HomeMy WebLinkAbout0001 OLD TOLL ROAD - Health 1 Old Toll Road•
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Town of.Barnstable
�FTHE r Regulatory Services
Thomas F. Geizer,Director
Public Health Division
BARNSTABLE, Thomas McKean,Director
90o i639. .`��Q 200 Main Street, Hyannis,MA.02601
ArFD MA'S A
Phone: 508-862-4644
Email: health@town.barnstable.ma.us
Fax: 508-790-6304
Office Hours: M-F 8:00—4:30 CO Ff
July 2,2009
Duane F.&Katheryn L. Gelzer RE:' Underground Storage Tank Removal
c/o Chase Manhattan MTG Corporation Order, 1 Old Toll Road,West Barnstable,MA
P.O.Box 569763 Map Parcel 109068,Tank#1
Dallas,TX 75356
Dear Sir/Madame:
The Barnstable Public Health Division(BPHD)is in receipt of a copy of the"Application and Permit'
for storage tank removal and transportation and the Inspection Report issued by the West Barnstable t Fire
Department demonstrating that the underground storage tank was removed from the above referenced
address on or about January 25, 1999.
The Public Health Division appreciates your attention to this matter and has updated its data base to
reflect this fuel tank status change. Should you have any further questions please contact Cynthia Martin of
this office at 508-826-4645.
omas A.McKean,RS,CHO
Director of Public Health
cc: Mrs.Kathy Gelzer
1 Old Toll Road
W. Barnstable,MA 02668
i
Barnstable
r � Town of Barnstable
0
9 Regulator Services Department
1 D'
Y APublic Health Division 2007
200 Main Street, Hyannis MA 02601
Office:508-862-4644 Thomas F.Geiler,Director
Fax:508-790-6304 Thomas A.McKean,CHO
To: Date: April 1, 2009
Duane F. &Katheryn L. Gelzer
c/o Chase Manhattan MTG Corp
PO Box 569763
Dallas, TX 1,S-3
RE: Underground Storage Tank at:
1 Old Toll Road
West Barnstable,MA
Map Parcel: 109068
Tank NO: 1
Our records indicate that your underground fuel (or chemical) storage tank is over 30
years old, and has not been removed as required by section 326-3: subsection 2 of the
Town of Barnstable Code regarding fuel and chemical storage systems.
You are directed to remove this tank within sixty(60) days from the date of this notice.
After your tank is removed, please furnish this office evidence in the form of a permit
from your local Fire Department within ninety(90) days of the receipt of this notice.
You may request a hearing provided a written petition requesting same is received by the
Board of Health within ten (10) days after this order is served.
Per Order of the Board of Health
Thomas A. McKean, RS, CHO
Health Agent
�w 6-A-At"k.
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f.
Barnstable
Town of Barnstable
� MA Regulatory Services Department
200'
Public Health Division
200 Main Street, Hyannis MA 02601 --
l'/
Thomas F.Cieiler,Director
Fax: 0s-790-6.,04 Thormis A McKean,C HO
JPMorgan Chase Bank.N.A. irate: April 1 , 2t109
o: FCCElveo
Duane F. & Katheryn. L. Gelzer
c/o Chase Manhattan MTG f'017) MAY 15 2009
PO Box 569763 �C( �- �] � `� `�t✓�
Dallas, TX Prop Pres Naz Claims ! I
RE: Underground Storage Tank at:
1 Old 'roll ;Road
West Barnstable, VIA �Q �a.51ACt
Map Parcel: 109068
Tank NO: 1
Our records indicate that your underground fuel (or chemical) storage tank is over 30
years old, and has not been removed as required by'section 326-3: subsection 2 of the
"Rouen of Barnstable Code reLardint.:t, fuel and chemical storage systems.
You are directed to remove this tank lvid,iin sixty(60) days from the date of this notice.
After yrntr: ts�r>>: is rerriov(�d of ,- se furnish this offi.cc evidence in the form of a erinit
from your local Eire Department within rtirrety(90) days of the receipt of this n1tice.
You may request a hearing provided a vvi-Itten petition requesting same is rec�'ed b_y d7i ;
Board of 1leallh v�-ithin ten 0 0) cl x}"s �.Ifter this order is sei-ved. -
0 >
e
Per Order of the Board o Health— >'
i {•
1:, 6 Thomas A. McKcan, RS, C'1110) ca, r
F-[calth Agent
•• L✓ /.. f^ 7 �• �/ VAS r 11 i
L
.; WEST BARNSTABLE FIRE DEPARTMENT
2160 Meetinghouse Way
P.O. Box 456
West Barnstable Ma. 02668
www.westbarnstablefire.com
Chief
Joseph V. Maruca
Emergency: 911 Business 508-362-3241 Fax: 508-362-3683
10 June 09
Kathryn Gelzer
One Old Toll Road
West Barnstable, MA 02668
RE: OIL TANK REMOVAL
Dear Ms. Gelzer:
According to this department's records, the oil tank at your home was removed on or
about January 25, 1999. Enclosed are copies of the Application and Permit and the
Inspection Report.
