right of the a�i
cc
f return address of the article,date,detach,and retain the receipt,and mail the article.
LO
3. If you want a return receipt,write the certified mail number and your name and address
on a return receipt card,Form 3811,and attach it to the front of the article by means of the
gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article Q
I
RETURN RECEIPT REQUESTED adjacent to the number. Q
4. If you want delivery restricted to the addressee, or to an authorized agent of the C
addressee,endorse RESTRICTED DELIVERY on the front of the article. M
5. Enter fees for the services requested in the appropriate spaces on the front of this E
I receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. 6
ILL
` 6. Save this receipt and present it if you make an inquiry. 102595-97-e-0145 d
�oFtHElp�� Town of Barnstable
o�
Department of Health, Safety, and Environmental Services
BARNSPABM
9� ' 10� Public Health Division
P.O. Box 534, Hyannis MA 02601
Office: 508-8624644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
November 23, 1998
Mr. James Olson
1524 24th Avenue East
Seattle, Washington,MA 98112
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 7 Crocker Road, West Barnstable was inspected on
October 27, 1998 by Troy Williams, a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of
1995 TITLE 5 (310 CMR 15.00) due to the following:
• Liquid depth in leaching pit was less than one-half day flow.
You are ordered to bring the septic system into compliance within two (2) years of receipt of
this order letter. Therefore, the septic system shall be repaired or replaced on or before October
27,2000
First, you must hire a licensed Town of Barnstable septic system installer to submit a sketch
diagram of a proposed system to the Town of Barnstable Health Division Office(Town Hall, 367
Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00,
The State Environmental Code, Title 5.
In the meantime, you shall ensure that no raw sewage backs-up into the dwelling or discharges
onto the surface of the ground or into surface waters. You must maintain the system by hiring a
licensed septage hauler to pump the septic system whenever it is necessary.
Any person aggrieved by any order issued by the local approval authority may appeal to any
court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOA OF HEALTH
Thomas A. c Cean,R.S., C.H.O.
Agent of the Board of Health
q\health\dbfiles\titles i.doc
Olson/wp/q/Is
SINE Town of Barnstable
BARNSTABM : Department of Health, Safety, and Environmental Services
11639. ,m� Public Health Division
367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO:
( �2 tf y ` ► Cn.�e ( S�- DATE: )O
98�i-z
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5. -- �
The septic system owned by you located at / Cy-b 46r- �n-, to S�
was inspected on C>I- ---2 7 1 cr-,& , by Wiz, a Massachusetts ✓S'crtsi"2
licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• 1—i v i k--- ,-n L'4 S lS�-
You are ordered to bring the septic system into compliance within two (2) years of the
date of discovery. Therefore, the construction of replacement septic system component(s)
must be completed on or before Oc - --.2-r7 , Zan
First, you must hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of proposed replacement septic system component(s) to the Town of
Barnstable Public Health Division Office (Town Hall, 367 Main Street, Hyannis) that will
bring the septic system into compliance with 310 CMR 15.00, The State Environmental
Code, Title 5.
In the meantime, you shall ensure that no raw sewage discharges onto the surface of the
ground or into any surface waters. You must maintain the system by hiring a licensed
septage hauler to pump the septic system whenever it is necessary.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
q\hWth�la\ideSi.da
TOWN OF BARNSTABLE
LOCATION G'"u`'kR� I��JI SEWAGE # kszg•
pc.✓v.
VILLAGE � '� � � . ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �� c
LEACHING FACILITY: (type) (size) " C
NO.OF BEDROOMS
BUILDER OR OWNER S U
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet.
