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HomeMy WebLinkAbout1855 OLD STAGE ROAD - Health 181 5 Old Stage. Road W. Barnstable P A._. 152 035002 o t a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE MA required for 6/5/09 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. Important:When filling out A. General Information forms on the computer,use 1. Inspector: ✓�/ only the tab key to move your DOUGLAS A. BROWN cursor-do not Name of Inspector use the return key. DOUGLAS A BROWN INC Company Name r� P.O. BOX 145 Company Address CENTERVILLE MA 02632 7BdB" City/Town State Zip Code 508-420-4534 S 14297 Telephone Number License Number B. Certification 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 ma tenan ;of on,_Me sewage disposal systems. I am a DEP approved system inspector pursuant to ection 3S.3407'0f Title 5(310 CMR 15.000). The system: f ® Passes ❑ Conditionally Passes ❑ FaRm It" c ❑ Needs Further Evaluation by the Local Approving Authority ; co .. Cs 6/5/09 v ;_.. Ins tor'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 shOLId 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. d Tide V Inspection Form.doc•011/06 Title 5 Official Inspection Form:Subsurface Sewage DisposISyem•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is required for W BARNSTABLE MA 6/5/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: SYSTEM MEETS MINIMUM PASSING REQUIREMENTS AT THIS TIME 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 Title V Inspection Form.doc•08/06 This 5 Official Insp ection 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 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name required rmation or is W BARNSTABLE MA f every page. City/Town Date of State Zip Code Date of Inspection B. Certification (Cont.) B) System Conditionally Passes (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. 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 environmen t: ❑ 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. Title V Inspection Form.doc•08106 Title 5 Official Insp ection 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 . 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE MA required for 6/5/09 every page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cunt.): ❑ 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: k"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 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:he 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. Tide V Inspection Form.doc•08/08 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 M 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is required for W BARNSTABLE MA 6/5/09 every page. City/Town State Zip Code Date of Inspection B. Certification (Cont.) D) System Failure Criteria Applicable to All Systems (cont.): 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. Title V Inspection Form.doc•08106 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE required for MA 6/5/09 every page. City/Town 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? ® ❑ 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)] Tide V Inspection Form.doc-08106 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Mmm Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE required for MA 6/5/09 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Number of current residents: 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 Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): WELL 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 readings, if available: Last date of occupancy/use: Date Other(describe): Tide V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts _ Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE required for MA 6/5/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: DOUG BROWN Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? TANK TRUCK Reas on for pumping: MAINTENANCE p Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: INSTALLED 1999 ACCORDING TO AS-BUILT Were sewage odors detected when arriving at the site? ❑ Yes ® No Title V Inspection Form.doc•08/08 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE required for MA 6/5/09 every page. Cityfrown State Zip Code Date of inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: •5 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ---------------------------------------- ----------------------------------------------------------------------------------------- Dimensions: 1500 Sludge depth: PUMPED CLEAN FOR MAINTENANCE Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Title V Inspection Form.doc•0&06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE required for MA 6/5/09 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TANK WAS PUMPED FOR MAINTENANCE AT TIME OF INSPECTION 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): Title V Inspection Form.doc•08/06 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE required for MA 6/5/09 every page. Cdy/Town State Zip Code Date of Inspection D. System Information (cunt.) 