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HomeMy WebLinkAbout0148 KETTLEHOLE ROAD - Health E148 KETTLEHOLE, W. BARNSTABLE A = , o CERTIFICATE OF ANALYSIS-- Pages 1 I� t a ^ I Barnstable County Health Laboratory Report Prepared For: Report Dated: 4/23/2008 Todd Nickerson Order No.: G0845852 148 Kettlehole Rd. West Barnstable, MA 02668 Laboratory ID#: 0845852-01 Description: Water-Drinking Water Sample#: Sampling Location: _ Kettlehole Rd.West Barnstable,MA-7-7 Collected: 4/22/2008 Collected by: T.N. Received: 4/22/2008 Test Parameters ITEM RESULT UNITS RL MCL Method# Tested Fecal Coliform 0 CFU/100 mL 0 0 MF-SM 9222D 4/22/2008 Total Coliform 0 CFU/l00mL 0 0 MF-SM 9222B 4/22/2008 Approved By (Lab ector) 4'. co 3 .gC__.--I ttl�. Cn ND=None Detected RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 l - rtifr� + f J1'� { �] COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION tf4 r i >F y I f�y• XI y TITLE 5 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM _ PART A y i CERTIFICATION Property Address: 148 KETTLEHOLE RD WEST BARNSTABLE,MA 02668 M109 P036 L21A Owner's Name: DAVID ELLIS Owner's Address: 148 KETTLEHOLE RD WEST BARNSTABLE,MA 02668 � i 4 Date of Inspection:3/6/01 l� Name of Inspector: (please print) OHN GRACI Company Name: SEPTIC INSPECTIONS + r ` Mailing Address: P.O BOX 2119 TEATICKET,MA.02536 Telephone Number: 508-564-6813 FAX 508-564-7270t ` CERTIFICATION STATEMENT I � I certify that I have personally inspected the.sewage disposal system at this address and that the information reported below is I 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 systems inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes), _ Conditionally Passes ; # , E _ Needs Furt r valuation by the Local Approving Authority _ Fails { ` Inspector's Signature: Date: 3/6/01 The system inspector shall submit r copy of this inspection report to the Approving Authority(Board of Health or DEP)within „#I_ i 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 . y inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be 1 , sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. 1 y Notes and Comments THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFULL L•IIFE. '44 rr ;l Itik ****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. h P nxl °F t .,fl - Page 2 of 91 ." t; OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A �' : '�=t CERTIFICATION(continued) Property Address: 148 KETTLEHOLE RD WEST BARNSTABLE,MA 02668 M109 P036 L21A Owner: DAVID ELLIS s° Date of Inspection: 3/6/01 Inspection Summary: Check A;B,C,D or E/ALWAYS complete all of Section D i�tGc� A. System Passes: , X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEM'S,USEFULL LIFE. B. System Conditionally Passes: " { _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Health,will pass. r,. . Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. L ' n/a The septic tank is metal and over 20 years old*or the septic tank(whether rretal or not)is structurally unsound,exhibits Jq}. substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced y K, .. i r 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. i r * ND explain: n/a .+ n/a Observation of sewage backup or break out or hi static water level in the distribution box due to broken or obstructed g P f� pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): rir tti*3' _ broken,pioe(s)are replaced _ obstruction is removed 1. _ distribution box is leveled or replaced r . ND explain: n/a ` n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): j. _broken pipe(s)are replaced _obstruction is removed ND explain: n/a Page 3 of 11 1 s OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS x� E SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .CERTIFICATION(continued) Property Address: 148 KETTLEHOLE;RD WEST BARNSTABLE,MA 02668 M109 P036 L21Ai; Owner: DAVID ELLIS Date of Inspection: 3/6/01 C. Further Evaluation is Required by the Board of Health: 1 _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to 1:r'1 protect public health,safety