If you have any further questions, please feel free to call me.
Ve[phuV,
ly yours,
Jos . Maruca,
Yi1
ef
jvm/jkk
Make application to local Fire Department.
z
Fire Department retains original application and issues duplicate as Permit.
err�zG`o��rixe� tscced— 0 aa4lal olpOle ✓ q'&V &O'n
APPLICATION and PERMIT Fee:;-
for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 148, Section 38A, 527 CMR 9.00, application is hereby made by:
Tank Owner Name(please print) A 1 Q ren X
ignature i ap yinq or permit
Address P 0 Box 52 ; saernstable , MA 02530
city
Stare zip i
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Company Name Advanced FnyirnnmPntl _ Co. or Individual 7-Piini
Print
Address n Roy 479 r1 g7 Great Western R Pddress Print
I
Signature (j1 plying permit'�r .y;- ,r Signature (if applying for permit)
IFCI Certified Other s O IFCI Certified 0 LSP # Other
1
Tank Location l Old, Toll Rd . , W. Barnstable , MA I
Sleet Address Oily i
Tank Capacity(gallons) 1 000 Substance Last Stored #2
Tank Dimensions(diameter x length)
Remarks:
i
I ,
IFirm transporting wasteAdvanced Environmental. State Lic. # MV5083856100
Hazardous waste manifest# E.P.A.# `
Approved tank disposal yardJames G.Grant CA. , Inc Tank yard# 008
Type of inert gas f' Tank yard address Wo i cot t St Rea did 1 I e-, MA
` ~r�i�`3•� cc- FDID# Z Permit# 1 sal
City or Town b� —
Date of issue 'fv , Z �I 9 Date of expiration v A N ' U q�cj
� ,
Dig safe approval number: 1 ()990=0 1 q Dig Safe Toll Free Tel. Number-800-322-4844
9
Signature/Title of Officer granting permit
After removal(s)send Form FP-290R signed by Local Fire Dept. to UST Regulatory Compliance Unit, One Ashburton Place,
Room 1310, Boston, MA 02108-1618.
�09 rravicgri 9/961
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�. WEST DARNSTABLE-:-FIRE.-DE?AP,TMENT - - - .FIRE PREVENTION•DIVISION
.1 IN P E C T I 0 N R E P O R T
DATE OF REQUEST .� ��. TIME `J SUS: DATE _ - REC'D BY' �t = € . .
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REQUEST BY,-,
WS 26F BI;ASTI 6 COURTESY PRE FLAN
TYPE INSPECTION.: FA FP OB ___;-
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PUB FACILA OTHER
REASON FOR,-! (if applieable� V.
INSPECTION LOCATION:
CURRENT OWNER N l�t `Lrctl �YC1'c �J�J a -A- P
7777
CURRENT OCCUPANT N P
NEW,'OWNER'; N
A7777777-7,
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NEW OCCUPANT N'
ADDITIONAL NAMES, OCCUPANTS r
REMARKS t
PRELIM INSP ��; � � � 2nc1 IrNSP` FINAL _ ;
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ADATE f Z5 ',CPT F#�`F1 3 FEE $ DATE RCPT
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STREET`N UMBERS
PHONE STICKERS LOCATOR 'ILE ,S4TREET LISTING s r', OTHER {
WBFD,form_36 1/85
Mrs.Kathy Gelzer - _ "`* •. .., a--
`1 Old Toll Rd. -CAPE CC)D -MA 02-5-02.6 •
W.Barnstble,MA 02668 _
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�� -- CHASE CP
Chase Home Finance LLC (OH1-8021)
800 Brooksedge Boulevard
Westerville OH 43081-2822
May 22, 2009
Town of Barnstable
Regulatory Services Department/Public Health Division
200 Main Street
Hyannis, MA 02601
We Are Unable To Act on Your Notice
Property Address: 1 Old Toll Road
West Barnstable, MA 02668
Dear Municipality:
Chase Home Finance LLC recently received the enclosed notice(s) from your office regarding the above-
referenced Property.
Chase Home Finance LLC is unable to take action at this time on the matter of your notice; however, we
will forward the notice(s)to the borrower(s). Chase Home Finance LLC reserves the right to be notified
of future violations.
If you have any questions, please contact us at the number below. Your prompt attention to this matter is
greatly appreciated.
