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HomeMy WebLinkAbout0053 CURRYCOMB CIRCLE - Health 53 Currycomb Circle F/R A = 151 070 C l` 1 `1 I� i f TOWN OF BARNSTABLE CC- 6 LOCATION �J Ct)f►r4-CD/-4.6 c-Vr. SEWAGE # „ 002' a 7 Y VILLAGE lNe'I��°'"A� S . MAP & LOT IS I-o7a INSTALLER'S NAME&PHONE NO. ✓ SEPTIC TANK CAPACITY LEACHING FACILITY: (type) r` ��� /�-1✓(b� (size) NO. OF BEDROOMS BUILDER OR OWNER 1 vlr COtiJ PERMITDATE: o2 COMPLIANCE DATE: 0 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 e o I � h � � ) CvuoD J/n Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Currycomb Circle Property Address Anthony Gregory Owner Owners Name information is West Barnstable MA 02668 September 16 2008 required for p , every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. ImpoWhen filling A. General Information When filling out ,{ forms on the computer,use 1. Inspector: i only the tab key to move.1 David D. Coughanowr cursor-do not Name of Inspector use the return key. Eco-Tech Environmental Company Name r� 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State [ Zip Coree 508 364-0894 1328 Telephone Number License Number =`s B. Certification I certify that I have personally inspected the sewage disposal system at this addres and thati the information reported below is true, accurate and complete as of the time of the insp ction. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Locai Approving Authority September 16, 2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the futu under the same or different conditions of use. t5-3037.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 15 r Y Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is P required for west Barnstable MA 02668 September 16 2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E I always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound';not leaking and if a Certificate of Compliance indicating that the tank is less than 20,years old is available. ND Explain: ❑ 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 15-3037.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is west Barnstable MA 02668 September 16, 2008 required for P every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passies (cont.): ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. �. SystemDili pays Unless:Boaird of liea€th dleternz.i oes in accordan a Frith 310 CM 15.303('i)(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. t5-3037.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is required for west Barns P table MA 02668 September 16 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS Is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"'or"No"to each of the following for all 14soectioris: 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. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. t5-3037.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments LAM , 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is west Barnstable MA 02668 September 16, 2008 required for p every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) D) System Rdlure Criteria Applicable to All Systems (coat): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For.large systems you must indicate either"yes; or°no"to each of the following,,in addition to the questions in Section D: Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-3037.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is required for west Barns p table MA 02668 September 16, 2008 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined? (If they were not ® ❑ available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? Leach pit also inspected ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? _ ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] 15-3037.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 , Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is required for West Barns p table MA 02668 September 16, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® Nc Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 238 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 3 months ago Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow tbased:on.310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): t5-3037.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is required for west Barns p table MA 02668 September 16 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ------ ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) Innovative/Alternative technology. Attach..a copy of the current operation and Elmaintenance contract(to be obtained from system oinrner) ` ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Age: 22+years. Certificate of Compliance issued 112111986 (Board of Health permit#85-867) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-3037.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is west Barnstable MA 02668 September 16 2008 required for p , every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 4 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leakage or backup into dwelling was observed. Septic Tank(locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years leage ccnfiimed by,a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 5 in Distance from top of sludge to bottom of outlet tee or baffle 29 in Scum thickness 3 in Distance from top of scum to top of outlet tee or baffle 8 in Distance from bottom of scum to bottom of outlet tee or baffle 13 in How were dimensions determined? Previous inspection report t5-3037.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 53 Currycomb Circle Property Address , Anthony Gregory Owner Owner's Name information is p required for west Barnstable MA 02668 September 16, 2008 every page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank ar_r'tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top.of scum to top of outlet tee or baffle --- - Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5-3037.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 II 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is west Barnstable MA 02668 September 16, 2008 required for p every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimension's: Capacity gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required).. Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At 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-box appears structurally sound with no evidence of leakage in or out. Some solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-3037.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is West Barnstable MA 02668 September 16, 2008 required for p every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): fi Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: _ 4 ❑ 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.): Soils above leaching pit appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. Leaching pit was uncovered and found to be dry. No effluent contact staining was observed at cover interface or into riser, t5-3037.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is West Barnstable MA 02668 September 16 2008 required for A , every page. Cityrrown State Zip Code Date of Inspection D. System information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-3037.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is required for west Barns p table MA 02668 September 16, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. LOCATIONS A B 1 29 Ft- 21 ft 2 3B ft 16 ft 3 44 Ft 38 Ft EXISTING DWELLING # 53 I � ° w SEPTIC 0-Box Z TANK J LEACH PIT s � IW H G 3 CURRYCOMB CIRCLE NOT TO SCALE t5-3037.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 53 Currycomb Circle Property Address Anthony Gregory Owner Owner's Name information is West Barnstable MA 02668 September 16, 2008 required for p every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 50+feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/ob4ervation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed IJSGS database -explain:. p Barnstable GIS Department records '' '''` You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 50 feet above groundwater table. t5-3037.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection FgrssTABLE Not for Voluntary Assessments a` Subsurface Sewage Disposal System Form 20L15 JUN 17 V, g: 54 Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification vMISION Important: When filling out 1. Property Information: 'fr forms on the computer,use 53 Currycomb Circle only the tab key Property Address to move your Frank Anigbo cursor-do not Owner's Name use the return key. .53 Currycomb Circle owner's Address VQ West Barnstable MA 02668 City/Town State Zip Code rem Date of Inspection: D May 6,2005 2. Inspector: Michael Kellett Name of Inspector Aardvark Environmental Inspections Company Name P.O. Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation b the Lo Authority InspeCtors gignature Date The system iinspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "**"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 53 Currycomb Circle Property Address West Bamsable MA 02668 City/Town State Zip Code Frank Anigbo May 6,2005 Owner's Name 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 any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. 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 exfiftration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Y Subsurface Sewage Disposal System Form A. Certification (cont.) 53 Currycomb Circle Property Address West Barnstable MA 02668 City/Town State Zip Code Frank Anigbo May 6, 2005 Owner's Name Date of Inspection B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ 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: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 53 Currycomb Circle Property Address West Barnstable MA 02668 Cityrrown State Zip Code Frank Anigbo May 6,2005 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria 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: t5insp.doc•1112004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form re A. Certification (cost.) 53 Currycomb Circle Property Address West Barnstable MA 02668 City/Town State ZipCode Frank Anigbo May 6,2005 Owner's Name 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 Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. t5insp.doc 1112004 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5of16 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments g� Subsurface Sewage Disposal System Form M A. Certification (cont.) 53 Currycomb Circle Property Address West Barnstable MA 02668 Cityfrown State Zip Code Frank Anigbo May 6,2005 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area pnterim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ,e Subsurface Sewage Disposal System Form B. Checklist 53 Currycomb Circle Property Address West Barnstable MA 02668 City/Town State Zip Code Frank Anigbo May 6,2005 Owner's Name Date of Inspection Check if the following have been done. You must indicate'yes"or'no'as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) lE ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 53 Currycomb Circle Property Address West Bamstale MA 02668 City/Town State Zip Code Frank Anigbo May 6, 2005 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms (design): 3 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: 1 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available Oast 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter headings, if available: Last date of occupancy/use: Date Other(describe): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments s Subsurface Sewage Disposal System Form C. System Information (cunt.) 53 Currycomb Circle Property Address West Barnstable MA 02668 City/Town State Zip Code Frank Anigbo May 6, 2005 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Sysl:em: ® 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: 1/21/86 per Board of Health Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9of16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 53 Currycomb Circle Property Address West Barnstable MA 02668 City/Town State Zip Code Frank Anigbo May 6, 2005 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 49 Inches p g feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 39 inches p g feet � Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions: 1000 gallons Sludge depth: 2 inches Distance from top of sludge to bottom of outlet tee or baffle Winches 2 inches Scum