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
a6-u ,
f
L A-
p � y 3 G
TROY WILLIAMS
� - 3z
%*, A
SEPTIC INSPECTIONS 9
Certified by MA Department of Environmental Protection / / (508 385-1300
19 Hummel Drive 00T t
South Dennis, MA 02660 3
-\ COMMONWEALTH OF MASSACHUSETTS 1998
via 0 EXECUTIVE OFFICE OF ENVIRONMENTAL RS�X D
DEPARTMENT OF ENVIRONMENTAL PRO 7u
ONE WINTER STREET. BOSTON, MA 02108 617.292-5500
WILLIAM F.WELD GovernorTRUDY COaE
Secrctary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr
PART A
CERTIFICATION
Property'Address: C fZW 3ter � 5 f �-
Address of Owner:
Date of Inspection: 10 117 / f (If different) J
Name of Inspector: Troy Wi l I i ams / S.2y ;���1, /�✓z �y
1 am a DEP approved s tem inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Troy .Williams Septic Inspections Se.. H1
Mailing Address:
rnnis , MA 02660
Telephone Number: _ C 50.8T3 8 5-13A 0
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
:;(Fails
�r
Inspector's Signaturtr" Date: /C
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, 8, C, or D:
A] SYSTEM PASSES: N 44
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
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.
Indicate yes, no, or not determined (Y, N,or ND). Describe basis of determination in all instances. If'not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
Irw1��d 0�/]f/f7) Paq. 1 of 10
- f�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
E TIFICATION (continued)
7 Crocker Road,West Barnstable,
Property Address: James Olson
Owner: October 27, 1998
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued) ^(/i9
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
Pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: AIIA
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy.is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank,and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 7 Crocker Road,West Barnstable,MA
Owner: James Olson
Date of Inspection: October 27, 1998
D) SYSTEM FAILS:
YouVst indicate elr.er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health h s ould be contacted to determine what will be necessary to correct
the failure.
Yes No, S.yM s {��..� !�►w hM:s 1-
,L/ Backup of sewage into facility or system component due to an 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.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
V _ liquid depth in Gsw4wsl is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
N12 Any portion of a cesspool or privy is within a Zone I of a public well.
A/19 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
N/I Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS: N/9
You must indicate either "Yes" or"No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
7 Crocker Road, West Barnstable,MA
Property Address: James Olson
Owner: October 27, 1998
Date of Inspection.
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Ye; No
Pumping information was provided by the owner, occupant, or Board of Health. r
None of the system components have been pumped for at least two weeks and the system has been receiving normal .
flow rates during that period. Large volumes of water.have not been introduced into the system recent)as part of this inspection. y or
As built plans have been obtained and examined. Note if they are not available with N/A.
Y/ _ The faciliy or dwelling was inspected for signs of sewage back-up.
_ ._ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
v _ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material-of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
_ Existing information. Ex. Plan at B.O.H.
.tL _ Determined in the field (i(any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.302(3)(b)]
(r• iud 04/25/97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7 Crocker Road, West Barnstable,MA
Owner: James Olson
Date of Inspection: October 27, 1998
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g•p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents: O
Garbage grinder (yes or no):�1!V
Laundry connected to system (yes or no):
Seasonal use (yes or no): ^/O
Water meter readings, if available (last two (2) year usage (gpd): f✓;✓ct 4- GJ. 1/ .
Sump Pump (yes or no): IV(,N
Last date of occupancy: Vt�4u� ¢ �;p�rok �•+,o.• f/�
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title S system: (yes or no)_
Water meter readings, if available:.
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and iN source of information: �f y _.cA S v IS Ct 4 c J I— -—.A 4. L,J .+, ..,J .-•L✓
System pumped as p n of inspection (yes or no)LV d
If yes, volume pumped: gallons
Reason for pumping:
TYPE QF 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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of+all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no) No
e4 21 .1;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7 Crocker Road, West Barnstable,MA
Owner: James Olson
Date of Inspection: October 27, 1998
BUILDING SEWER: A//I
(Locate on site plan)
Depth below grade:
Material of construction: —cast iron_ 40 PVC _other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:
(locate on site plan)
i
Depth below grade:
Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance —(Yes/No)
Dimensions:_ S r
Sludge depth: 'y
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 1-/
Distance from bottom of Scum to bottom of outlet tee or baffle: /'A ''
How dimensions were determined: —Pelt'
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) L Pv` T« _ /c/N
t v 1. .� �,at h/ k a n d .� c✓
7e6 k
W le
GREASE TRAP: N11
(locate on site plan)
Depth below grade:
Material of construction: _,concrete _metal _Fiberglass _Polyethylene —other(explain) .