Sincerely,
High Risk Unit
Chase Home Finance LLC
(614) 776-8052
(800) 582-0542 TDD/Text Telephone
(614) 776-8688 Fax
High.Risk.Violations@Chase.corn
Enclosure(s) M
1. Code Violation Notice(s)
w
HR502
I
Barnstable
Town of Barnstable
MAE, Regulatory Services De artment
p
Public Health Division 2007
200 Main Street, Hyannis MA 02601
4511''`
Office:508-862-4644 Thomas F.Geiler,Director
Fax:508-790-6304 Thomas A.McKean,CHO
31513i'
JP organ Ch$se Bank,NA, Date: April 1, 2009
i o" Fc�EiVED
Duane F. &Katheryn L. Gelzer
c/o Chase Manhattan MTG Corp MAY 15 2009
PO Box 569'763 ,,
Dallas, TX Prop Pres/Haz Claims t
RE: Underground Storage Tank at:
1 Old Toll Road
West Barnstable,MA
Map Parcel: 109068
Tank NO: 1
Our records indicate that your underground fuel (or chemical) storage tank is over 30
years old, and has not been removed as required by section 326-3: subsection 2 of the
Town of Barnstable Code regarding fuel and chemical storage systems.
You are directed to remove this tank within sixty(60) days from the date of this notice.
After your tank_is removed, please fv.rnish this office evidence in the form of a permit
from your local Fire Department within ninety(90) days of the receipt of this notice.
You may request a hearing provided a written petition requesting same is received by the
Board of Health within ten(10) days after this order is served.
Per Order of the Board of Health
Thomas A. McKean, RS, CHO
Health Agent
Y, CERTIFICATE OF ANALYSIS RECEIVE age: 1
Barnstable County Health Laboratory
Report Prepared For: Report Dated: 6/10/2003 JUN 16 2003
Order Number TO NSTABLE
PT.
Katheryn Gelzer
P0 Box 515
Cummaquid, MA 02637
Laboratory ID#: 0320033-01 Description: Water-Drinking Water
Sample#: 20033 Samnline Location: 1 Old Toll Road, West Barnstable Collected 6/3/2003
Collected by: Katheryn Gel Received 6/3/2003
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates 2.6 mg/L 10 EPA 300.0 6/4/2003
LAB: Metals
Copper 0.1 mg/L 1.3 SM 311113 6/10/2003
Iron <0.1 mg/L 0.3 SM 311113 6/10/2003
Sodium 19 mg/L 20 SM 311113 6/10/2003
LAB: Microbiology
Total Coliform Absent P/A Absent 307 6/4/2003
LAB: Physical Chemistry
Conductance 174 umobs/cm EPA 120.1 6/3/2003
pH 6.8 pH-units EPA 150.1 6/3/2003
Note: Water sample meets the recommended limits for drinking water of all above tested parameters.
Approved By:
(Lab Director)
a
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
i
' . Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 Old Toll Road
West Barnstable
Owner: Greg Mitchell
Date of Inspection: 5/14/2003
Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D
C. S stem Passes!
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Condi' al Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or re . ,as approved by the Board of Health,will pass.
Answer yes,no or not determined (Y,N,ND)in the the following statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old* r the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltrati or tank failure is imminent.System will pass inspection ifthe
existing tank is replaced with a complying septic as approved by the Board of Health.
*A metal septic tank will pass inspection if it is cturally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years of is available.
ND explain:
Observation of sewage backup or reak out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken, ed 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 requir pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with proval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
i
Page 3 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 Old Toll Road
West Barnstable
Owner: Greg Mitchell
Date of Inspection: 5/14/2003
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require further ev/thee Board of ealth in order to determine if the system
is failing to protect public health,safety or the e
1. System will pass mien Board of Healtdetermines' ccordanee with 310 CNIR 15.303(1)(b)that the
system is not functioning in a manner eet public health,safety and the environment:
Cesspool or privy is within 50 fib oaterCesspool or privy is within 50 feet o vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water S plier,if any)determines that the
system is functioning in a manner that protects the public health,saf and environment:
_The system has a septic tank and soil absorption system(S S)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 ' within a Zone 1 of a public water supply.
_The system has a septic tank and SAS and the S is within 50 feet of a private water supply well.
The system has a septic tank and SAS and a SAS is less than 100 feet but 50 feet or more firo m a
private water supply well**. Method used to ine distance
"This system passes if the well water an is,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds in ' that the well is free from pollution from that facility and
the presence of ammonia nitrogen and ni a nitrogen is dual to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of analysis must be attached to this form.
3. Other:
f
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: I Old Toll Road
West Barnstable
Owner: Greg Mitchell
Date of inspection: 5/14/2003
D. System Failure Criteria applicable to all systems:
You most indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or
cesspool
_ _&j4iquid 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
WSW supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ y portion of a cesspool or privy is 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 eoliform 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 most be attached to this form.]
