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Home My WebLink About0016 OLD TOLL ROAD - Health 16 OLD TOLL ROAD,W. BARNSTABLE 67 A= 109 0 Commonwealth of Massachusetts o Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments c;~ 16 Old Toll Road ,.•. Properly Address Ann Klickstein Owner information is W stgBamstable required for every MA 02668 7-19-18 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. Please see completeness checklist at the end of the form, Important,When f A. General Information filling out forms on the computer, OF Aft use only the tab y ••"' ' ., �� 1. Inspector: :•' �+ key to move your cursor-do not JAMES •Ny James D.Sears use the return key. Name of Inspector :y Ca ewide Enterprises *'•%L � Company Name .��•��.,,.. •••,,.G� `� 153 Commercial Street � S 1N50- Company Address r�tuwt,a►�"oll# Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number r 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 maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-21-18 spector'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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5iru.doc•rev.6/16 We 5 Official Inspaction Form;Subsurface Sewage Disposal System•Page 1 of 17 I. a5ed xed dH L6:6Z 860Z £Z lnr Commonwealth of Massachusetts Title 5 Official Inspection Form 4�e Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Sri 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name information is West Barnstable required for every MA 02668 7-19-18 page. C1tylrown 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: The system is a 1000 Gal. Tank and four chamber's 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. x 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. ❑ Y ❑ N ❑ ND(Explain below): t5ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Z a5ed xed dH L1,4e 860Z EZ lnr Commonwealth of Massachusetts { Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v, 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name information is every West Barnstable required for eve MA 02668 7-19-18 page. City7own State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cant.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 15ins.d0c rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 £ a5ed xe:1 dH L6 6Z 860Z EZ lnr Commonwealth of Massachusetts Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name information is required for every west Barnstable MA 0266E 7-19-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2, System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 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 the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in 094M is less than 6' below invert or available volume is less than 1/day flow LEAell jmS t6ins.doc-rev.6116 Title 6 Official Inspection Form:Subsurface sewage Disposal System•Page 4 of V 17 a5ed xeJ dH Ll,:2 860Z EZ lnf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 4 16 Old Toll Road Property Address Ann Klickstein Owner Owners Name information is required for every West Barnstable MA 02668 7-19-18 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliforrn 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- 10,0009pd. ❑ ® 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 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Wns.doc•rev.6116 Title 5 Official Inspection Form:Subsurface sewage oisposal system-Page s of 17 5 a5ed xed dH L6:6Z 860Z EZ lnf i Commonwealth of Massachusetts _ Title 5 official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments L.; 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name Information is every West Barnstable required for eve MA 02668 7-19-18 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ 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)] D. System Information Residential Flow Conditions. Number of bedrooms (design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5itis.doc-rev.61'6 Title 5 Officlal Inspection Form:Subsurface Sewage Disposal Syelern-Page 6 of 17 9 a5ed xed dH L 6i 6Z 860Z EZ lnr Commonwealth of Massachusetts Title 5 official Inspection Form 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name information is required for every West Barnstable MA 02668 7-19-18 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1000 Gal. Tank and four chambers, Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Well Water Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/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: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Psge 7 of 17 L a5ed xeJ dH 860Z 8Z lnr Commonwealth of Massachusetts Title 5 official Inspection Form `i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name information equir at for West Barnstable MA 02668 7-19-18 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 2010/2013 12015 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5inc.tloo•19v.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pages of 17 9 a6ed xeJ dH 91.:2 8l,0Z EZ tnr Commonwealth of Massachusetts Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name information is required for every West Barnstable MA 02668 7-19-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known)and source of information: 1998 98-530. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 27"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.): Pipeing is 4"PVC, Septic Tank (locate on site plan): Depth below grade: 17"feet Material of construction: ®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 1" t5ins doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 6 a5ed xeJ dH 61,4Z 8l•0Z £Z lnf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name information is required for every West Barnstable MA 02668 7-19-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge 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 at working level. Tank and cover's at 17" below grade. In and outlet baffles. No sign of leakage or overloading. 