thickness Distance from top of scum to top of outlet tee or baffle 8 inches Distance from bottom of scum to bottom of outlet tee or baffle 14 Inches How were dimensions determined? measured t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal'System Form C. System Information (cont.) 53 Currycomb Circle Property Address West Barnstable MA 02668 Citylrown State Zip Code Frank Anigbo May 6, 2005 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 53 Currycomb Circle Property Address West Barnstable MA 02668 City[Town State Zip Code Frank Anigbo May 6,2005 Owner's Name Date of Inspection Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Even 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.): The box was level and tight with no sign of carry-over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 53 Currycomb Circle Property Address West Barnstable MA 02668 City/Town State Zip Code Frank Anigbo May 6, 2005 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 � ❑ leaching chambers number: ❑ 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.): This system has a 6'x6' precast pit which was surrounded by2 feet of stone. The pit was dry with a stain line two feet up. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts . Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 53 Currycomb Circle Property Address West Barnstable MA 02668 City/Town State Zip Code Frank Anigbo May 6, 2005 Owner's Name Date of Inspection Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. system Information (cunt.) 53 Currycomb Circle Property Address 02668 West Barstable MA City/Town State Zip Code Frank Anigbo — May 6,2005 B Owner's Name ate 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. 1 v�k* (b qY t5insp.doc•11/2Q04 Tile 5 official inspection Form:Subsurface Sewage Disposal System Page 15 of 16 l Commonwealth of Massachusetts v, Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 53 Currycomb Circle Property Address West Barnstable MA 02668 Cityrrown State Zip Code Frank Anigbo May 6, 2005 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database- explain: USGS Maps show an elevation of over 25 feet You must describe how you established the high ground water elevation: t5insp.doc•11i2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 Lti CAT ION S C:�UzowCfmp, SEWAGE PERMIT NO. VILLAGE - INSTA LLER'S NAME a ADDRESS B U I L D E R OR OWNER Lam' DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED � C_j i i II t t No. N -7 FEB.... .. THE COMMONWEALTH OF MASSACHUSETTS BOARD�O_F HEALTH .Tow.1.1.................OF......1. r�tFZl�l-.riT ................................ Appliration for Uispaaal Work.5 Towitnutinn Fermi# Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal tt System at ................ .. ........................... Location-Address or Lot No. ..... . ..... ............ .. Ow Address Installer Address -. Type of Building Size Lot..l5t;V7E�...Sq. feet aDwelling—No. of Bedrooms_.....��. ).71-W. 0....Expansion Attic ( ) • Garbage Grinder ( ) 04 Other—.Type of Building ..........................:.. No. of persons............................ Showers ( ) — Cafeteria ( ) 04 Other fixtures ......................:.. 6 Design Flow............1.1.�C?........................gallons pe e--r day. Total daily flow..............C�.�----•--.....gallons. gal n Septic Tank—Liquid capacity.1.Q ..gallons Length.8I_.-� Width4."-.1Q. Diameter................ Deptha..`-4).1 W Disposal Trench—No..................... Width.................... Total Length.................... Total-leaching area..........--._......sq. ft. x Seepage Pit NO..O.LY..... Diameter.._....V....... Depth below inlet......ro......... Total leaching areaMI.-1......sq. ft. Z Other Distribution box 1$Q Dosing tank-( ) '-' Percolation Test Results Performed by..j tb.t ..rt4Ct>• �I�YeDate.__..G./L .` F,�.... Test Pit No. 1..E!.....minutes per inch Depth of Test Pit..16t....... Depth to ground water.mo�. 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ....... .............................:.................................•---------•-----............................................._............. O Description of Soil.... G��-QTp��C1 .t. �rz��.- i'o�.c5(1g35L'tiL,- $�t ----•------------ w VNature 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 LImLZ 5 of the State Sanitary Code -The undersigned further agrees not;to place the system in operation until a Certificate of Compliance has been ' e�y the ar f health. Si ned_ (/!/ -•----•----•..............•---- (�....��...�. j� ....... .. /... , Date Applicati Approved By.... �---. '. ��`. ...........-•-----•-•---•-•- . D -�9 Date Application Disapproved for the following reasons:_.............................................................................................................. ...............•-•-•---...............:...---.......---•----..-----------••-----...................................-•---•--........--•-----•-----........_....._.....................Date.............. PermitNo........ .��.--•---�.... --. Issued.............................................,........_ Date _ _ :�• .�� f� w,Ill _ � .Y . a --7 FEs. THE COMMONWEALTH OF MASSACHUSETTS ` BOARD OF HEALTH OF..... - ............ .. ........ ApPrtttiun fur P'Inpnaal Nforkg Tontitrurtiun "prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: l _ .11i �.. t.Yd:.".._....-_ ......!_ems ....r.-._l -1...__.... 1 y� t L �i�eca4�w [ldtlress� Tle. '�1 �� �b �/l= 7u�_ / (� r. or I ot`No ' .....--•---•-------•-------------- ....-------•---•------•-•- W Address a .......................................... ppqq ;x jj pr Mess d Type of Building lSize Lot..,a.=.... ...Sq feet aDwelling—No. of Bedrooms .....Expansion Attic ( ) Gat�b ge Grinder ( ) WOther—Type of Building .------- ! .,,NO.,_of persons_............::............ Showers ( ) — Cafeteria ( ) Q Other fixtures •---- ..............:........ W Design Flow.................•-•---.......- gallons pe7 �risoA''per day. Total daily flow.......---_-.. .��..a...............gallons. f� Septic Tank—Li uid C�capacity._, !'"`1. r-"�- P q p y- ...gallons Length Width:14,�..: . ��D:ameter . Deptl� .y n.a� x Disposal Trench—No............:....-.... Width..................... Totals ngth......._._.......... Total leaching,area-_--------=...._._sq. ft. 3 Seepage Pit No....,.. -...._._._... Diameter....... Depth below inlet.........!........ Total leachingar s , ft. C a� . - i P # �31.. f._.... q Z Other Distribution-bo ( ) f Dosing tank ( ) ! Percolation Test Results J Performed b .�-- ,� Y-- •. - •• ,._, •- .r-, Date... I"..� - _.v�.�t�i f . ..M. c.;�l�ir�Tl��C at�i�. r ,.a Test Pit No. 1.......� minutes per inch of Test Prt..�u,,...... Depth to ground water.a. �... j.__. Li Test Pit No. 2. ..= ._. minutes per inch Depth of Test Pit.................... Depth to ground water.' `".._..- ( ... ......................• -••••-•-•-•-......-••-•----•-••••• O Description of Soil... ............ /.......... lJ�r' ` �`l�"� ,•Fy=: , , ►....... . .�..a-«., tom-. �.. -� ... �"� w ...................................................... . �A4z...:�Z:'-- �.-.._._../tod.�__. _..... :7...:'................. VNature of Repairs or Alterations—Answer'wffien applicable................................... .....:... ................................:............. ! 1 ..........4• •........................................ ... ................ Agreement tl,){w, ! The. undersigned agre;t--s to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of AITLZ 'ti of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certiticat� of Compliance has been issued bVthe a.rd of health. Signed :....���f: k X 2Date .. �zApplicati ed BY - -,o � .!' ....,.. -[ ._r �._ ... �._• `— 2:;Date Application Disapproved;for the following reascrns:................................................................................................................. .......................................... ..................................................... ................................................................................ ................. • i� Date Permit No.......t..�S.. •� _s `�• T,' .. Issued...............•........ !' Date THE COMMONWEALTH'OF MASSACHUSETTS f, BOARD OF HEALTH .OF � C�rrtiiactttr u� f�uttt��ttnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) bY................................ ........... At.� ... r s:.,i, ,.................................................................................. `r P 1 i a/f��i'is` •l1l ---•••-------------------••----- at..............•••-•--••-••-- has been installed m ae-cordance with the rovisions of ff LE j of he State Sanitary Code as described in the application for Disposal Works Construction Permit No........c- .__. .�_ dated........ .... _ ,r. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FjUNICTION SATISFACTORJf. DATE. ........ ....... Inspector - Wilt .... .. _.._ _ .. -----,...... -- ._ t __ _.. ...... ,..,.... - -_ .._..,........,<._ _. . ... THE COMMONWEALTH OF MASSACHUSETTS BO,E!\RD OF. HEALTH No......5? r ........... rl....-.....OjF=....:...%Jig ' a'76�.? ..c'........................ .... U J 1' FEE. T_ ;! 13isplaind ifrkii Tunutrurtiun Vrrmit Permission is hereb ranted.................... ... . !...................... ..................................... to Construct ( J'�f^Repair ( ) an Individual Sewage Disposal System,t �..at No................... / f Street ti td as shown on the application for Disposal Works I--onstruction Permit No._�°r-_.<tl,--Dated.._.-. r f.../.a. ...... 1 1' d.ardi"of'Health�� 7 / r ilI - 1 .� . r , P � , DATE ---- 00___ PROPERTY ADDRESS: 53, Currycomb Circle __ ---A4aSs_0264&----------- on the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1 -1 000 gallon septic tank. RECEIVED 2. 1 -Distribution box. �&ED INSPECTION 3 . 1 -1000 gallon leaching Based on my Inspectlon, I certify the following oondltions: SEP 1 3 2000 4 . this is a title five septic system. ( 78 Code ) TOWNOFBARNSTABLE 5. The septic septic system is in hydraulic failure. HEALTHDEPT. System is filled to capacity. 6. A- new leaching area should be installed. Waste water is over the pit and into . the risers on the pit. 7. System should be pumped. SIGNATURE:,/ N a m e;_,L L,.-tsssmlz.a.r._�I.�_.._--- Company; Joa!1?h_p:. Nacomb�r b Son , Inc . Address: Box-66 ------- CentervilleL Ha__02632-0066 Phone:___ 509 775_3398_______ THIS CERTIFICATION ones NOT CONSTITUTH A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tanks•Cesspools•Leachf lelds Pumped L Instilled Town sewer Connections P,o. Box 6y7'6.3J38erY1114, MA 102632.0066 COMMONWEALTH OF MASSSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.6600 TRUDY COXE Secrata,ry ARGEO PAUL ^ELLUCCI DAVM B. STRUHS Governor CommissionerSUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CEATIFlCATION Property Address:53 Currycomb Circle Mama of Owner Lori Thorton West barnstable Addr"sofOwnw:197 8f-h ct Unit 6 L4— Date of Ir-P-tI,-: 9-7-0D Charleston Ma 02129 N&Tw of Inspector: (Press.Print)Joseph P. Macomber Jr. I am a DEP approved system 4tspector pursuant to Sec"n 16.340 of Tltie 6(310 CUR 15.000) Clomp,mNafT1e; Jose h P. Macomber & Son Inc. µazrgAddr*ss: bOX bb, Centerviiie , Ma . O2632-0066 Te4phone Nw .j>w —7 7 5— cEnTiRcATtON STATIDAENT i cerdty 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 ezperlence In the proper function and maintenance of on-site sewage disposal systems. The system: Passes C nditionally Passes Beds Further Evaluation By the Local Approving Authority F Is Inspec.-tor's Sigrtrtu �rtf2 Data: The System Inspe t shall submit a copy of this Inspection report to the Approving Authority (Board of Health or DEP)wltNn thirty (30) days of completing this inspection. If the system is a shared system or has a design now of 10,000 gpd or greater, the Inspector and the system owner %hall submit the report to the appropriate reglonal ofnce of the Department cKnvironment+d Protection. The odglnel should be sent tobw system ownst and copies sent to the buyer, If applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 page Iorii " Printed on Recycled Paper L SU93URFAtx SEWA09 DISPOSAL SYSTEM 1043►£CT10N FORM • PART A c3avv-l1T10N (oondrvuo l f Op.wTy Addrau: 53 Currycomb Circle West Barnstable Ma 02668 °rn'a'. Lori Thorton °" ofkWP ` n: 8/16/00 visK-C=N SUTAM lAY: / A, 0, C, or Dt A. SYSTE7J PASS � klndlwUw that .ny of thfr rib• 310CM z+L Myraaudon wNch Odin R td_�!I v� not found any inform+ i crheria not evaluated we Indlcata •ow. CO h11lFXT3: S. SYST A C0NC>M0NALLY PASSES: On., of doore system of the r sow pmon•onot ds&o