or the:environment. lit 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the system is not functioning in a manner•which will protect public health,safety and the environment: ik E 4 _ Cesspool or privy is wrthm SO,feet of a surface water #y�. _ Cesspool or privy is within 5q',feet of a bordering vegetated wetland or a salt marsh { . + 7 c t�� 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 f r+ rY PP Y ' ' i•A supplyor tributary to a surface water su 1 . _ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ai k4; _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. e _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance n/a "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and Y� volatile organic coin ounds'ihdicates that the well is free from pollution from that facility and the presence of ammonia g P P 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. + , 1 i 1lM txt ; 3. Other: F ' 1 rsY r , Page 4 of'11 XI171 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM tq . PART AAvI ; CERTIFICATION(continued) j Property Address: 148 KETTLEHOLE RD WEST BARNSTABLE,MA 02668 M109 P036 L21A Owner: DAVID ELLIS Date of Inspection: 3/6/01 s i a� D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: „A i Yes No X Backup of sewage into facility or stem component due to overloaded or clogged SAS or cesspool - p g tY Y p gg p # �'�• {a,F - X Discharge or ponding of effluent,to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool sF `` - X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool hh, - X Liquid depth in cesspool is less than 6"below invert or available volume is less than''/Z day flow - X Required pumping more than 4 times in the last year NDT due to clogged or obstructed pipe(s).Number of times pumped nLa. 1 � t - X Any portion of the SAS,cesspool or privy is below high ground water elevation. X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. - X Any portion of a cesspool or privy is within a Zone 1 of a public well. - X Any portion of a cesspool or privy is within 50 feet of a private water supply well. - X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality,analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or + a�a less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be r attached to this form.]: 3 ` _ (Yes/No)The system fails.I.have determined that one or more of the above failure criteria exist as described in 310 l CMR 15.303,therefore the system fails,The system owner should contact the Board of Health to determine what will be raj• .I' necessary to correct the failure. AL E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. ,� You must indicate either"yes"or"no"to each of the following: 6 ur (The following criteria apply to large systems in addition to the criteria above) . 4", � .. ;?4",1� . yes no - X the system is within 400 feet of a surface drinking water supply x E r X the system is within 200 feet of a tributary to a surface drinking water supply ark' ,- - X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public waters supply well ' you If have answered" es"to any question in Section E the system is considered a significant threat,or answered i Y Y,s , , �b� F "yes"in Section D above the large sykstem has failed.The owner or operator of any large system considered a significant threat k _0;n 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. 2. , ` ; . t Page 5 of'I I r� OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i `` �'' PART B CHECKLIST Property Address: 148 KETTLEHOLE RD WEST BARNSTABLE,MA 02668 M109 P036 L21A ;¢ Owner: DAVID ELLIS Date of Inspection: 3/6/01 Check if the following have been done. You must indicate yes or no as to each of the following: Yes No 9 4; X _ Pumping information was provided by the owner,occupant,or Board of Health 11 r h_y X Were any of the system,components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? f X Have large volumes of water been introduced to the system recently or as part of this inspection'? p • fyt'C X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ` t X _ Was the facility or dwelling'inspected for signs of sewage back up? k� X _ Was the site inspected for signs of break out? ;. t X _ Were all system components,excluding the SAS, located on site? E R X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? :1 �y X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no t _ X Existing information. For example,a plan at the Board of Health. :. 