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.): *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 0 Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): SLIGHT SOLID CARRY OVER PROBABLY DUE TO LACK OF MAINTENANCE Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Title V Inspection Form.doc•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE required for MA 6/5/09 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: NO OBSERVATION PORTS Type: ❑ leaching pits number: ® leaching chambers number: 7 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): COULD NOT DETERMINE LEVEL OF PONDING DUE TO LACK OF OBSERVATION PORTS Title V inspection Form.doc•08= 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 '< 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE required for MA 6/5/09 every page. Cltyrrown 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.): Title V inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE required for MA 6/5/09 every page. Clty/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. ----------- r 1 r'3'' " 2 Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1855 OLD STAGE RD Property Address INGRAHAM Owner Owner's Name information is W BARNSTABLE MA required for 6/5/09 every page. City/Town 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: GREATER THAN 5 FT feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: HAND AUGERED IN BACK YARD TO APPROX 9 FT NO G.W ENCOUNTERED Tide V Inspection Form.doc•08/oS Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Page: 1 CERTIFICATE OF ANALYSIS r Barnstable County Health Laboratory Report Prepared For: N .o Report Dated: 10/31/2002 /, Report Ol/ Order Number: G�t��793j Christopher L. Theodore tiFy� 1855 Old Stage Rd. T,�O�ASTq West Barnstable, MA 02668 Laboratory ID#: 0217935-01 Description: Water-Drinldng Water Sample#: 17935 Sampline Location: 1855 Old Stage Rd.,West Barnstable Collected: 10/25/2002 Collected by: CLT Received: 10/25/2002 Routine ITEM RESULT UNITS MCL Method# Tested LAB: IC Lab Nitrates 0.1 mg/L 10 EPA 300.0 10/25/2002 LAB: Metals -Copper <0,1 mg/L 1.3 SM 3111B 10/25/2002 Iron <0.1 mg/L 0.3 SM 3111B 10/28/2002 Sodium 10 mg/L 20 SM 3111B 10/25/2002 LAB: Microbiology Total Coliform Absent P/A Absent 309 10/25/2002 LAB: Physical Chemistry Conductance 102 umohs/cm EPA 120.1 10/25/2002 pH 6,2 pH-units EPA 150.1 10/25/2002 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. Approved By: (Lab Director) +( 4 Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605 i TITLE 5 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1855 Old Stage Road West Barnstable,MA 02668 Owner's Name:Chris Theodore Owner's Address:same OCT 2 ro 1 ?442 Date of Inspection: 10/9/02 WN oh HEAL H pNSTAB Name of Inspector:(please print)David J.Burnie APT LF Company Name:Wind River Environmental Mailing Address: 120 Great Western Road MAP 1 `L South Dennis,MA 02660 � Telephone Number: 508-760-4827 PARCEL CERTIFICATION STATEMENT LOT ' 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: . Date: D Q� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: This system appears to be functioning as designed. ****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. 4 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1855 Old Stage Road Owner: Chris Theodore Date of Inspection: 10/09/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer �°es no or not determined N ND in the for the following statements.If n yes, �> ) g of 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 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: i OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1855 Old Stage Road Owner: Chris Theodore Date of Inspection: 10/09/02 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 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: OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1855 Old Stage Road Owner: Chris Theodore Date of Inspection: 10/09/02 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool 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 NOT due to clogged or obstructed pipe(s).Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. _X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _X_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _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 less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] _No_(Yes/No)The system fails.I have determined that one or 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. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-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. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1855 Old Stage Road Owner: Chris Theodore Date of Inspection: 10/09/02 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ Pumping information was pr ovided by the owner,occupant,or Board of Health _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? _X_ Has large volume of water been introduced to the system recently or as part of this inspection ? X_ _ Were as built plans of the system obtained and examined? _X_ — Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X_ _ Were all system components,excluding the SAS,located on site? X_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ? X_ — Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No _X_ _ Existing information.For example,a plan at the Board of Health. 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)] I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1855 Old Stage Road Owner: Chris Theodore Date of Inspection: 10/09/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): _NA Number of bedrooms(actual):_5_ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA Number of current residents:_4 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] Laundry system inspected(yes or no):_ Seasonal use:(yes or no):No Water meter readings,if available(last 2 years usage(gpd)):NA well water Sump pump(yes or no):No Last date of occupancy:Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):— Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records 10/15/02 post inspection Source of information: Wind River Environmental Was system pumped as part of the inspection(yes or no):yes Post inspection If yes,volume pumped: 1500 gallons--How was quantity pumped determined?Site glass_ Reason for pumping:_Maintenance 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) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information:_Approx 20 years old with the leaching facility replaced in 1999. Were sewage odors detected when arriving at the site(yes or no):No OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1855 Old Stage Road Owner: Chris Theodore Date of Inspection: 10/09/02 BUILDING SEWER(locate on site plan) Depth below grade:_Slab foundation Materials of construction:_cast iron X_40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):Normal SEPTIC TANK: C_(locate on site plan) Depth below grade:_9"_ Material of construction: X_concrete_metal_fiberglass_polyethylene —tank If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 1500 gal. Sludge depth_1.3" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_5" Distance from top of scum to top of outlet tee or baffle:_9" Distance from bottom of scum to bottom,of outlet tee or baffle: How were dimensions determined:_Probe and measure Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.):_Due to the depth of sludge and top solids in this system it was highly recommended that pumping be done and the owner ordered pumping post inspection,done 10/15/02. Tank appeared to be sound with no signs of leaking.Baffles in place GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1855 Old Stage Road Owner: Chris Theodore Date of Inspection: 10/09/02 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_E._(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:Liquid 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 to be solid with no signs of leaking,levels normal PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): f OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1855 Old Stage Road Owner: Chris Theodore Date of Inspection: 10/09/02 SOIL ABSORPTION SYSTEM(SAS):_F_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ _X_leaching chambers,number:_high capacity infiltrators with length of 49' leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): _Leaching was view with a sewer camera run from the d-box and it was found to be dry,area around site has rocky backfill with no signs of backup or ponding,normal grassy vegetation 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 or 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.): I ' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1855 Old Stage Road Owner: Chris Theodore Date of Inspection: 10/09/02 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. A b CO D 33�� © Gt� C ZZ �f Pffot)nV G-G I�' d� S aU tin -(36�2 5 U.) 6-6bvN r OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1855 Old Stage Road Owner: Chris Theodore Date of Inspection: 10/09/02 SITE EXAM Slope area of system level Surface water none Check cellar Slab foundation Shallow wells Estimated depth to ground water_28_feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the hig h gh ground water elevation: Per Topozone.com site appears to be approx. 