tbod In tthhed by the �o d of Hevth�wW on need to be replaced or rcpakod. The •yst.m. up- Lr4cat• yes,, or not determined(Y, N, or NO), D*6cAbe baale of detarreJnadon!n @J M+urwea. If 'not d•termlrsed', axd•1!1 why rw%. The septic tank 1a metal, unless the owner Or oparatW has provided the system 4tapect A-inartJAut• or Ccmptlsn nk c• (•"ached)Indicating that the ta was lnwt&"d within twenty(20) Ysata plot to ow data of ttw tnap�caon whether or not moral, Is stacked, aweturolly unwound, shows wbstandal Lnftivadon a oxftry vn O `aDe L. the septic tank, failure is Imminent. The system Will peas kup•odon If the existing eepdc tank Is replaced with a cotnplytng approved by the Board of Health, r high static water bserved Ln the tJon box (WO to brok"of Ob1VVCUd pip — or due to a broken, +raid d oroun v level en dlstrlbudonbox.o u w The system will pawwtr 4poctlonIt Wtt DfNovaJ Of VW Ito-WO Of Hearth(. broken plpo(s) we replaced obawcdon la removed distribution box Is levelled w replaced The eyhrtem reQutrad pumpbiglnmv tunlour-drnes-voyoarduo tro brogirn a obwu oted pipe(+). The r/hrwm 19��r x Inspection II (with approval of the loud of Health), ' broken pips(+) us replaced obswcdon Is removed r page 2 of 11 revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM � PART A CERTIACATION (corrdrased) PrWw Y Addrsas: 53 Currrycomb Circle W Barnstable Ma 02668 0-0-rw: Lori Thorton D.0 of tn:p.cdon. 8/1 6/0 0 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ,4)l) Conmons exist which require further evaluation by the Board of Health In order to determine If the system Is hafting to protect tlw public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 C>IAR 16.303(1)(b)THAT THE SYSTEM I3 NOT FUNCT10NW HU 0 IN A MANNER WCkj WIL1.PRaYEC7 THE PUSUC HEALMAND SAFETY AMD THE ECOBQIILtBrL' Cesspool or privy is within 60 feet of surface water Cesspool or privy Is within 50 feet of a bordering vegetated wetland or a sell marsh. I) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF A)M DFTI111AXE5 THAT THE SYSTt31 tS FJNCTIONWG LN A mANNEA THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE BiWONMFMT: The system has a septic tank and soil obsorptlon system (SA31 and the SAS Is within 100 fowl of a surface water wpprY or trlbvtory to a svrlec• water supply. UCI The system has a septic tank and soil absorption system and the SAS Is within a Zone I of a pub-ic water supply wou The system has a septic tank and soil absorption system and the 3A3 Is within 60 lost of a private water wpp+Y wou. The system has a septic tank and toll absorption system and the 3A3 Is less than 100 het but 60 feet w mwe hom a private water supply wall, unless a well water analysis for collform bacteria and volatile organic compounds Indicates 0%81 uW wall Is trse hom pollution from that facility and the presence of•mmonls nitrogen and nitrate ntuogen Is equal to of toss than 5 ppm. Method used to determine distance- - (approxlmardon not valid).- 3I OTHER 44) AN revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL YSTE)A INSPECTION FORM PARTy CERnF*CAnON f corrtirx+ed) 53 Currycomb Circle W barnstable Ma 02668 own..: Lori Thorton 8/1 6/0 0 p, SYSTDA FAILS: b"4 for this Y` must Indicate either 'Yes' or 'No' to each h the following: S followingof failure I have determined that on• fMot The Boardo} H althshouldnbeticonUCUd to deUons exist as �bed i rrtl� whatOwlU be necea+IrV to w ta+Ju determination Is Identified below. Yea N0 ooanportertt doeto tart overloaded ot^cleggad Backup 0+oowa9e I^wfoclNtyror•�t1+m Discharge or ponding of effluent to the surface of the ground or surface we due to an overloaded a dogged SAS or cesspool. Static liquid)oval In tpo dlstrlputlon box above outlet Invert due to an overloaded or clogged SAS or cesspod• 1 Al i fr�l- Llquld depth In soo+poVF s less then 6' below Invert or available volume Is loss than 1/2 day flow. Required pumping more than 4 times in the last Yost NOT due to clogged or obstructed pipe($)• _ Number of times Dumped�� 1/ Any portion o1 the Soil Absorption System, cesspool or privy Is below the high groundwater elevation. pply or tributary to • surface water wDDIY Any portion of & cesspool or privy Is within 100 fast of a surface water su Any portion of a cesspool or privy is•withIn a Zone I of a public well. Any portion of s cesspool or privy is within 60 feet of a private water Supply wall. Any portion of a cesspool or privy Is less then 100 feet but greater then 60 foot from I private water waleupply w%& with o acceptable bacter ia,volaltlie ao(gonio•eof mpounds the well h ammonia as been anlu gennalyzed tandenluato Ntrog attach copy of wall water analysis to -collform E. LARGE SYSTEM FAILS: You must Indicate either 'Yes' or 'No"`0'atgo systethe eInoaddition to the criteris above. The following criteria apply i The system servos & facility with a design flow of 10,000 gpd or greater(Largo System) and the system Ie I $JgnMcant West to health and lately and the environment because ono or more of the following condition/ exist: Yes No j y the system Is within 400 lost of a surface drinking water supply ar io�ourtwa•d.�4'.s'aser'ou►►IY.... / the system lerwI%'%;A 200 feet of+ ►t Y d Zor-4 II of $ D 6 the system Is located In a nitrogen sensitive are&flnterim Wellhead Protection Area.IWPA) or a mappe water supply Well) ordance with J10 CMR 16.304121. Please consult the 1Oc'I ret The owner or operator of any such system shall upgrade the system In Icc office of the Department for further Infognation. Psile 4 of 11 revised 9/2/98 SUBSURFACE SEWAGE DLSP03AL 3Y3TVA MPECTION FORM PART 3 CHECKI-13T Property Ad&*": 53 Courrycomb Circle W Barnstable Ma 02668 Owner: Lori Thorton Deu of inspection: 8/1 6/0 0 k If following have been dons: You must Indicate either 'Yes' or 'No' as to each of the following: Chock Ns o g 9 Yes No Pumping Information was provided by the owner, occupant, or Board of Health. Nona of the systemcon4w&&rta 4waj~pow►wd4*P4RJe,"t:two•waake aw6414a7ystom haabarawoalraogeaaead r rates during that period, large volumes of water have not been Introduced Into the system recently or as pan of uvs InspectJon. As built plans have been obtained and examined. Note If they are not available with N/A. _ The facility or dwelling was Inspected for signs of