9 X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) J,1x;.+ ¢u5 J •• �loJ E 1 J r rF.`py. r� c Page 6 of'I I r ' r � i • i �l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 'a= PART C , SYSTEM INFORMATION Property Address: 148 KETTLEHOLE RD WEST BARNSTABLE,MA 02€68 M109 P036 L21A Owner: DAVID ELLIS Date of Inspection: 3/6/01 7 FLOW CONDITIONS RESIDENTIAL r Number of bedrooms(design):3 Number of bedrooms(actual): 3 d+� 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 or no):NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] , .r� Laundry system inspected(yes or no): NO ,� Seasonal use:(yes or no): NO r �' Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL {R Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a t• i� '_ Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO "';'fir;:•: Non-sanitary waste discharged to the Title 5 system(yes or no): NO ?}• Water meter readings, if available: u/a Last date of occupancy/use: n/a OTHER(describe): n/a i GENERAL INFORMATION r Pumping Records �-y4 Source of information: n/ac Was system pumped as part of the inspection(yes or no): NO +' t If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a if i.Reason for pumping: n/a # ,;." � ,���r � , �s V TYPE OF SYSTEM X Septic tank,distribution box,soil absorption system ?�� _Single cesspool Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) i� . _Tight tank Attach a copy of the DEP approval ' yyP. Other(describe): n/a ` v Approximate age of all components,date installed(if known)and source of information: 1978 j Were sewage odors detected when arriving at the site(yes or no): NO { �s k A Page 7 of'I 1 L :; =:4 Y '4 OFFICIAL INSPEYCTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ,;;' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t! i PART C SYSTEM INFORMATION(continued) 4i" Property Address: 148 KETTLEHOLE RD WEST BARNSTABLE,MA 02668 M109 P036 L21A f },; �' Owner: DAVID ELLIS 't i Date of Inspection: 3/6/01 } BUILDING SEWER(locate on site plan) , r Depth below grade:42" EYE Materials of construction:_cast iron =40 PVC Xother(explain):20 PVC k ,,. Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): 'k TOWN WATERfli ,fir* SEPTIC TANK:X(locate on site plan) } ;' Depth below grade:36" . Material of construction: Xconcrete' metal_fiberglass polyethylene other(explaiii)n/a :A= If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6" H 5' 7"W 4' 10"" 1 tf tf Sludge depth:2" Distance from top of sludge to bottom of outlet tee or baffle:32" Scum thickness:2" Distance from top of scum to top of outlet tee or baffle: 6" , � Distance from bottom of scum to bottom'of outlet tee or baffle: n/a How were dimensions determined: MEASURED t ;[ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.):, " . , THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE. GREASE TRAP:_(locate on site plan) r � Y kr" Depth below grade: n/a "ak Material of construction:_concrete_metal fiberglass polyethylene_other(explain): n/a _ rr f Dimensions: n/a � . Scum thickness: n/a Distance from top of scum to too of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a ,x Date of last pumping: n/a 1"a Comments(on pumping recommendations, inlet and outlet tee or baffle condition;structural integrity, liquid levels as related ? to outlet invert,evidence of leakage,etc.): �. n/a r i $ N t! fi�gE�t Page 8 of 11 Yi OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS z t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 148 KETTLEHOLE RD WEST BARNSTABLE,MA 02668 M109 P036 L21A Owner: DAVID ELLIS j Date of Inspection: 3/6/01 , HT r HOLDING TANK: tank must be pumped at time of ins ection locate on site Ian) TIGHT o p )( P ( P p Ar.