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of Scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(r-i-d 04/25/97) - _ _
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
7 Crocker Road,West Barnstable,MA
Property Address:Owner: James Olson Date of Inspection: October 27, 1998
TIGHT OR HOLDING TANK: NA (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working order_Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: Y
(locate on site plan) /
Depth of liquid level above outlet invert: 1 <y y
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)
c ✓ - ✓ r/ x w . t k .a
�1 r ��' IG .ia.. t .� —F C✓ at t .. � t � �� c h✓r
i
PUMP CHAMBER:--LV//;
(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.)
(r•vl ud 0�/15 io�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7 Crocker Road,West Barnstable,MA
Owner: James Olson
Date of Inspection:October 27, 1998
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number•..` G "X G ' L
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number: '
Alternative system:
Name of Technology:
Comments:
(note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
w1f da s
t c:1 L✓Gt
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: - 119
(locate on site plan)
Materials of construction:
Depth of solids: Dimensions:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
1-1—d 04/25/97) 'y
F.9. E of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7 Crocker Road,West Barnstable,MA
Owner: James Olson
Date of Inspection: October 27, 1998
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
6
2q'
1.'�
s to 0Z.
15.2'
D.'(3"x
N: 2;
(revised 04/2S/97)
Pays 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 7 Crocker Road,West Barnstable,MA
Owner: James Olson
Date of Inspection: October 27, 1998
Depth to Groundwater Feet adjusted high groundwater lcvcl
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Y Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
Wtf� 0.J� J f rC tt ✓tCA
r a✓ r A 3—f�c L, v l c. L!-. , H ► s '�' j" c.M'e't. r s
P.q. 10 of 10
ai SENDER: I also wish to receive the
(� ■Complete items 1 and/or 2 for additional services.
'gin eComplete items 3,4a,and 4b. following services(for an
In Print your name and address on the reverse of this form so that we can return this extra fee):
card to you.
> •Attach this form to the front of the mailpiece,or on the back if space does not' 1. ❑ Addressee's Address
permit.
m ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery W
C ■The Return Receipt will show to whom the article was delivered and the date
delivered. Consult postmaster for fee.
a 3.Article Addressed to: 4a.Article Number
z `
4b.Serviceayp
to �� ? 0 Registe"rer 18 Certified CC
4t&
❑ Express ❑ Insured
LU On
❑ Retu ise ❑ COD
7.Dat
z
M 5.Received By:(Print Name) 8.Add GIs',A s if requested
and aid t
`6.Sill
U
Ps F receipt
-- — +
UNITED STATES POSTAL SERVIC S L E �- _ First-Class
�� ✓9 o take&.Feas.eaid
PM
1=
® Print yours ame�'a
s, and ZIP ode irrthis bow®i9
Public Health DIVisi®11
town of Barnstable
P 0. Box 534
Hyannis,Massachusetts 02601
I
1,1111 Ili 11,1,1,11111111sMid IllleiIII
TOWN OF BARNSTABLE
,
LOCATION 7� ✓ 1'� . Rd SEWAGE # 71
VILLAGE L412. ��' ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Z00 0
LEACHING FACILITY: (type) � G7(� (�1 (size) ' .� ?.
NO.OF BEDROOMS 3
BUILDER OR OWNER C{
PERMTTDATE: .&—
—-----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
Furnished by
r ,
�vELi,
J
r
1
G
9 - V3
No. ` Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Migozar 6petem Construction Permit
Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. �` ' (�-1�,^-`�,S`j, Owner's Name,Address and Tel.^No.