A/O(Yes/No)The system Lqils. I have determined that one or more of the above criteria exist as
described in 310 CMR 15303,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 he considered a large system the system most serve a facility with a deli flow of 10,000 gpd to 15,000
SP&
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria a e)
yes no
the system is within 400 feet of a surface drinking water su ly
T _the system is within 200 feet of a tributary to a surface king water supply
— _the system is located in a nitrogen sensitive area im Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yea"to any question in Section the system is considered a significant threat,or answered
"yes"in Section D above the large system has fail a owner or operator of any large system considered a
significant threat under Section E or failed under on D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the ropriate regional office of the Department.
i
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: t Old Toll Road
West Barnstable
Owner: __Greg Mitchell
Date of Inspection: 5/14/2003
Check if the following have been done. You most 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?
j C i Was the site inspected for signs of break out?
_ Were all system components,excluding the SAS,located on site?
�aC — 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 than owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
_ Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of distance
is unacceptable)P 10 CMR 15.302(3)(b)]
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL P TECTION ,y}�.q�y.
MAP
PARCEL. 6 .»_..... M (Y2 9�t2003'
LOT - - _ rtf0VW1U'6BARNSTABLt.H {'
H l ffGERIP—t _ a
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
` CERTIFICATION
Property Address: I Old Toll Road
West Barnstable
Owner's Name: Greg Mitchell
Owner's Address:
Date of Inspection: 5/14/2003
Name of Inspector: (please print) Kevin J.Sullivan
Company Name: Ready Rooter
Mailing Address: P.O.Box 371
Sandwich,MA 02563
Telephone Number: (508)888.6055
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310,CMR 15.000). The System:
_Passes
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
Inspector's Signature: rr - � Date: .->
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 Old Toll Road
West Barnstable
Owner: Greg Mitchell
Date of Inspection: 5/14/2003
FLOW CONDITIONS
RESIDENTIAL.
Number of bedrooms(design): 4- Number of bedrooms(actual): _
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): S5 C>C.;�t}j.
Number of current residents: c_ Z_
Does residence have a garbage grinder(yes or no):Y
Is laundry on a separate sewage system(yes or no):cif yes separate inspection required]
Laundry system inspected(yes or no): —
Seasonal use:(yes or no):h,-K:o
Water meter readings,if available(last 2 years usage(gpd)):.t.ti y z r k �
Sump Pump(yes or no):A,29
Last date of occupancy: ���a
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): d
Basis of design flow(seatslpersons/sgft etc
Grease trap present(yes or no):
Industrial waste holding tank present or no):_
Non-sanitary waste discharged to the itle 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use.
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: cn,.�,,,,,�
Was system pumped as part of the inspection(yes or no):4"
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_�eptic 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:.
.e,Q nr S.e c�.r vw ► Y, r�G Z'I
�1 O�a.c�, o�' {-�tru►lT' WS loch\"t'
Were sewage odors detected when arriving at the site(yes or no):
Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 Old Toll Road
West Barnstable
Owner: Grey Mitchell
Date of Inspection: 5/14/2003
TIGHT or HOLDING TANK: (tank must be ped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete Tm _fiberglass,polyethylene other(explain):
Dimensions:
Capacity: sallo
Design Flow: astday
Alarm present(yes or no):
Alarm level: Alarm in king order(yes or no):
Date of last pumping:
Comments(condition of al and float switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:J=L"
Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
ta L`wv-. k 3 coca cu k c 'r 5
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note conditions of pump chamber, ition of pumps and appurtenances,etc.):
Page 9 of 11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 Old Toll Road
West Barnstable
Owner: Greg Mitchell
Date of Inspection: 5/14/2003
SOIL ABSORPTION SYSTEM(SAS):—tZOoeate on site plan,excavation not required)
If SAS not located explain why:
Type
v�eaching pits,number:
leaching chambers,number:
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.):
CESSPOOLS: (cesspool must be pumped as of inspectionXiocate 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 or no):
Comments(note condition of SOP igns 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 h ulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 Old Toll Road
West Barnstable
Owner: Greg Mitchell
Date of Inspection: 5/14/2003
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.
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 Old Toll Road
West Barnstable
Owner: Gr,S Mitchell
Date of Inspection: 5/14/2003
SITE EXAM
Slope ✓
Surface water
Check collar-
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
__.�/O^btained from system design plans on record—If checked,date of design plan reviewed: S
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with the local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You most describe how you established the high ground water elevation:
.T
r
Coninionwealth of Massachusetts
Executive Office of Envirommental Affairs
Dept. of Environmental Protection
One wititer Street Boston Ma. 02108 'Joh.n Grad
• U.L.P. 'ritie v Septic inspector
P.U. 13o121.19
rlTeatick
WILLIAM F.WELD (S 9
Governor
ARGEO PAUL CELLUCCI
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION �1 lg
,9,9
Property Address: 1 OLD TOLL RD.W.BARNSTABLE MAP 109 PAR 68 Address of Owner: N
Date of Inspection: 12/10/98 (If different)
Name of Inspector: JOHN GRACI COLDWELL BANKER 2 WILLOW ST.SAND 63 ATT.C
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) ry
Company Name, Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X_ Passes This Inspection Is based on criteria defined In Title V
Conditions P code 310CMR16.303.Myfindings are of how the systemis
yasses performing at the time of the inspection.My inspection does
_ Needs Fdihsr Evaluation By the Local Approving Authority not Imply any warranty or guarantee ofthelongevttyofthe
Falls septic system and any of Its components useful life.