+,. Depth below grade: n/a ,; +e Material of construction: concrete_metal_fiberglass polyethylene other(explain): n/a r . Y. Dimensions: n/a 4. Capacity: n/a gallons Design Flow: n/a gallons/day F Alarm present es or no): N/A Alarm level: N/A Alarm in working order(yes or no): NO Date of last pumping: n/aJ�" ,rx Comments(condition of alarm and float switches,etc.): '�'►" n/af. DISTRIBUTION BOX:_(if present must°be opened)(locate on site plan) t Depth of liquid level above outlet invert: n/a Comments(note if box is level and distribution to outlets equal,any evidence of sr4ids carryover,any evidence of leakage into or out of box etc.): ' n/a , $� r � i PUMP CHAMBER:_(locate on site plan) C Pumps in working order(yes or no): NO Alarms in working order(yes or no)-NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): t ijq; n/a . F ' i{NAB *r r ':sty � q W� Page 9 of II 1 t' ;4.yy OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 148 KETTLEHOLE RD WEST BARNSTABLE,MA 02668 M109 P036 L21A Owner: DAVID ELLIS Date of Inspection: 3/6/01 sa�ft ' SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: n/a Type 000 GAL 6' X 6' leaching pits, number: n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a .a n/a leaching trenches, number, length: n/a ' n/a leaching fields, number: n/a f ; n/a overflow cesspool, number: n/a L n/a innovative/alternative system Type/name of technology: nla t { l a � Comments(note condition of soil,'gigns of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT IS STRUCTURALLY SOUND AND APPEARS TO BE FUNCTIONING PROPERLY.THE PIT HAD 3' OF WATER IN IT AT THE TIME OF THE INSPECTION. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) t i Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a is Materials of construction: n/a I '• ` Indication of groundwater inflow(yes or no): NO Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) . i Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): z$. n/a ,. ski ,i.4 ,l n f Page 10 of I 1 f"}' rah.: s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS p; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 4.• t'a PART C SYSTEM INFORMATION(continued) Property Address: 148 KETTLEHOLE RD WEST BARNSTABLE,MA 02668 M109 P036 L21A04 , Owner: DAVID ELLIS ' Date of Inspection: 3/6/01 SKETCH OF SEWAGE DISPOSAL SYSTEM a' 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. . , , t, ;. R• k �y VPAI . }T 1C g r f�HF AA a3a i � AR ILAC i "J i y.. (�C CA ae$ D G i{ in Page 1 I of 11 .i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) '_} Property Address: 148 KETTLEHOLE RD WEST BARNSTABLE,MA 02668 M109 P036 L21A � Owner: DAVID ELLIS Date of Inspection: 3/6/01 SITE EXAM 3.. _Slope _Surface water _Check cellar - .f Shallow wells jillis Estimated depth to ground water 12+feet r Please indicate(check)all methods used to determine the high ground water elevation: s NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a i NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a }. NO Checked with local excavators, installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET y .q M5 hd. 1N ; ti 1 No.........I&....... .............. THE COMMOr WEALTH OF MASSACHUSETTS BOARDFF O� e HEALTH , 24T/H , C ....Fo - ...................0F.................. -.A...Y./. ..... ..................' ......................... Allpfiration for Uiiivoiial Vorkg Tomitrui rtion Frrutit Application is hereby made for a Permit to Construct (�or Repair an Individual Sewage Disposal S t t to, Ail A y s 76,` 4,le A 4 , ................................................................................... ...................... -------------------*------•------ .................... ......................................................................... ....... leer ASdd;K1. ............ .. ............................................................... ............................ 0..e................................................ ....................... Installer Address coop Type of Building Size Lot............................Sq./ feet U 2 ................ Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder P4 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria P4Other fixtures .................................4_'-w4o-—------------------------------------------------------------------------------------------------ Design Flow............2.:.......I/Z.&--........._gallons per per day. Total daily flow........................3.........4............gallons. 1:4 Septic Tank—Liquid capacity-KC.".gallons' Length.......ao..... Width-----1/....... Diameter................ Depth.... Disposal Trench—No. ..................... Width....._._............ Total Length_______-..__ Total leaching area....................sq. ft. Seepage Pit No........./......... Diameter......... ------- Depth below inlet........ -Total leaching area.. ��...sq. ft. Z Other Distribution box (kj Dosing t k Percolation Test Results . .......... Performed by....... . ................ Date..)9 1.4 -Y---------- w ,_l Test Pit No. 1...9'5r ..minutes per inch Depth'of Test Pit___--- ............. Depth to ground r------------------------ Test Pit No. 2---.0f..F.minutes per inch Depth of Tr it._....._.2------- Depth to ground wa er........................ 1:4 ................................................ 0 Description of Soil........ -I....... .. .... ... �---. . ................. ............. 1.,2-- --------- 4.....................e.......r -------- . ......................J-�p ...... ....... -------------------------- OL. ... ..........0-----ff­_4tr...n..?._Y�.. ..4----------C_ PA.%... .• . 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 TL I T 1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu y,Ye cqrd of helfb I gned_._.. .. . ............. Signed,V _--_ ---_----_- Au's....&W Date Application Approved By...... ....... . ............. ......................................... ....... Date Application Disapproved for the following reaW'ns:............................................................................................................... ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued_--. ................................... Date No:�:.....11��----- FEB....:�5. ..� ....... THE COMMONWEALTH OF MASSACHUSETTS BOARDF� HEALTH ....................OF........---.'!!Y... ........................................ Appliratinn for UhipmFal Works Tonstrnr#inrt ramit Application is hereby made for a Permit to Construct ()jf or Repair ( ) an Individual Sewage Disposal System a ....�f�� .. ....�z :..W.. ---------------- . .... 2.1 2_ - .... ., Location-Add ss / ( j, qr I' o�N W d •c=� Y ...L caner......................................... IRr�[( " �F� /7f� ..._........... a Installer Address d Type of Building Size Lo --Xm-------------.--------Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder (41,p Other—Type of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ................................. W Design Flow......... .�� ) gallons per per day. Total daily flow.._...___ �0 W Septic Tank—Liquid capacity/.•gallons Length._......... Width......_..._..Diameter________________ Depth..Olons lt?:. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......f.___... Diameter...../0....... Depth below inlet......��__......... Total leaching areacZk5 .....sq. ft. Z Other Distribution box (14 Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ © a Test Pit No. 1._ 4.�..._._minutes per inch Depth of Test Pit....A;7....... Depth to ground water........................ fsl Test Pit No. 2--0-:.5.....minutes per inch Depth of T st Pit....A;7........ Depth to ground water........................ _ ........... �' Description of Soil �" U Nature of Repairs or Alterations—Answer when applicable................ .............................................................................. -----------------------•--•------...........--------"•-'----------------'-------'----...........----•••••--•-•----•-•'--'-•-'-•---••••-•-•••-•--•--•-----••--•-•---"•--'----•-•----•-••-•......