80 A.S.L. Site located in area monitored by USGS well SDW 253 Zone B Online information shows groundwater at approx 52' A.S.L.with adjustment for Maximum potential High Groundwater at 7.8' aV`11, Bottom of SAS is approximately 6' below grade. difference of 12.2 feet between bottom of SAS and adjusted groundwater, i `3 ao�o� Vill A No. /'. / t Fee i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLEs MASSACHUSETTS Yes s ZW[iration for Mioogar *rztem Conetructton Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System V4ndividual Components Location Address or Lot No.i �� oil) Owner's Name,Address and �Tel. )No. Assessor's Map/Parcel `1 1 Oo Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �-� �`I��✓ t(1L 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 - " 75 gallons per day. Calculated daily flow � gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 159X1 9X � ^ Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) c� 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 b y this Signed Date Application Approved by _ Date Application Disapproved for the following reasons Permit No. _ 7 Date Issued Z TOWN OF BAMSSTABLE c LOCATION S� U 117 S-�P�GF SSG SEWAGE # ��7 VILLAGE Iy �O,N�u�J� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. MCA A (��'mN �— SEPTIC TANK CAPACITY LEACHING FACILITY: (type) an�C s. �=t_(�� �(size) NO.OF BEDROOMS BUILDER OR OWNER =D�SQIIJ PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by W �-- - 6 0 M Y F 3'' �v� 01D, - ` No. T`( i ' ' Fee THE COMMONWEALTH OF MASSACHUSETTS Enteredain computer:' Yes PIrBLiC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS 01ppYication for �Digogaf *pgtem Construction Vermit Application for a Permit to Construct( µ )Repair( )Upgrade( )Abandon( ) ❑Complete System VLJndividual Components Location Address or Lot No.110 jS 0!05AO Owner's Name,Address and Tel.No. Assessor's Map/Parcel �`` "'C k, Op- Installer's Name,Address,and Tel.No. Designer's Name,Address,a�d Tel.No. Type of Building; g y�iC Dwelling No.of Bedrooms �! J Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons' Showers( ) Cafeteria( ) Other Fixtures !! �.� Design Flow "R .SJV gallons per day. Calculated daily flow S %F gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank T _ c Type of S.A.S.C Description of Soil �J\,PQ�Co W tz C I�y� Nature of Repairs or Alterations(Answer when applicable) "SY`-SZ W-<� (7Yt- `A A"-V— Date last inspected: 1. 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- a cate of Compliance has befit-isst>•d"6y tl�is Signed Date J' Application Approved by Date Application Disapproved for the following reasons Permit No. 7 " 7 q Date Issued Z n,, .. —————————— ,� THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the O - '99 Sewage Disposal System Constructed LLG ) epair"e` C ) graded Abandoned( )by G�k OE- � at s S r has been cotrt eted in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated �� / Installer Designer The issuance of this permit shall not be construed as a guarantee that the syst will functip 's design�e[d. Date T - g`I Inspector is Lifif f-f C�t fist 1 � �� � d G; �� S-v � G,r�ran*A) ——————————————————————————————————————— No. % / _ 1 ` Fee 501 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migooal *pgtem Con5truction 30ermit Permission is hereby granted to Construct( )Repair( )Upgrade Q,/ Abandon( ) System located at 1(-2 V� o and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. f' , Date: '19 f Approved by 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANSl hereby certify that the application for disposal works construction permit signed by me dated concerning the ® property located at `'K 010 SVA.ol�p Co,C (a,Vl # ? i, meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less.than or equal to 5 minutes per inch. : A • There are no wetlands within 100 feet of the proposed septic system c/• There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed XThere are no variances requested or needed. / The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] zf the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not'be located less than fourteen(1 4) feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information). ` B) G.W, Elevation 37 +the MAX. High G.W. Adjustment .Z` 3 = 3 cl DIFFERENCE BETWEEN A and B S SIGNED : DATE: i [Sketch proposed pl of system on back]. q:health folder:cent a O S' Id IA r LOC T N l � O SEWAGE PERMIT A. `VILL- 1 T ER'S NAME i ADDRESS _ u - ® UILDE R DR OWN DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �� ���-his C��� �� �� `; 1� �G fln � l 7 h� 1� /,! ���8- C'A T ION SEWAGE PERMIT NO. �VILLACE INSTALLER' N/AME & ADDRESS U I L R OWNER DATE PERMIT ED DATE COMPLIANCE ISSUED a-� � =4, A__. S I �. Fi it � - �y aY �� No. �.... .... Fmc....3.5.