Assessor's Map/Parcel ` ✓ (J 1 �� im OL / 4 �
Installer's Name,Address,and Tel.No. P pwvv � c� TL— Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow ?c gallons per day. Calculated daily flow _ gallons.
Plan Date Number of sheets Revision Date
Title 4
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ,5Z;6 6gL&r1_1 Z61W ayly 5 S1�L
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and mai tenance of the afore described on-site sewage disposal system
in accordance with the provisions of Titl 5 of the EtYironme al Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b t is Bear of�Hr ealth
Signed Date It
Application Approved by Date 1`
Application Disapproved for the Mlowing reasons
Permit No. L3 Date Issued
No. �j Fee J
• THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
' Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
0(pprication for Dt!5poear 6potem Construction Permit
Application for a Permit to Construct( )Repair(il)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.7 CRx 5 Owner's Name,
Address and Tel.No.
Assessor's Map/Parcel c �� /(1 J1 M vL� 7 CAoc-`61-4—
Installer's Name,Address,and Tel.No. .8 R l p/f J(19 y(j'n Designer's Name,Address and Tel.No.
DLO TRH ToP 6if—
fiSUNIS l -s G�2.6s
Type of Building:
DwellingNo.of Bedrooms Lot Size s . ft. Garbage Grinder( )
9 g
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow � U gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Jl Nature of Repairs or Alterations(Answer when applicable) Q SOO 6)W01_1 L4Z,40 61iHAWXS T��
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Tits 5 of the Enwironme al Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by//this Board/of/Health.
Signed ��.1_!_/fitIA Date
Application Approved by �" t�__� Date
Application Disapproved for the Mlowin,g reasons
Permit No. 1:Y $ --7 Date Issued
--------------------------------------- - -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( )
Abandoned( )by
P y077�
at f ,/ _G i has been constructed in accordance
with the provisions of Title 5 and the fox Disposal System Construction Permit No. dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date / 1 '' f Inspector
�J
No. 1 U � / ----------------------------
I � Fee 15_cl�>
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS
lwigaaf bpotem Construction Permit
Permission is hereby granted to Construct( )Repair({f)Upgrade( )Abandon( )
System located at 7 ir.Aack(,Q. e I.� . �nQn/Cr/!�e (_
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: Approved by �1 ��
�{ J
7/98
NOTICE: This Form Is To Be Used For the Repair Of Failed j
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, �' , hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at :7 Cr--(ZI meets all of the
following criteria:
® e
• There are no wetlands located within 100 feet of the proposed soil absorption system.
• There are no private wells located within 150 feet of the proposed septic system.
0
• There is no increase in flow and/or change in use proposed.
• There are no variances requested or needed.
0
• If there are any wetlands located within 250 feet of the proposed soil absorption system,the •
observed groundwater table is 14 feet or greater below the bottom of the leaching facility.
• I understand that the attached Title V Calculation Chart may only be used for the design of a
septic system if the existing naturally occurring soil is classified as Class I(sand or loamy sand)
in the most hydraulically restrictive layer included within the five foot zone beneath the proposed
soil absorption system. If the soil conditions are not Class I within this above described zone,a
professional engineer or registered sanitarian is required.
SIGNED : DATE:
LICENSED SEPTIC SYSTE1 9TALLER IN THE TOWN OF BARNSTABLE NUMBER
Please complete the following:
A)Elevation at top of ground in the location of the proposed soil absorption system
B)Elevation of groundwater
[Attach a sketch plan of the proposed system. Also if the licensed installer possesses a certified
plot plan,this plan should be submitted].
q:health folder:Cert2
Ckrj- RD3
C)
I�
.k
o few G./�uox 7/+Jvf�
_ OLO LW Pzr
e
a � GIIu-OH
L6W4
4
i
9
No........... ._.. x - Fss..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
----------ToU..............oF.........O Z1U.S I
App iration for Iliapntia1 Vorkti Tontitrn.rtion Viumit
Application is hereby made for a Permit to ConstrucC,) 9}-nlZepair ( ) an Individual Sewage Disposal
System at
................-.. �:.................. ...
i�y�,� ,: tion-Add'ressC or Lot No.