sewage backup. The system does not receive non•sanhary or Industrial waste flow. The she was Inspected for signs of breakout. _ All system components. owluding the 3oll Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the Interior of the septie tank was Inspected for condition of be or tees, material of construction, cilmsnalons, depth of UQuld, depth of sludge, depth of scum. The slts and location of the Soll Absorption System onthe site has been determined based on: ExlstJng Information. For example, Plan at B.O.H. v _ Determined In the fleld Of any of the failure crlteria related to Pan C Is at Issue, approximation of dietance Is unacceptat 11 6.702(3)(b)1 The faciUty owrw land.arrup-al Jf dlfluaat frouLzAmm),wrars wouldarl wUh lafaunsalomon th,pra;-r m.iol-^•M- - SubSurface Disposal Systems. revised 9/2/96 Pagesof11 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM > PART C x• SYSTEM INFORMATION Property Ad&eus: 53 Currycomb Circle W Barnstable Ma 02668 Owrw: Lori Thorton °is of V"°"tiw' 8/1 6/0 0 FLOW CONOfT10NS Rf SID0"L: Design flow:fA_.g•p•d.thedroo Number of bedrooms�esl ✓ Number of bedrooms(actual):, Total DESIGN flow Number of currant residents: 7"e—u Ce-4 Garbage grinder(yes or no):_ _ If yes, sepuateJn+p+ctlon,requlrad Laundry(separate system) 1 a or"•_: Laundry system Inspected ye or no) Seasonal use lye& or no): Wet@, meter reading&, If available (lest two year's usage(gpd): Vel— _ Sump Pump lye$ of no): � � f_Qa Last date of occupancy: COM1AERCtAL M4pVSTRIAL: Type of establishment: Design flow: A, 9 opd ( Based on 16.203) Basis of doslgn flow 0ress@ trap present: (yes or no) 1 Industrial West@ Holding Tank present: (yes or no), Non•s&rutary waste discharged to the Tlt o 6 system: (yes or no)� _ Water motor reading*,If evall ble: Last data of occupancy: 1L OTHER:(Describe) i Lest date of occupancy: • GENERAL INFORMATION PUMPING RECORDS and source of Information: System pumped as pert of In ectlon: (yes or no) 11 yes, volume pumped: �� gallons ,Reason for umping: .0 System should have been pumped at time of inspection. T e system is presently filled to capacity. TYPE of SYSTEM �e Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool 4 Privy Shared system(yes or no) (If yes, attach previous Inspection records,If any) I/A Technology sic. Attach copy of up to dote operation and maintenance contract Tight Tank Copy of DEP Approval Othor AppROXJMATE AGE of all components, date Inotsllodilf known)-and eouFoe o44MOM adon: Sewage odors detected when•orriving at the'sito: (yes or no)/� revised 9/2/98 Psee6orIi SUBSURFACE SEWAGE DISPOSACSYSTEM INSPECTION FORM -:✓ PART C SYSTEM WFORMATION(oorstlnwd) Property Address:53 Currycomb Circle W Barnstable Ma 02668 Own«: Lori Thorton Deu of vt"ctlon: 8/1 6/0 0 BUILDING SEWER: Ilocate on site plan) Depth below grade.— Material of construction:0cast Iron L 40 PVC/ /other (explain). Distance hom wivate water supply well or suction line i Diameter_ Comments: (condition of Joints, venting, evidence of feakage,-etc.) 4- Joints S TANK: Musa vent. (locate on site plan) Depth below grade /' Material of construction: [_/ConCrotemetaf41,�2F]berglessAaPolyethylonwt,��ther(explalnI if tank Is fnetal. Ilst ape__ is.age.conffrmed by CertlAcate of Compliance da(Yes/Nol )f r" r�r Dimensions: � Sludge depth: Distance hom top of s �ga to bottom of outlet tee ortratfte' Scum thickness: r/ Distance from top of scum to top of outlet %as or baMe:� )/ Distance from bottom of Scum to bolt of outlet t9 or baffle:•_ Mow dimensions wets determined: Comments: irecommendation for pumping conditlon Qf Inlet and outlet tees or-baffles, depth of liquid level In relation to outlet invert tr. suctvrsi-integrity. evidence of leakage, etc.) Once Lne new leaching tank sh ou a tees are e n is no evidence of ea a e GREASE TRAP: (locals on site plan) Depth below grader g on�other(sxpisin) Material of con*tructIoZtoncreta AmetaldAFlber Iasr Posyethyl Dimensions: Scum thickness: Distance hom top of scum to top of outlet tee or baffler_ Distance hom bottom of scum to bottom of outlet tee or baMa: ' Date of last pumping: Z22*1— Comments: (recommendation for pumping, condition of Inlet end outlet tees or baffles, depth of Uquld level In rotation to o"ol Invert, structural integrrty. evidence of leakags, etc.) re I Pagtlorit revised 9/2/98 SUBSUR,FACi SEWAGE DISPOSAL SYSTEM WS11"£CT10N FORJA PART C SYSTDA WFORMAT10N icon s4ed) '. PTW-Mr Addrsas:53 Currycomb Circle W Barnstable Ma 02668 Owmw: Lori Thorton Dww of Vupecdon: 8/1 6/0 0 nOHT OR HOfDWO TAHKV.I,&_Z(Tank rrwst be pumped prior to, or at time of, Inapecdon) (locate on We plan) Depth below grads:- M•terlal of construction/lJA concf.te4"/m•t�¢ Flb•rplt,r<tv�R►olyf,thylenfa/f�Ql otherl•xplrin) AA Dimensions: k Capaclry: gallons Olsign flow: gallons/day Alarm present Alarm level: Alarm In working order:Yes.tg No&If Dole of prevlovl pvmpingt 41A Comm•nu: Icondldon of Inlet t••, condition of alarm and float ewltchee, *to.) Or holdina taQk—ar-e—Ret p' W"ISUTION 5OX:L11 I:o<sts on Nte plan) Depth of lipvld level above ovdet Inven: Comments: (n •,III vol and dlstrlbvUon Is eQ • den" of Id carryo er, wldence of Iookage Into or ovt of lava, etc.) is�ributi dal one �aera�.Th 'IQ aviAanCe Of . NO scars _ %VQ ea sae i ntn nr n„+ e o pUTAF CHA11ABFR:.d fee, llocats on else plan) ��� Pvmps In working order:IYss or No)N�� Alarms In wOrking order IY•s or No) Comments: Ingle conditon of pvmp chamber, condition of pumps and oppurtonancee, eto.) pres—e—nt. revised 9/2/98 of It SUBSURFACE SEWAGE DISPOSAL SYSTEM tNSP£CT$ON FORM .. PART C SYSTEM INFORMATION (condr"od) P-9«tyAd&—: 53 Currycomb Circle W Barnstable Ma 02668 O w: Lori Thorton Data of irtsp.ction. 8/1 6/0 0 ,f��t1 SOIL ABSORPTION SYSTEM(SAS):�Oy/* (locate on site plan, If possible:excavation not required,location may be approximated by nondntrusiv methods) If not located, explain: Type: leaching pits, number: leaching chambers, number: leeching galleries, number:_ leaching trenches, number, length: leaching fields, number, dime Ions: overflow cesspool, number: Alternative system: (� Name of Technology: Comments: (note condition of soil, sign&of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) L clayan ' T.eaf i nc1 nit i c ; n hvrir���1 ; .. �- ; i .