Inspector's Signature: Date: 12110198
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B. C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
_One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 0 412 7)9 71
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 OLD TOLL RD.W.BARNSTABLE MAP 109 PAR B8
Owner: COLDWELL BANKER 2 WILLOW ST.SANDWICH MA.02563 ATT.CHRIS
Date of Inspection:12110198
_ Sew,aae backup or.breakout or hicih.static water level observed.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliforrn bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
_ — Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Mclhaige or punding Of of Llelit ti)the slltfdce of (fie gibt)iid o) sii)face Wateis due lu an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 OLD TOLL RD.,W.BARNSTABLE MAP 1e9 PAR 88
Owner: COLDWELL BANKER 2 WILLOW ST.SANDWICH MA.02563 ATT.CHRIS
Date of Inspection:12NO198
D] SYSTEM FAILS(continued)
Yes No
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
— _ the system is within 200 feet of a tributary to a surface drinking water supply
— _ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area(IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04127197)
L_ _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 1 OLD TOLL RD.W.BARNSTABLE MAP 109 PAR 68
Owner: COLDWELL BANKER 2 WILLOW ST.SANDWICH MA.02563 ATT.CHRIS
Date of Inspection:12110199
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
_x_ Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— — flow rates during that period. Large volumes of water have not been Introduced into the system recently or as part of this
inspection.
— x As built plans have been obtained and examined..Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
_X_ — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected
— — for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
x _ The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is
unacceptable)[15.302(3)(b)]
(revleed04127/97)
� I
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 1 OLD TOLL RD.W.BARNSTABLE MAP 109 PAR 58
Owner: ' COLOWELL BANKER 2 WILLOW ST.SANDWICH MA.02563 ATT.CHRIS
Date of Inspection:12110198
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 440 g p•d./bedroom for S.A.S.
Number of bedrooms: 4
Number of Current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings,if available:(last two(2)year usage(gpd):
n1a
Sump Pump(yes or no): No
Last date of occupancy: NOV 161999
COMMERCIAL/INDUSTRIAL:
Type of establishment: n1a
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings, if available: n1a
Last date of occupancy: nra
OTHER: (Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
rva
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: n1a
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed(if known)and source information:
1979
Sewage odors detected when arriving at the site: (yes or no) No
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 OLD TOLL RD.W.BARNSTABLE MAP 109 PAR 68
Owner: COLDWELL BANKER 2 WILLOW ST.SANDWICH MA.02563 ATT.CHRIS
Date of Inspection:12110199
SEPTIC TANK: x
(locate on site plan)
Depth below grade: V
Material of construction:x concreate_metal FRP_Polyethylene_other(explain)
If tank is metal, list age n1a . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: L8'6"H5'7"W4'10"
Sludge depth:1'
Distance from top of sludge to bottom of outlet tee or baffle: 22"
Scum thickness:8"
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle: 10"
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to Outlet invert, structural integrity,
evidence of leakage, etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAINED EVERY TWO YEARS.
GREASE TRAP:_
(locate on site plan)
Depth below grade: rva
Material of construction: concrete metal FRP Polyethylene_other(explain)
Dimensions: rVa
Scum thickness:rVa
Distance from top of scum to top of outlet tee or baffle:rVa
Distance from bottom of scum to bottom of outlet tee or baffle: Na
Date of last pumping;,la
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
rVa
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 1-6,,
Material of construction:_cast iron x 40 PVC_other(explain)
Distance from private water supply well or suction line?00*
Diameter: nla
�vaimments: (conditions of joints, venting,evidence of leakage, etc.)
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 OLD TOLL RD.W.BARNSTABLE MAP 109 PAR 68
Owner: COLDWELL BANKER 2 WILLOW ST.SANDWICH MA.02563 ATT.CHRIS
Date of Inspection:12110198
TIGHT OR HOLDING TANK.:
(locate on site plan)
Depth below grade: nta
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: nia
Capacity: nla gallons
Design flow: Na gallons/day
Alarm level:_nia Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Na
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)Nu
Alarms in working order(yes or no)_ve:
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
Na
O
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 1 OLD TOLL RD.W.BARNSTABLE MAP 109 PAR 68
Owner: COLDWELL BANKER 2 WILLOW ST.SANDWICH MA.02563 ATT.CHRIS
Date of Inspection:12110198
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
rda
Type:
leaching pits, number: 2•1000 GALLON LEACH PITS
leaching chambers, number:Na
leaching galleries, number rda
leaching trenches, number, length: n!a
leaching fields, number, dimensions:nla
overflow cesspool, number:nla
Alternate system: rda Name of Technology:_nra
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation. etc.)