....................... ........._...
Owner Address
................................
Installer I Address
d Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............. ......................:....Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
Pa Other fixtures ------------------------------- - -
W Design Flow............................................gallons per person per,day. Total daily flow-_______31a.......................gallons.
WSeptic Tank—Liquid capacity[6.QOkallons Length..... Width._._ ..... Diameter................ Depth................
x Disposal Trench—No.................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------->........ Diameter-----�j�7`'.._. Depth below inlet......R.......... Total leaching area.. `.'..K ...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------•--•--•----•----•----•................••-----. --------•--_... Date........................................
`la Test Pit No. 1.. .C' ....minutes per inch Depth of Test Pit.—AG_1____. Depth to ground water_.
(% Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
-------- ... - ------• ............................................ --....--- ---
.... I ...-ODescr>ption of Soil.........Q .. ---------------
e
----- •... --•----•-----------------------------------•------•--..
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------..................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------------•-----------....------=---------------------------......---- "
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of A ITL, 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 b the b d f health.
S- ned----- --- -•••.....--- -- ••-•-----------------------•---•----•----•••--- -�r�G-A7
�_--Date
Application Approved By....'; --..... .�!!111- �. 7%`••----
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
-------------------------------------•---•-----------------....------•----••-----•---------•----------------•••••---•---•--•-•••---•------•------•------••---•-----...----•-----------••-•--------.-----
// � Date
PermitNo......................................................... Issued--- '�.-�1.--_...... ....--.-.....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH I
......... OF......... JAI dI......................................
Appliration for Di-4pag al Works Tonstrnrtion Permit
Application is hereby made for a Permit to Construct ( ) 0 epair ( ) an Individual Sewage Disposal
System at:
................_._._......'..�.. % - - tom,` ........ 0.a _-.nn............. .............
Location-Address or Lot No.
Owner Address
a ......................... +rv. Installer !
.. ------------------------------------- ----------------------------------------------A
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............. _Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Q' Other fixtures ..................................
WDesign Flow............................................gallons per person per day. Total daily flow........ . ..................-........gallons.
WSeptic Tank—Liquid capacity./._�. <-gallons Length.....6..... Width._..f�._.._.. Diameter.....'° ..... Depth..—........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No------------;_....... Diameter..... __. Depth below inlet.......e........ Total leaching area.....2_�..Csq. ft.
z Other Distribution box ( ) Dosing tank ( )
'-, Percolation Test Results Performed by.......................................................................... Date................
.._..
Test Pit No. L.°. .. minutes per inch Depth of Test Pit------ Z Depth to ground water....
(a, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-_____-_-•__.__---_____
D Description of Soil.__... � � Ea ' rSt3 r � t r � � 1_.: .�_✓1..>��--•-.-•------
x 1 - R
WJ._..... ....................." ....__ _._.......................------' ----.-
----�-i� ..�mf >�---------------------------------------------------------
-------------------------------------------------------------------------------------------- ----------------------------------
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 TITI; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued.byte boa-0-of health.
�. �
S' ned ----- ! D to ..... _..
�
Application Approved By----. . -- .....�----•.....� ---------------------••-_..._ -----/p-'_ R '�'---
_ .... / Date
Application Disapproved for the following reasons------------------------------------------------------------------------- ......................---........ -
t
Date
PermitNo.......................................................... Issued-........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... 0�a,�; .................OF.,. .,�✓rr ' ............................................
Datifiratr of To$npliianrr .
T�O C TIF , That the Individual Sewage Disposal System constructed (!.)-or Repaired { )
f --•-
Installer ! ..l!",�7_.......