�........... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .. .....OF ...... ................................�- � --�.5...�-00 P A liratiun f&Vie veal arks Tumuur#tun amit y Application is hereby mad r`st ermit to Construct ( i�or Repair ( ) an Individual Sewage Disposal System at: L Loca'on-Address or Lot af4.S1.. #7QD....l.[.K-W �t n............. Ste. (1145.�/7.. TT.._.S� dYe�lS.rna : "F Installer Ads Type of Building Size Lot--- ._..... ' ___&1-feet U Dwelling—No. of Bedrooms..........%5.............................Expansion Attic (tic) Garbage Grinder (10) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures .................................. W Design Flow.............ti.0......................gallons per person per day. Total daily flow.........33 ......................gallons. WSeptic Tank—Liquid capacity a gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-----------box rf.?.:!_ y_�.......................... Date......!_Q' 4."AR. ........... a Test Pit No. I------40.....minutes per inch Depth of Test Pit----.«__........ Depth to ground water....DSalle...... f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...................... �+ ----------------------------------------•-.............................................................--•--•-•--•------------........•---••-•--••-•--••--•- O Description of Soil �?�9t12__91-...5�_tiJS�I!�- �1�t�( = `� t _ 6'�:_.. !4 ----...-•-------- x W •-•-•-----••----•--•----••••••-••-•-•••-••••-•-••-•----•---•-•-•---•-------•----------------••--•...----•••••••.......•-•••••••••----•-•----••-•-•-•......_.............................._.............. UNature of Repairs or Alterations—Answer when applicable............................................................................................... -•----------•...................................•----------•---------------------------....._.........................--•-------...........•••••....••••••••••....•----•--...•••••••-••-----•-------•... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bSoi.4ssued by the board of health. Sig .....-----� "'- ' ........................ �D e Application Approved BY• �_�,�.Y Z-....._._ Date Application Disap ve r e following reasons----------------•------------------...-------------------------•--------------------------------------....------ ............................ .... -•-----•--•-------•-•-----•-•--•••-•--------•-•••-•--•.._................................................................................................. Date PermitNo....................................................... Issued........................................................ Date 1 No.9.Z." .1.... FEs....3.. ................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ----....".................................0 F.......................................................................................... ApplirFa#ion for Uiipn,a al Works Tnnitrurtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal,. System at ...�?f. R.�x�...± .�►.. ..... .._&qP,/s rqd 1, _ -----------------11 .............................................................. -----------------------• - --------------- Location-Address or Lot N.g ........................r......... .......................... ............ Owner Addre s W I�hR J....5 -- hJ L 7............................ .� ........ ............. Installer Address / t � C d Type of Building ,, )J»Size Lot___.__......7._....•.........Sq. feet U Dwelling—No. of Bedrooms.......................................Expansion Attic (N0) Garbage Grinder (tJo) Other—Type of Building ............................ No. of.persons............................ Showers ( ) — Cafeteria ( ) ••--•y••---•-----••••••_.............-•••••••�------•----•----•----------------------•--- Design Flow.Other fixtures ......................................................... . allons per person per day. Total dailyflow_:-_-__•----_a-.....................gallon. WSeptic Tank—Liquid capacity tQq( gallons Length ............... Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width......... cf4Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed b _�_e ..�'N ............. Date ''�` a Y ._..I....• .....------ Test Pit No. I.......4?.....minutes per inch Depth of Test Pit-----/�K....._.. Depth to ground water.....n��02q�»-__ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-__--._____-___.