------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has een�issued t o r f health. G Signed. %' ' �. �� lJ `� • ._... -- •-- �- � Date Application Approved By.....:.--••--./�:: f..,./.� 1. .. ----- = P%--..7 -=--- `' Date Application Disapproved for the following reasons:--'...--"------"-----------------'-------------"--'-------------------------•--'-•-----•-------•-•••••......_ .....................•-------........--'-----.....------'--'...'-•--------.................._..............-----•----------------•-"--------------'------'------'------- ............................... Date s^ Da PermitNo.......................................................... Issued..... Date------ - -----•------•-•-•--------- M :. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF�HEALTH .....................OF.......... 1..�yv ..............................._.............. " Tatifirttfts of Tompliatta THI$ IS TO CEI�IIFY, That,the Individual Sewage Disposal System constructed (�) or Repaired ( ) bY-----... i�--n.:, = �+�'./.fc ._� 1...... ----- -•---------------------------------- ------------------------'---'---...._.....----.....---------.."----------- �� V d In tall I j l / / has been installed in accordance with the provisions of TI"' r 5 of The State Sanitary Code as described/the = - application for Disposal Works Construction Permit No._' _r�_______l_`// "--------.. dated----•_7::-. _ 2 -----=---'-•-•---- THE ISSUANCE` OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUffCTION SATISFACTORY. DATE... ..: a -- ----. Inspector '+'.`_ ,,.. -m 43�.•c-.r-.t k' �&i:A�S.p^$:o..r+'r y ,.,1fJCy, .-Y,Yt+<d`;.�^hF.`F.+.�'�'�'f'r.`�}'+'.�i•^.'iw�s ✓..� m,?:K_ .� ,w:.-f.-' Insp e..;..c;.-.c t�o�s r�. �•�. ----._n...•.�..,•-�.•.:.x.. ..�. .•r:•n•-, - ,. THE .. COMMONWEALTH OF MASSACHUSETTS �+ _ 111 BOARD OF HEALTH � f` .......... .....OF../...✓.. `v!._t............................................................. No........... FEE.....�.5............. ` Dispnoal Iforkv nn#ra inn an it Permission �is hereby granted.... / 44,. .�••. ^ =--------'-----------------------.---....................-----.............•.. to Construct (/ )!v or Repair ( ) 'afi d/'ndy'v al ewage D sposal Syst at No.- �C=>�/ I, fit.. /t = --•---•--.... i act "= ---£= -------------1-� .-_ads °-����E� ----------� ---. �.�-•�-- --------•--- r; - as shown on the application'for Disposal Works Construction Permit%No/_%__..J........... Dated.._5...... .:_.� ______________ /�-/ ry Board of He th DATE "... ---------1-- t f ✓. /fv-t� s /. FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS a .1 v 1 � 4,..:•f h:. .+F h s._ 1 r 4'�- l a_¢ e r :t: y ea'-y a'4i 1 �k: Y r r, t r r i ) i.. tt:.r +{ f 4 tn)` t �' �,.� �.y 'li r :r rtti� r t.t n y S n �j`•: 1 y -G. P t; Sys it a 4` , Y t i.. 'r5 �*W r !! 6F i Yly S 'A: S r r 3 f"P f r ,k: 1.`s.� t 4' +. ,. is S v.S \ !•.-'�.,t 3 ,}� � '�,..+t(zr � �.' FS � t.; t fki'�, 7a,11F n reTr a r k,_ a I i 1 y;«,1, � k^, , q r . , r. � .•' i'r r..r, r �t r..' - ° �.i r.. +. A 4 5 3 P , F}-fiC .' 4 . i of ;u r �z y 1 �.� .,r Se •t Iq( i kt P 41 SST ; .,r . ) � F + , ,.. r r � / y y�i.., �J r' �r/�� � Y �• �+ -V y�.•r '� y . � � ea '� ,}.7 k •� S \ �� .ii y 9 �' y .:� r v. .2 � 1• +,. T 'i`� � � ����� > , '-`�J yl�^'L :}.�� "'� b\X cp t ! tis ,\ \ of �, O \ ''' ,.� \1�1 7 ti•f 'y x,. ^y ,4at t F,~�� 4,.p Ikt,, —It .. #,. �,•,,. `\. .�_ U ��. «> y ^rr - , t;y a ti. Sw, irry. y.. s'L'i ~t ^�. � l ,.-_ � ,�' /y V r S r �� i )'/— � CP - f,ytl 1 J.. i `A.. �P P�` a. ,r3• � + ;7!f yfi: "�+., .I.!� /I -L�. / ) -y .n ♦`.� t i;�7 Pf yj r',t ,i ),ne; st IliL. r, CERTIFIED F !_OT . '`' PLAN -EXISTING^ " SP.OT :EL:EVATI ON Ox0 4, t. EXISTIN �- CONTO'UR — p �FINISHE[ 4 SPOT ELEVATION [0. 0� r - \ '" u� r FINISHE ) CONTOUR 0 �>��<<�� -L,i .r /,, �! � r /e a>.t y �APPROVED BOARD OF HEALTH SAA ,ter` �* SCALE = 5'�> DATE ®AT-E AGENT _ /l {RE DGE RE'OGE ENGINEERING CO. ING�� CLIENT I CERTIFY` .THAl THEa PROPOSED EGISTERE 'REGISTERED JOB N0. 