•. A new 1 ear•h i nrr a rlla gotatinn lS n�rm�l � CESSPOOLS:D (locate on site plan) Number and configuration: �✓ Depth top of liquid to Inlet Invert: Depth of solids layer: Dapth of scum layer: Dim&nslow of cesspool: Materials of construction: Indication of groundwater: Inflow (cesspool must be pumped as part of Inspection) Cesspools are not present Commenu: (note condition of soil, sign& of hydraulic failure, level of ponding,condition of,vegetadon, etc.) Cess pc)l q are nni-racQnt PRm:AiNe' (locate on site plan) Materials of construction: Dimensions: lei�l Depth of solids:_, Comments: snots condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation;etc.) Privy is not px-eaeni� revised 9/2/98 rig,9orii 3UI3VA/ACC IEWA09 OLSPOSAL iYSTUA WSPtCnOw FQ" ►AAT C 3 SYSTUA WFOP."*IOw (oon vw*4 v,oq..tv Add—: 53 Currycomb Circle W Barnstable Ma 02668 Owrw; Lori Thorton D.u °' " 8/16/00 SKETCH Of SEWAGE DISPOSAL SYSTEM: Inciudo des to at least two permanent reference landmarks or benchmuks IOGete all welli wlWn 100' (locate where publlo water supply comer.Into house) ,S3 Cu���car", b �ar�>bnx `tit,•!/.r of Gary O � 1 3o` nje 10 or 1t .revised 9/2/98 SV93URFACE SEWAGE Dt3►9SRALCEM W SYSTEM FORMA 1, PA 3Y3TOA I/JFORMAT10N (con*-*d) 53 Currycomb Circle W Barnstable Ma 0'2668 own«: Lori Thorton G ew °' tn`°"dOf 1 8/1 6/0 0 NRCS Report name SoU Type_ Typkai depth to groundwater USOS Date websile Ashed Observation Wells checked Moderet• Deep Oroundwater depth: Shallow SITE EXAM Slops Surface water Check Cellar Shallow wells r (sumatsd Depth to Groundwater Feet ploose Indicate sU the methods used to determine High Groundwater Elevation: 2SIt. Obtained hom Deslpn Ilan$on record Ob►srve0 lAbutdnp propert bsorvetJon hole, basomeot sump etc.) Osurmined Irom local conditions Checked with local loved of health _Checked FEMA Maps ..Z/Checked pumpinp records .Z/Chocked local excavators, Installs($ Used USOS Date Describe how you established the High Groundwater Elevation, Ibio be completed) Used water contours map. Gahrety & Miller Model 1 2/1 6/94 Pil;ellofll 98 revised 9/2/ '11UNN OF BI�$rTcTARTF DOARD OF HEALTH J 9U119 FUItFACF 9FNAc) 1)19f'U9AL SYSTEM INSPECTION PORN PART D - CERTIFICATION _ -TY/C Olt PAINT CL6AALY- P1tOPERTy INSPEC7'ED STREET ADDRESS 53 Curr comb ASSESSORS NAP , DLOCK ANU PARCEL y OWNER' s NANE pART D - CERTIFICATION NANE OF INSPECTOR Jose h P . Macomber Jr COMPANY NAME Jose h P . Macomber & '`Son Inc. nt rville MA. 02632-0066 Tovn or ty it�t• r FF— COMPANY ADDRESS trfft FAX ( 1'7�� COMPANY TELEPHONC ( 508 ) 775 3338 CCR'fI !^ICATION STATEMENT I certify that I have personally cesorteddisthe true,�age accurape9aendsystem nc this address and that the il�formation The inspection was performed and any omplete as of the time of , inspection , il, upgrade , maintenance , and repair are consistent on• recommendations regord g N With my training and experience in the proper function and maintenance site sewage disposal systems 1 ,I'a'�• Check one ; System PASSED Tile Inspection which I hasestemdfails ucted tosadequatelY protect any public which Indicates that theY It8alLI, or, the environment as defined ed in the FAILURE 3CRITERIA fsection of criteria not evaluated are his Corm , ails System FAILEUs The. inspection which I have conhecendironmentnintaccordancesNithfTitlet protect the i)ublic health and t 5 , 110 CMR 15 , 303 , and as specifically noted on PART C - FAILURE Cfl1TERIA of this inspection . Date Inspector Signature of this ert.ification must be provided to the OWNER , the BUYER ne COP and th• DOARD OF HEALT1l' ( wh• r• appl ioab14 ) ,",,. . I ( th. impaction FAILED , thb oNner or operator shall vowed or re eyetern year of the LED ,dAte of the inspection , unless allowed or require within one partd . dc otherwise as provided in J10 CHR 16 � J0 No. � !y � 6"7'-. Fee / 4 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes ✓ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01p prication for �Digool *po em Con!truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System E Individual Components Location Address or Lot No. C'r O ner's Name,Address and Tel.No. V,� #//_6C Assessor's Map/Parcel � VJ Installer's Nae,Ad ress,and T N . Designer's Name,Address and Tel.No. n -}5 T' �av lI IL-Ifqr ve 54yee-1 W r 0 3 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 gallons per day. Calculated daily flow 3 3 �4, gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank oKX/g Type of S.A. . Description of Soil Nature of Repairs or Alterations(Answer when ap licable) 60© (X L66612 INSTAI I ATION AND CERTIFY IN WRITInIC. Date last inspected: THE SYSTEM WAS INSTALLED IN STRICT ACCOP"'­ _� T' ' 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 Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by thi Board of=- A SignedDate 17I CL�Application Approved by L" Date U Application Disapproved for the following reasons Permit No. Date Issued A No. r- _� 9�p:9 '.. � V;�, .., Fee THE COMMONWEALTH OF MASSACHUSEII- SZ— Entered in computer: Yet/ L� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS rication for ;Mi!5 o.5ar stem Congtrurtion ermit Application for a Permit to Construct( )Repair( )Upgrade )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. r �Grde rN Assessor's Map/Parcel �� V r �` �..: g�� '� h`7 �N'll i� 1 log Installer's Name,Address,and Tel No. r+5 Designer's Name,Address and Tel.No. evtr° �o �clv 1�L 00 A asw 11PI, 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 gallons per day. Calculated daily flow .3 J gallons. Plan Date Number of sheets I Revision Date Title 1 Size of Septic Tank �� J�'I 5-1'j n� Type of S.A. . 1)04-1 �M, Off✓'S Description of Soil Nature of Repairs or Alterations(Answer when applicable) IAJ I I JL G )600 a V 3 . { 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 Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this Board of Health. 4 Signed f Date D Application Approved by / ��f7V�.0 �1 Date T Application Disapproved for the following reasons Permit No. fX.). '��y Date Issued l --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance ti THIS IS TO CERTIFY, that the.On�}'te Sewage Disposal System Constructed( )Repaired( )Upgraded(tll Abandoned b I /J C at _ �r ( J l U 1 has been constructed in accordance with the rovisio of Title 5 d the for Disposal System Construction Permit No. c):r- /4dated U�. Installer /A..O //l"��L p,� p y Designer The issuance of s ermit shall not be construed as a guarantee that the syste"�1/Wl fn d }i u desi Date Inspector . --------------------------------------- i THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS &!6poof *pztem Con!