THE LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.ONE LEACH PIT HAS BEEN 314 FULL,THEN OTHER PIT HAS NOT HAD MORE THAN 2'OF WATER IN IT.
CESSPOOLS:_
(locate on site plan)
Number and configuration: nla
Depth-top of liquid to inlet invert: rda
Depth of solids layer: n!a
Depth of scum layer: We
Dimensions of cesspool: nla
Materials of construction: rda
Indication of groundwater: nla
inflow(cesspool must be pumped as part of inspection)
rda
Comments: (note condition of soil, signs of hydraulic failure,level of ponding; condition of vegetation, etc.)
rda
PRIVY:_
(locate on site plan)
Materials of construction: rda Dimensions: rda
Depth of solids: nfa
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
nla
(revised 0427197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
1 OLD TOLL RD.VQ.BARNSTABLE MAP 109 PAR 68
COLDWELL BANKER 2 WILLOW ST.SANDWICH MA.02563 ATT.CHRIS
12/10198
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
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(revised 04127197) Pay of 10
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+ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
1 OLD TOLL RD.W.BARNSTABLE MAP 109 PAR 88
COLDWELL BANKER 2 WILLOW ST.SANDWICH MA.02563 ATT.CHRIS
12/10198
Depth of groundwater 12,
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
X Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
X Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS MAPS AND CHARTS AND VISUAL,BOTTOM OF PITS ARE AT7'
(revised04127197) page 10 0[ 10
^ TOWN OF BARNSTABLE C d
LOCATION r SEWAGE
:`ILLAGE bj ( -_A 12fU- ASSESSOR'S MAP & LOT 1:14,'R
INSTALLER'S NAME & PHONE NO. 1 I' 1pftlril 3e2-- 3a
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) �
NO. OF BEDROOMS PRIVATE WE(jLL OR PUBLIC WATER
BUILDER OR OWNER Pb I(la 14ff 14
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
,-.. ,
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ASSESSORS MAP NO. l y
GGyy??i� PARCEL NO: l' G
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF !-HEALTH
TOWN OF BARNSTABLE
Appliratiou for Dig oittl Worko Tonotrurtivit Famit
Application is hereby made for a Permit to Construct ( ) or )R�e/p'air (�) an Individual Sewage Disposal
Systeml .../�! ... ......................... ! f' 5 G7/. �..................................... ( ....
Loc.tion-Add s or Lot No.
Owner dress
a . '..._.. . . 1- ----------------------7-5.------� f ---- -,6�.�--�4e.. `� ��'�t�.�.------------------------..........---
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling— No. of Bedrooms----- -----------------------------------Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—Type of Building G'-9 No. of persons............................ Showers — Cafeteria
YP g �---------- P ( ) ( )
Otherfixtures --------------------------------------------------------------------------------------- -------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacitv............gallons Length---------------- Width................ Diameter....------------ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........... .......... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by_-----------------_- .................................................. Date........................................
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-.__-_-_--_-_-_------._.-
GZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ------------------------------- -----------------------------------------------------------------------------------------------------------------------------
0 Description of Soil----------------------------------------------------------------------=-------------------------------------------------------------------------------------------------
x
W ------ - --- - - --- ----- --- --- ------ --
UNature of Repairs or Alteratiytns—Answer when app)�cable_-_.-ETC ---__-_-/4�4......�'�.4---.1...........................................................
------------�- �.• -----------��-- ----- �� r`�r�
Agreement-.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia ce h s been issu�by t board of health.
4��
Signed ------------- --- lr. ...t� �.�..............................
Application Approved B Li.... ............. - ----- ----.._ -- - -- .......
Dace
Application Disapproved for the following reasons: ............................................ ...................................................... ..................
............ ...................................................... . ................................................. . ...........................----------------------- ........................................
Permit No. ------ �' .`...r ... Issued ....... .....
ram/
Dace _ e
v// -'---'---------------------------
• F x`
THE COMMONWEALTH OF MASSACHUSETTS V
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Mrip ial Wurk,5 Tomitrurtiinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair (fk) an Individual Sewage Disposal
System at: ±.