-----_._ 9 -----------------------------------•-•-•.•--•- .......-------•-•.......------•------•---....••-•---•-•------........-••......- 0 Description of Soil..__-�©/?/Yj--� 5 t 3501.L._._.��_.&-Gt il A: 5." M C_-0.. 7-0 f"-r nI6- 5W; 17 x ----------•-------•------------••---......•---•----....._.. U --••---•-------------•-•--------------•-••----•-----------•----------------------•------•----------••---------------------•--•----- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ------------------------------------------------•-•----......-•--•-......----------........--••--------•-----•-------------------------------------------------------------------------.............._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance'has be • sued by the bo, d f health. Sign e -... _ D e Application Approved ` � ' By.....: Date Application Disapp e t e following reasons:-------•--------------•--------------------------------•--------------------------------._............•--•_..._ .................................... •... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H H ? .........................OF.. '.............................................-............. .................. Trrfifiratr of Tlaimptinnrr T TWIST RTIFY, That the Individual Sewage Disposal System constructed r Repaired ( ) by----•--- .............• ........................... -- ---------------------••--------.-.---.-----.-•.-------------------------------------.---------- Installer at...K ......................... -: = has been installed in accordance wi he provisions of T�� 5 The State Sanitary od` a *scribed in the application for Disposal Works Construction Permit No........................r................ dated--�d _ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIK FJJNCTION SATISFACTORY. DATE.....I--ZTr l........................................................ Inspector...--- --- ----- ----------------- ---------------•----•---•--------- THE COMMONWEALTH OF MASSACHUSETTS BOAR OF H H f . 2- 7 % ...................0 F.................................................................................... .t" No.......-•------------- FEE..- .... Bilivoriblvinkli�unotr Uan motif Permission is hereby granted... ... ..... td --- --- to Constr <or Repair ( di ,a D' oSal System at No... •---'--••.......• ---•-..........C✓:.....:......... 1.r.... = r �f Street �~ as shown on the a li ion for Disposal Works construction Permit Nam /ea-ted, ___. .................. ...........................•-• ---•- --------•-----------...------•..........-- Health DATECJ./--•---•..............................•••---•-•-•-- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - SIL4C,LE rAMIL'l! FDA Se5lnG Tp yK.. uKE loop eAt I O1 PoSAL PiT V;f. t000 Is L �Q STbrJ .. . ' t BoTToM AIZeA !yt fLz ,m' �� L: c' s4 SF 10 °j LoT. 0 . .L V pEZC�L.QT I otAl EdTC- to'I t`I r IA OF Or ALAN IsL&g i . � 4'yip 'r' •• MM rs�-;rrr �uv lv� 1AAw1' 4 j''p lnoa lwv. ( �k4 sac.. 1oo•S ••: . � .: 00� Tra tj&4 P ac., ; • : . loop 9410 tud. z' ' To ' . . 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SEPTIC TANK CAPACITY LEACHING FACILITY: (type) g'J�L(size) NO.OF BEDROOMS BUILDER OR OWNER _:: Q�I QtJ PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Xj b � - w etl O t I � 1S0 Al 0 1 D a 0 ASSESSOR"S i � , ... �:� .. i:*�:��.�j,�Ii;�::. "I * �' �: /�� - , — 1 5 i'. !!,:1.��_ :4i 1��,V�v- ,�; �-.,�--,--Sii�..�.:.�..._" .� .1 , . : - :q-.-.iuKil . �' 4 wa .>w }sf . ­:: y\ , , � i ::: .. ...­1 - -. - 9 - (�fl y` 1.,­..:,;...��,;� i� " .. �. .. ;�O� .1 ; .. " - ==;;-_.­-­::: V f 'S, /\ ::: � ).. .... .: . . 1AT', --w_.. .... .i:� � . iZ____ 1. . ..N-, ... . , . " _`71� X :. ,:� -i:�.�,i�� :: ­i.�i:i_-.�i��.i::­­...:!.::.:::,.,. " : .. 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HM ] 51 H E A L T H M A S T E R ] HELP [ ] R E C 0 R D ) ACTION Cl For Parcel Number 1521 0351 0021 ] Rental Property(Y/N) [ ] Owner Name BEATY, MARK L TRS ] Zone of Contrib (Y/N) [ ] Location 1845 OLD STAGE RD ] Contaminant Rel (Y/N) [ ] Business Name [ ] Area Number Contact Person [ ] Phone [000] [ ] Fuel Storage Tank Permit [ ) Card on File [ ] Perc Test Well Septic File/Permit No. [P9267 ] [W98-50 ] [98-736 ] Issuance Date [1110981 [1116981 Completion Date [ ] [1221981 Last Communications [ ] (MMDDYY) Comments [1500 ST DBOX 4 CUL 330' S IN 12X33X2 LT ] Cancel [ ] NEXT SCREEN [HM ] ACTION [ ] PARCEL NBR [ ] [ ] [ ] TANK NBR [ ] ] [ ] -y TOWN OF BAR�NSSTABLE �/ c LOC TION S� d I D S- C- SEWAGE # ��7 "VILLAGE�.I� WN066- ASSESSOR'S MAP &LOT 11 P INSTALLER'S NAME&PHONE NO. 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