7 >JJ/ � BUILDING -:SHOWN ON-, THIS Pi CIVOL : LAND ': CONFORMS ; TO TF'E ,,ZONING LAWS x'x DR. BY.: EN GIPdEER l S_URVEYOR - OF BARNSTABLE ,r MASS. ' t [33 NC MAIN ST 7!2 MAIN ST. CH. BY ARMOUTH, MASS. HYANNIS, MASS �_f SHEET_r- OF _ DATE REG. LAND SURVEYORI: _� _.----- ---- �; �e_ • z �Q FT.,/"///1[ a sr E._^` J �/Y07 E LF EI TiYER.,7�w�:S`PT�G,:TAN_k OR,: DEL D kV /D'Fp M/N >, ,s , b t ""'.' '�/�'/a1 OEM^iii /1 • //S I �,T.� ..CO/yek' �`� CO!/,ER - �� � `�� . .. . "" ' yHA�,L B6 BQDG/GN�" �.� 61�.4.®.� �.y/✓.•EXTR�9 {.. a 1 �l.ES N1 f1 N 3 4 PYC P/GE x i NEA 1!y CAS?' 7 R.�e FICV T t . P/TFC .lo/ o T-o T n N L7f? VEVf Y.�BnPE,Q - • :ra' ar'� a /4 --7 Z. ORA Ole C' ^EA eA 7:7- - � s �•—. - - - L'1 n L/!�U/D LE,vEL � �' _ . _ w. I; " ,�:Y ;',_ �� } _ ,.p 4 d 4' CAST e rr.>f,- ­ . _ -- _ ��•2 LAYER R .. ON P 8�E ry PER P T. rSEPT/C TANK D/s T. j�A 5 HEO STi�/YE. c 6 Jo IL.�e Mh va ®. D ° \• ` FACT/VF 1 ' 3/4. - �` ` "o�. � F � s "� �.,. _ �� . . .-=-�� _ a:+-:; �•7 o a� ° w ' • OEf•'7N./:• • �,•e�w n� ,I`vASHEQJSTONE� - O �' ;c t s� _ �?.4 � s r6.Oao w,1 1 • 1�.x'• .• • / 1�;� ... =a=- _ C': . __ r gy. ' „ '; o.v..c.a 1 • • • e e � • • • •� D� �,� c� PREC;f45 T$LFE.PAGE`�- - k /N1-,`A-r erLE✓A7-/4Ns �+ . :. �1•( ^ �D • e ti 1 t e • y • • • e a P/T OR U/V • /N{�,ER�" .: I.'� BU/L!�/NG � �7.� F/'" r � _ �_ 6 FT D/f;M '_ i �` ',� ..-- ',' ._. ., ` `{ SEE TsBULATION9G,S C/HEFT SE F OCJTLFTj.SEI-'7 T-eNK _ �G. 3 FT• -:_ ;k - /NL,ET t�l$rR/®UT/ON BOX SECT/ON aF GRDu_[Vo �T ,..00/�LETID/ST:i:.:+cii ivN vui+ "`� Q� � - � ` �• /HEFT•SEEPAGE �i T SEN/AG1.ECC ,D/SAVoA A t. .-. dV f U/ME DES/GN CR/TER/A - 6 - SCALE ;P/T . a , D N FT ' /VL//dlOER OF BEl>ROOMS 3 ry' { D/NfE/VS/GN . C FT M• G/AR®AGsEO/SPOSAL UN/T TaTAL EST/MA'TE`O F. nw 'SOIL.TEST 16f/ 50/L.TESTobt2.' �- J _ O Sa/�g.¢TE5T "'TNUMBER OFSEEG4 DATE OF/ � . 7 S/Q6 LEACH/NG AREft P[T y"Lc+ ' P RFS,IJLTS it//TJE�5E0 'dY. 4 6 v TTO/W LEACH/NG PE 1�P/T_! g_'p$Q, GT '} e Pt' t COLAT/01r° +4iTE may,/h•;:. 0. 56 [y/N,//NCH " = TOTAL LEACH//YG. Al?EA. 6` SQ.. FT 0�°S.tl� s•,/ .• PERCOL4T RESERI�EGEACN/NG AREA_6e-5Q., FT �S �4a%�' j � .c Ad /'� ez & ELo� i ✓ i �`c�a /mac. �0.11(C( VIM �/'O•i` w ra ,. • _ .. ,;; " ' yr /� << • a. / f y� /' Ir�%`-i(i ' -s � .}?r _ 7,7� /e"fA •JT T .���Nb,' A//11fa8T�,' ' �.?�'a• �:�, -•�� q - @/s� 6 �'r � v „•� �- C '� •�� "�_s,�,�,a �'" 'WINN ,4e)A[[e►[J;f,.: �� ;��7- 1'�I..[�9A'.;'�- � t.. • a. S d air° .� �'� 1•v/UC9 AAA '�'e 0 �. .. ..ti i � -apt- �- arr-.:,'..�d a� -r`*,_:�:.+s'-�<•..a.��G�.�li... _�,.7��i .- �. - �` <�•^ �,.�C,�ti. -y'�s.� '`o°'" `l ' LT/OWN OF BARNSTABLE LOO-ATION / b ITT I C �-�o Imo-. SEWAGE # I f VILLAGE ASSESSOR'S MAP & LOT ) INSTALLER'S NAME & PHONE NO. L V 1 7 SEPTIC TANK CAPACITY ./0 0 LEACHING FACILITY:(type) JQ, - (size) . NO. OF BEDROOMS-PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER /4-1°v o,r ±21 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No jib uJ 7-1 3-5s s • y L • d3 ° o � W I.Q. 0 AT ION � '� SEWAGE PERMIT INO. VILLAGE 4NIA ? IN.STA LLER'S NAME & ADDRESS A), In lV 5 �/l d C._ BUILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED r 9 1Y ` i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property l q8 4_ l RC) . (,J--s t jju.�Hs 6 /e Owner's name Date of Inspection Q�N"' 7113 PART A CHECKLIST Check if the following have been done: °� ✓(/ Cf�L - -�L Pumping information was requested of the owne �,. oc 19 Health. d Do rd of _Z None of the system components have been pumped C and the system has been receiving normal flow rat e o weeks period. Large volumes of water have not been introduce) into thesystem recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs o g f sewage back-up. The site was inspected for signs of breakout. A1'l system components, excluding the SAS, have been located o site. n the The septic tank manholes were uncovered o e the septic tank wasand-inspected for condition ofdbaffleshoriteesior of material of construction, dimensions, depth of liquid, /sludge, depth of scum. depth of y The size and location of the SAS on the site has been determined based on existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of