-___._. _._._..tj .... ------•-------------- --•-------_.___-- ---......---
Loc tion-Addre_U, or Lot No.
fov er / as -------•-------•-------•-----------------•---
-----------------------------
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building _ �✓ ' _ ._ '_. No. of persons---------------------------- Showers ( ) — Cafeteria ( )
Otherfixtures -----------------------------------------------------.--------------------------------- .------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter................ Depth................
x Disposal Trench—No. .................... Width......-------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.............................................................. ----------- Date........................................
a
Test Pit No. I................minutes per inch Depth of Test Pit.--_--___.___.--.--_ Depth to ground water........................
G14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
----•------------------------------------------------------ -----------------------•------------•--------------
•--•••••.............
_____......
_---------
ODescription of Soil---------•-------------------------------------------------------•---------------------..--•-----••-----------------•-------------------------------•------------------.
x
V ---••----••---•---...---•-•-----•-------------------------------•--._.......------------.._..._....--------------------•--------------------•------------------•--••--------•--______-------•----------•
UW -----------------•-- ...- ................. ------------------------------------------------------------- -- •------0...........
Nature�fRe�i o Alter4ns—Answer whey applicable..__.. � .............................' ___.(____________________________
.................................�_._..._._.__..__`..........._ ...;± ...... .........__._.....----._____.......__..._----------..__..__......_....__..__..._..__.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has been issued by the board of health.
Stned :. ,�.::.. .......... •/`�/ ...- '.................. ..----------.....
�t
Application Approved By ---- = ...'.'-------- -t ---- "" - .': f
Dare
Application Disapproved for the following reasons- --- ---------------------------------------1 `-
........................ ..................... ................................................... .......... .................................,... .-........................ ........................................
Permit No. ......:z:.......//. '�/ :................................. Issued ....... .�.........'...............F....
�� �f � Dare
` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
V��TT Ertifi ate of Tompliance
THIS IS jT;0 CE I j�Y,� t the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by .. ....... .. -
at - -------------------------d ---------------------- ..IAII........ <f�.........._.. ........ ........ ........... . . .......... .
has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ------ dated .....�.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT lTH
SYSTEM WILL FUNCTION SATISFACTORY.
- `
` 7 ......... .. .. .... Ins ecto
DATE - _................_-_. p C�
i
--------------------------------------------- -----------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.
w TOWN OF BARNSTABLE BLEs
No.. �-... FEE........................
Dispout nrk � lii�#r uan rrnti#
Permission is hereby granted------ ....----r -----------------------------•-------------------------------.-.--------------_.._---
to Construct ( `l)nor„Repa' ( ) I dividual SewageFDisposal System
atNo............ ------ ........................................................ U--1----•- ....................•------------...........................................
Street �` +
as shown on the application for Disposal Works Constructio, Permit Igo.' '' ��ated..__� -y _.!�"� .��.":...��
„_„ Board of Health
DATE..... ------ ... ------------------------------ •••
FORM 36508 HOBBS✓i WARREN,INC.,PUBLISHERS
A
,t0` C�TION SEWAGE PERMIT N0.
',Y It LL"A G E
INSTA LLER.'S NAME i ADDRESS
arc (a -h � 7'
�I
B UILDE R OR OWNER
fi 4 A
DATE PERMIT ISSUED p
DAT E COMPL1IANCE ISSUED
aL
L�
-7S n
` No............ s-----.. - s..........
.
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® QF HEALTH
-.
dtZa�l..............O F............. . ..................................
Appliration for Diapos ai 10orkii Tnnitrnrtinn "permit
Application is hereby made for a Permit to Construct or ( ) an Individual Sewage Disposal
System t
s Locati Add s or Lot No.
ne Address
•................................ . . . ...•- -•- -`-�c:+.G'--- .-------------•-••--•---------- ---•------------------•--------•--•---------•--
Installer Address
Type of Building Size Lot ..��e! .:Sq. fe t
U Dwelling JE No. of Bedrooms............ ��-----------------------Expansion Attic ( ) Garbage Grinder )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures .............................. . .
W Design Flow. ......___ _. ...�. _...................gallons per person per day. Total daily flow__ ;_d....._._..__........_._gallons.
WSeptic Tank Liquid capacity............gallons Length................ Width................ Diameter....._.......... Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.....................) Diameter----------------.... Depth below inlet_............._ . T61 ot ching area. ... ............sq. ft.
Z Other Distribution box Dosing tank ( ) / Q�� �04q � - v -5`?
Percolation Test Results Performed by------ �. ---6-,f9at�a.-
-------------------------•------. Date...&--=�'-ZZ:.............
aTest Pit No. 1.....J6___.___.minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•-----------•------------------------- -------..-----
Descripti of S 1 ',/ .... �--L --4Z4.....� 7
U - - -- 1-.� p j(
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 T IT i.;,.. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be ued b the board of health.
Signd.. ..... ... ."�-_.......---•---•----•--•. ................................