�j
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application-for Disposal Works Construction Permit No.....................................�_. dated_...-_rf_`_;:.F 77. ................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM W L FUNCTION SATISFACTORY.
DATE..... - - .------..---- Inspector.. ------------
THE COMMONWEALTH OF MASSACHUSETTS
077�1
BOARD- F HEALTH
j .... Z................oF..-... ....... :. ... . ..GG ...
...........................
No...................•..... FEE....... . --•-•-
io oo orko on tr ion Permit
Permission hereby granted.••-• ---- -
to Cons " ) or Repair Individu sedge D ..................elo�. ................................................
i Syst
Street
as shown on the application for Disposal Works Construction mi Dated..... ` ........
o y _ surd alth
/D-
DATE.............=--------------------. -----------•--------------•---•-------•---- �.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
L
ao
R, 44
A '
.g4ow.,
iE'X7'RA_PYPZ
40#4? 4r
A/7 y
23>0 . OF J. f,�, ,
C4 hrAM .5A N AP
aACA
"CAST L.Z" AYER
V 0,
PIPE
COW
'DIS7.
WASHED 570ME
SEPTIC 7A 4 ao)e
I I OEoom, -crlyz
Vb
PRECAST r SAFAMA346E"
lAlVjCAr 4rl.ZVA7'1ON.S 1 0 ' 0 .0 0 a 0 a 0 0 P17 OR ZVLIIV.
f7e- �F L/
sr*r.
INVZoRT AT M111-olva _L.L4 Ocr 6 P//4)6o7.
/14/LE7* SEPTIC r,4,VK 0 AO,')
r ;F7. Z7,1A C(.S4L-Z 7;WLII-A 7D
.04174,ET SzPrlc -rA)v)< l Z 4-Fr
lAoLFr DI 5 rR/As a vom aox i c)7.9 c7- GROUND 0107-Elr TABLE
5-r SECT/ON/O/V OF
OUrL,-7_DJ WALMOly BOX /07. F7
INLET /-.-A CH VG Icm'Y 7- 149_r.0 ,&r 01SPOSAL Se.5-r&M
84AL-ATION,
_7A
4LEACHlIV6 .40/77,
DESIGN .SCALE oimo1v_v,,oi.v A 2 ITT.Cql'r.=-,T 1A JS FT.
A141MOER OF 3 7-
CRA R45A 6,E PlSoOO5A 4 aw., 50/Z- /-0&
C371MA-r_-Z> .02-OW 7*0 7*A 4 3 3 0. S014,7EST 0/ S014 7L
A14IM8EAP OF ZZrA CqlVCw P/TS Jos-. .J/-Lo -71 9117 ,9
510,E44ACHIM6-j 4041FIR A717- 5q �WT.
Ir
o P
BOTTOM r_rOM LA-54 CHM;C, PER P1 7- 2_fr_SQ. Ar
4-01t A,6R COL AWO" RATE jo
7 44 4Z4CH1AlCr.,"eA_ _5-013 S o R--�7-,F AkZ:
3
7" L ati7- 3 M
Rci
BERT
'ce
P.
BUNIKIS
No'22162 0
`� x� � 90 �C'/5'TE 6\�� j'-` � •Et_G'V•i g/D ��"r �r V � �`•. `�$ ', _ 11�/.�� �: ',,.�.�r .L�r�a//1f°.S'?' -
All
L
a
• ', - � - •� �t +tom ':'
.,. .
�.Y.
`a, Vll z_ n
.i
3
.. t + `i r4 C `•. , t` , 'k 'i jr
rti
_ -
/ ► y , ;
i/ V MI Y l— S Y'-^ ( '�+iw •.S .rjf f. qA ryas.
r),{�
Yam/' d �•r jr �^}�.- 1} �+.f ` , �� f .�r�'c �•~ .. •.
is Fes,c�biz -v �ir�' -z=ems r.R it'd "
7/Z A"!N` S7`: 33 Al d,MA/A/,sue