SSDS. -- I" � F SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION FORM PART B SYSTEM INFORMATION / FLOW CONDITIONS If residential •3 number of bedrooms _L number of current residents 10_ garbage grinder, yes or no, YeS laundry connected to system, yes or no Yti5 seasonal use, yes or no b„ If nonresidential, calculated flow: Water meter readings, if available: e"cIf Last date of occupancy GENERAL INFORMATION Pumping records and source of info ation: . i ti O N° System y pumped as part of inspection, yes or no if yes, volume pumped Reason for pumping: Typp of system _y 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) ' Other (explain) Approximate age of all components . Date installed, if known. Source of information: o. /t �v Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION Continued SEPTIC TANK: (locate on site plan) depth below grade: material of construction: concrete metal FRP _other(explain) dimensions:_ 6. /c.- Q� o J; sludge depth L� distance from top of sludge to bottom of outlet tee or baffle •,nrEscum 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 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, recommendations for repairs, etc. ) jau C- -LN �s T �`at u....1 Lo,n ��L O I Tt �b✓i.� . C O T/ G J �.. !.� I d 44—GL ✓G+ " 4z�A to, DISTRIBUTION .BOX:—Z (locate on site plan) �- depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.) 7'0 '9 c, d c,) Z�iti a �.At PUMP CHAMBER: A1114 (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possib e, excavation not required,, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits and number dhL XC _ leaching chambers and number ��� leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of ponding, conditio of vegetation recommendati ns for maintenance or repairs,etc. ) 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 on condition of vegetation, recommendations for maintenance or repairsnetc. ) PRIVY : A11 4 (locate on site plan) materials of construction dimensions depth of solids Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) ' 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L:SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 1001 w��1 i5 OUeAl 1 Fra • Syp�� T wk DEPTH TO GROUNDWATER depth to groundwater method of determinationn or approximation: / L S ►v c. -,7 a 4 � is SIIBSIIRFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r FAILURE CRITERIA ` Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) Jk-1 Backup of sewage into facility? .� Discharge or ponding of effluent to the surface of the surface waters? ground or Static liquid level in the distribution box above outlet' inv ert. N A Liquid depth in cesspool <6" below .invert or available volufDe< 1/2 day } Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below. the high groundwater elevation? within 50 feet of a surface water? .� within 100 feet of a surface water supply or tributaryto a surface water supply? _V within a Zone I of a public well? 6 within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? 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 ana1K_ for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. r 13 SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORM PART D CERTIFICATION Name of Inspector (�✓ l j� �• S y Company Name l�' CA •�, s S pro -�i �.s /o� Company Address yc) d �cl ,r34$S cv �ot Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Checone: _V5 I have not found any information which indicates that the system fa uatel Y fails to ade q y protect public health or the environment as defined in 310 CMR 15.303 . Any failure criteria not evaluated are As stated in the FAILURE CRITERIA section of this form. I have- determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303.. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature S Bate Original to system owner, Copies to: -= Buyer (if applicable) Approving authority j�a��,Ss/� Via- LOCATION SEWAGE PERMIT N0. VILLAGE _ 21 INS:TEA LLER'S NAME ADDRESS B U ffb E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED i. 3q