Application Approved By..--.--- �,.- ..._. t
4 --�-f�
Date
Application Disapproved for the following reasons:.............................................. = .............................................................
r-
Date
PermitNo......................................................... Issued................................... --------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O/F�" HEALTH
LL�''i �J ......................................
Trdifirate of T.umphaure
THIS TO CER FY, T at t Indivi al ewage Disposal System constructed ( or Repaired ( )
y�pqp - - In aller
has been installed in accordance with the provisions of T T 5 of The State Sanitary Code as descri d in the
application for Disposal ,�Vorks Construction Permit No. __..._.... _ �_l....._ da.ted_.[P jam..'-_� ...............
n
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
......
7
DATE ----..1!............ ...•--••.........................•. Inspector.,��___...------ 1W -- -----••---..-----.----.-
No...'3.�s........ FRA..............................
• THE COMMONWEALTH OF MASSACHUSETTS
'�f 2f21 BOAR 9,`�F -H .
1
for Bispniia1 ork,- Tomitrurtion Vamit
SystApplication is here ,y ma a for a Permit to construct ( ) r Repair ( ) an Individual Sewage Disposal
7
a :j
...... .....-------•---------------------------------------•--•----...-•--_.....-•--
--h r
' .I�ocatiAfess � or Lot No.
._..
�f J
.........;/..................-- ............ ...._..._...... -...
Owner Address
W ...._..•••--••....................•--•--......._.................... •-••--.....----------•--•-•-•---••--•-•-•-•-_............_...............-_ ....
� Installer Address
Type of Building Size Lot____ .. , ,_a_ q. feet
Dwelling,�-No. of Bedrooms______________ ------Expansion Attic ( ) Garbage Grinder
( .�.
pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria )
a
� Other fixtures -------•-------- -------•----------•-----------------------------•---------------------.---------•------------•-----•-•------._...-------._......._..
W Design Flow............. f7....................gallons per person per day. Total daily flow___ _!�. �.... ":................_..gallons.
WSeptic Tank 4 Liquid capacity............gallons Length................ Width-_---_--___.____ Diameter-----........... Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total Jeac ing area.__..............___sq. ft.
Seepage Pit No..................... Diameter.................... Depth be-l-owy+jWet.f.fE:�.yF. �T� h e _arena .� _�.7.7sq. ft.
Z Other Distribution box ( ) Dosing tRk- G) _ /C�`�' 77•
aPercolation Test Results— Performed by.......................................................................... Date........................................
r a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
h, Test Pit No. 2................minutes per, inc Depth of Test Pit......:....._._v_..,Depth t�oundGyvavte ...............
tx `.w,�.E .S uZ — 2 .........................................................
D Descri t'on of Soil �_ / 0.2'. ---------------------•••-••--------
P C t-------;y
x tit- i�! - j'`r`' 1
(� --------
•-------------------------------------------
•-------------------------------
.------------------------------------------------------------
•-----------
-----------
---.----------------•-----------
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 TIT1E 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee d by the board of health.
g f ►. --------------
� -----�s -:-
/ GG-�li� �/ r Date
ApplicationApproved BY--•----•--•-------•--- .....................................=..................................... ........................................
Date
Application Disapproved for the following reasons:............................................ -----•-----••-----••--•------•----•--•---•----•-•--•••....-••--_..
......-•-------------•----...-•--•---........----------•-•--....-•----------•-------................-•------••--------•---•-•---------••••--•-----•-•---------•----•---•------•-----------•-•-•---------
Date
PermitNo......................................................... Issued.......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OZHKA�LTH
..........................................OF.....................................................................................
(9rdifiratr of fir mplittnrr
S TO CERTIFY, That the Individual Sewage Disposal System constructs I) or Repaired ( )
THIS p
by .........................................7" 4`/1 ' � p at....--•=�--.�--•'----------•-••--------------------1..----•-......-�......._..------•-------------------;---1 --------------------------•-- •------fe->---/-L�-�-=------7 1
has been installed in accordance with the provisions of `I'IF'1 5 ofS�TMate Sanitary CO de as described in the
application for Disposal Works Construction Permit No......................................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............. .... . .. ...7. .......................... Ins ector.� L� t ........---
THE COMMONWEALTH OF MASSACHUSETTS
14
BOARD OF
r AN6TP
S
............................................OF.....................................................................................
No......................... FEE........................
Permissionis hereby granted..............................................................................................................................................
to Construct or Repair an In iv'du 1ewa a Dis os-1Sat No. ystem ( '
(r) P ( ) d g P 1 Y
4/1 .,//
r
.tl f G+� { �freet, � r
as shown on the application for Disposal Works Construction_Pp/rx ylXcaF_:._.�___.,%= a�d(�__�1�r.`.?��:_........
/ ------•---
�� �
DATE........ �� 29.....................
Board of Health
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
REVISIONS
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(�i�:�c'/'l, ,'lJ DPAWING NUMBER
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