�tndon on permit Pg Permission is hereby granted to Construct( )Repair( )Upgrade ) ) System located at r12) v ( ('. P 1/// 11 11M' 1 fn w ' I 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; ust be completed within three years of the date of this pp nit. j1 Date: ( / !t l Approved by TOWN OF BARNSTABLE Cc LOCATION J� GJ�r�r�A-C�� C-try, SEWAGE # VELLAGE �c^����'�-- _ASSES MAP & LOT I. I—0 70 INSTALLER'S NAME&PHONE NO. ✓ SEPTIC TANK CAPACITY �. 0 ` (size) 1� `LEACHING FACU M: (type)NO. OF BEDROOMS BUILDER OR OWNER' PERMTTDATE: -7 Z COMPLIANCE DATE: 3 Separation Distance Between the: Feet Maximum AdjustedGroundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Como (.,.rd(L IOMr 1 M '^�r e s - July 3, 2002 Outback Engineering 106 West Grove St. Middleboro, MA 02346 (508) 932-9857 Town of Barnstable Health Dept. 200 Main Street Hyannis, MA 02601 Re: Septic Inspection 53 Currycomb Circle To Whom it May Concern: Outback Engineering has conducted an inspection of the newly installed system at the referenced property. This system was installed in conformance with the approved plan. Very truly yours, ames A. Pavlik, P.E. SECTION - SEWAGE p —SEPTIC TANK — 5 -- —"D"BOX — —LEACH Fl T I i TOP F FDMN� (MSL)* —"2"OF►18TO 4r" WASHED STONE 11>irl I�- cov IN• OUT• IN• OUT• •IZ ESEPTIC ELEV. I ELEV. ELEV. EL ! l ELEV. ELEV. t48 4�( 140n �y! WASHED STONE. arc S+ f f r O O a"•`6Aamlljj c V TEST HOLE LOG p�'���� ; � � TEST BY IZ. E��.r1 tr. ►")(Q r'1 �-1J,C�. I ,, `, w► T-44, V' WITNESS -�} _.. - Z { •,. � ��� TEST DATE DESIGN BEDROOM HOUSE I J T H T.H. 2 l / - ELEV. 3a ELEV. NO (m' loan GZ DISPOSER DISPOSER + �` ► 4 PERC RATE MIN/IN. 1 V 'b_-x f4o' FLOW PATE (GAL./DAY) �Z-o i_.12.:�r SEPTIC TANK tp ry��� REQ'DSEPTICTANKSIZE A 51' ' LEACH FACILITY 2 114 133.5 SIDE WALL = tL (Z.`7) _ _ cQ •G/D. BOTTOM 421Zl?T '110.2at1,-Z> G/D. t It TOTAL Zpl ( _ 19e USE: �� LEACHING Q WATER ENCOUNTERED Cy l �G. �FP P ` r�G 1 7 t. aA ' O NOTES: (UNLESS OTHERWISE NOTED) 1.DATUM(MSL)!.TAKEN FROM QUADRANGLE MAP /. 2.MUNICIPAL WATER 14p __-•--AVAILABLE 3.PIPE PITCH:Va"PER FOOT�T_-„- 4.DESIGN LOADING FOR ALL PRECAST UNITS:AASHO- -44 S.MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1)FT. ``1R 06 6.PIPE JOINTS SHALL BE MADE WATERTIGHT i 7.CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. STATE ENVIRONMENTAL CODE TITLES �� AR"!F �• fn�'a SITE PLAN 8. T�-it pt.A�J FOL ?�G�+„•-_•� �+�O+t'.Y. C.����C ��t> '�. . `D o Okla' `".IY LOCUS: LOT ( ( CVT�f>:YCOM L3 C(offs --- ����tH of ygsr9� EST ��C�titsT'titsc.� MA . aU UIS�jui-rNbLfi 16E NND RF��L��� RE —_-p!( �((61NEER p� ARNE yG t` � l � WITH C,l�!*N MeptotA TO CO&Zsc, 6&NC7 T=o(? IL71 L�I-2ou�1 > SSIU ENC '• ' H. �\ REF: LOT �1 'e �1([. tC1� 3�ZCo � d0W# CQ�� �Il�'%91�'��%Al� OJALA hcL p y 3 PREPARED FOR: CIVIL ENGINEERS LAND SURVEYORS RE R (►l —_ /l O► BOARD OF HEALTH CONTOURS (EXISTING)...........•. �i4T2� �� tI1�8 1RliA St., APPROVED DATE _ SCALE (PROPOSED)—0-0�-0— MA �. _; D4<TE ��'• ' � �S ELE.=61.0 `J,JJ JI 1/LL U� 34.25' LONG 4,0 K I(• PO L-/\)1 NJ y 1 N CC ,/1 � AD MANHOLE COVERS.TO EXTEND TO 1 1.0' WIDE. f `(r� WITHIN 6' OF FINISH ORE 10� DEEP p,T C,� F to E:r)6tl BAFFLE REQ'D C S X1 1 31�0 2X ::: 2' PEASTONE PPING S CAP ENDS GENERAL NOTES: 6• c uSHED hNE 3. __ __ _- -_ _- - h�-3[4' DOLI �-O-u WASHED - ELEVATIONS SHOWN BASED ON U.S.G.S. DATUM. T,kt`1 K --+ STONE ALLNO �_.� s� SYSTEM PIPE SHALL BE EITHER C.I. OR . Ell 54.0 SCHEDULE 40 P.V.C. — THE BOARD OF HEALTH SHALL BE NOTIFIED PRIOR TO BACKFILLING OF SEPTIC SYSTEM. 20' MIN. 1.5 31.25' •5� •-- l�C�t:'I'Q�'{ b�USE FIVE (5) INFILTRATORS C1+I — SEPTIC SYSTEM STRUCTURAL COMPONENTS �u GAI'aGIT�) I �� SHALL BE CAPABLE OF WITHSIKNDING A SOIL TEST LOG PROPOSED SEPTIC SYSTEM , WITH 4.0' OF STONE ® SIDES �- R H-10 LOADING, UNLESS SPECIFIED OTHERWISE & 1.5' OF STONE O ENDS — SEPTIC SYSTEM UNDER DRIVEWAYS SHALL PERC RATE=< 2 MIN/INCH NO SCALE NO STONE AT BOTTOM COMPLY WITH A H-20 LOADING. - - THE DESIGN AND COMPONENTS OF THE SEPTIC DEPTH ELEV.= 60.0 SYSTEM SHALL BE IN COMPLIANCE WITH THE A LOAMY SAND 1OYR 3I STATE OF MASSACHUSETTS SANITARY CODE a LOAMY SAND ICYR A. THE I`�SSIL� TITLE V. AND SHALL BE IN COMPLIANCE WITH THE LOCAL BOARD OF HEALTH RULES AND REGULATIONS. CI MEDIUM SAND IUYR �/� Ut'j D(nt A -tA /-'{'C 6A5 SeUll-C. - THE CONTRACTOR SHALL BE RESPONSIBLE FOR \ LOCATION OF ALL UNDERGROUND UTILITIES AND SHALL NOTIFY DIG - SAFE PRIOR TO D j0 �O " ``� S [F'AGE. /� unl CONSTRUCTION. S� S� — NO GARBAGE GRINDER 4 � 00 Wk to / 151 1 L�r oho DESIGN CRITERIA: / ..;4. DESIGN FLOW LEGEND: S Z 1 3 BEDROOMS AT 110 G.P.B. / DAY 330 G.P.D. EXISTING CONTOUR REQUIRED SEPTIC TANK: WATER SERVICE W W- - �l U S C .[:-C f�71 t.)( I i 000 Lg A t- T/}�f K TEST HOLE Q f a t SEPTIC TANK PROVIDED IJQN� GAS SERVICE G—G i "I ;+ C ,�T, sw /.,gy T�' ij DESIGN PERC RATE <2 MIN/INCH 1j (J SIZE OF REQ'D (SAS) AREA = 330/0.74 = 446 S.F. BENCH MARK rdBNG ENGINEER It -1-��� I0 DESIGLLINATION AND CERTIFY NU WRITING 1 INSTA ° ° d �/\ SIDEWALL 75.12 S.F. THE SYSTEM WAS INSTALLED II�STRICT� s CORD,• T^PI fin), / CC7 r '; 5� BOTTOM �2)�0.83)(34.25)+(2)(0.83)(11)= 11 (34.25) = 376.75 S.F. AC / i S' , =4 G 4a M t L o�Y�1i^I yL SIZE OF LEACHING FACILITY PROVIDED: LI N � To P�4eL-0 ' .ILt` 376.75 S.F. + 75.12 S.F. = 451.87 S.F. 334.4 GPD NOTE: PRIOR TO INSTALLING THE NEW (SAS) THE / _ 1, V EFFECTIVE DEPTH: 10" CONTRACTOR SHALL PUMPOUT ALL LEACH P.CrS &9 AND BACK FILL WITH CLEAN MEDIUM SAND , 5 �' ~ i EFFECTIVE LENGTH: 34.25' IF LEACO P[TS ARE ENCOUNTERED IN THE (� �/ EFFECTIVE WIDTH: 1 1.0' (SAS) AREA THEY SHALL BE REMOVED• O' SZ Q-4 OUTBACK ENGINEERING (�O r , S;Z �A4MOFs 106 WEST GROVE STREET J MIDDLEBORO, MA 02346 oa JAMES A. tiG (508) 946-9231 � � IK -' PROJECT: SEPTIC SYSTEM REPAIR PL CIVIL A No. -CU`RRYCO M FOR G 1 Q G LIB 53 s O axe AS SHOWN op*'" JP y� ��`o�Q� ( 3 F`ss'/ONALEN f 0 0 MAP 15I / LOT 07020 f LO dix _ 0 z- OWNER: L A% IZ I F- (.4 I1-7 8 TN ST• dd CaC3 GHARLG TOl--)rJ OA 02 ► 2. I.