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 6ins.doc-rev.6116 Title 5 official Inspection Form:Subsurface Sewage Dlsposal System•Page 10 or 17 pt abed X2J dH 61,:2 860Z £Z lnr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name Information is required for every West Barnstable MA 02668 7-19-18 page. City/Town State Zip Code Date or Inspedion 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.): 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 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 t5ins.doc•rev.W16 T tla 5 6ficial Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I,L abed xej dH 66:2 860Z £Z lnr Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name information is required for every west Barnstable MA 02668 7-19-18 page. C4y/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet in No Box 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No' Alarms in working order: ❑ Yes ❑ No' Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): " If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ina.doe•rev.6M6 Title 5 Official Inspection Form'.Subsurface Sewage Disposal System-Pape 12 of 17 Zi, a5ed xed dH 61,4e 860Z £Z lnr Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name information is required for every West Barnstable MA 02668 7-19-18 page. City/Town State Zip Code Date of InspWlon D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativelalternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is four infiltrators w/3' stone.Camera out and prob area. Chambers-are clean wino sign of holding water. 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 t5insdoc rev.N16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 19 of 17 El, abed xed dH O LE 860Z EZ lnf Commonwealth of Massachusetts uv Title 5 Official Inspection Form iSubsurface Sewage Disposal System Form - Not for Voluntary Assessments 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Name information is required for every West Barnstable MA 02668 7-19-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): 15ins.cloc-rev.6116 TO 5 Oftal Inspection Form:Subsurface Sewage Disposal Syslem•Page 14 of 17 tq a6ed xed dH 02 860Z £Z tnr c Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 16 Old Toll Road u Property Address Ann Klickstein Owner Owners Name information is required for every West Barnstable MA 02668 7-19-18 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below, ® hand-sketch in the area below ❑ drawing attached separately C A FOR z 31 . f -�T 36-4 t5ins.doc-rev.611E Ttle 5 Official Inspectior Form:Subsurface Sewage Disposal System•Page 15 of 17 g 6 abed xed dH OZ:2 8l•0Z £Z lnr c Commonwealth of Massachusetts Title 5 Official Inspection Form �s Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 16 Old Toll Road `f Property Address Ann Klickstein Owner Owner's Name information is required for every West Barnstable MA 02668 7-19-18 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells N� Estimated depth toFigh ground water: 2 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: Area and lot high . No G.W. problem seen. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 This 5 official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 gt abed xeJ dH OZ:6Z 860Z £Z lnr i p Commonwealth of Massachusetts ,g Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �I 16 Old Toll Road Property Address Ann Klickstein Owner Owner's Narne information is required for every West Barnstable MA 02668 7-19-18 page. City/rown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ine.doc•rev.6A6 Title 5 Ofxial Inspection Form:Subsurface Sewage Disposal System•Page V of 17 a5ed xed dH 2:6Z 860Z EZ lnf 5 � s It v , N , ti Q TOWN OF BARNSTABLE LOCATION G cQ �C�� 2—� SEWAGE # VILLAGE 1aTP .�,b eQ,�� ASSESSOR'S MAP & LOT_ INSTALLER'S NAME&PHONE NO. „X SEPTIC TANK CAPACITY LEACHING FACILITY: (type) L4 /,� Tom' (size) NO.OF BEDROOMS 79 BUILDER OR OWNER V. PERMITDATE: _ Q - 1�Z,9'`;' COMPLIANCE DATE: Sl - --GCB 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 9:. TOWN OF BARNSTABLE LOCATION 4/: SEWAGE # 1,Y-S3Q VILLAGE 1�/.�' �.+�� ASSESSOR'S MAP & LOT )a 9 0, , 7 INSTALLER'S NAME&PHONE NO. 12,04,4 4�..��..� SEPTIC TANK CAPACITY moo LEACHING FACELM: (type) —�'/.� (size) S't NO.OF BEDROOMS BUILDER OR OWNER - 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 100, Nr - ' - a� e a v� No. Fee !��""' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for ]0i_qpoga1 *pgtem Cow5tructiou Permit Application for a Permit to Construct( )Repair(x)Upgrade( )Abandon( ) ❑Complete System El Individual Components Location Address or Lot No. /6 U L'A Tb I-L 1 a-1�:- Owner's Name,Address and Tel.No. Gv 4-,Ln.s T °1�C (,� W0 Cl� 9N-, /Gtt. vLF / 3GL-Z�97 Assessor's Map/Parcel /o 9 /0(a l6 O o 7 l oo c-G.. /�''� A)• 69r.x i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1,400 6-4«-V^J Type of S.A.S. r Description of Soil Nature of Repairs or Alterations(Answer when applicable) C'}C5—, w Sn/ .cTr1n^ J 7 C-c—s Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is ed by t -Health. Signed Date Application Approved by Date Application Disapproved fort folio ' g reasons Permit No. — Date Issued No. Fees THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS rication for Migpozal *p5tem Conotruction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 6 U d.JD Tl►CL 12. Owner's Name,Address and Tel.No. / /(.v �9 �`G.rn/u'� 3Gz-G337 Assessor's Map/Parcel /B 9 D&? y �� 7 �6 o67 %it.L 6� Ull. j 3ty Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ' 39el- ;*7 j. .. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date 1 Title Size of Septic Tank / o C,-,« o^J Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) T W 4 ow cT Date last inspected: Agreement: The undersigned agrees to ensure the construction and rnaintenance of ttie afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is.s ed by t , and-of Health.. Date A/Y Signed _� -� .z �._F � _ Application Approved by _ r Date` _ 3 ._ _C Application Disapproved for t9follow4g reasons T U 4. Permit No. — .J to =Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by f � at has been constructed 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 co trued as a guarantee that the system will function as designed. Date Inspector .� No. --------------------------Fee p. THE COMMONWEALTH OF-MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS - lwigpogar *pgtem Construction Permit Permission is hereby granted to Construct( Repair( Upgrade( )Abandon( ) System located at 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. I Provided:Construction must be completed within three years of the date of this permit. Date: F — Approved by v� ' 7/98 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 PLANS) I, �� •^m ` ^""� , hereby certify that the application for disposal works construction permit signed by me dated '`t b P , concerning the property located at 0 c-0 7yc-(- /Z-, meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed soil absorption system. • There are no private wells located within 150 feet of the proposed septic system. • There is no increase in flow and/or change in use proposed. • There are no variances requested or needed. • If there are any wetlands located within 250 feet of the proposed soil absorption system,the observed groundwater table is 14 feet or greater below the bottom of the leaching facility. • I understand that the attached Title V Calculation Chart may only be used for the design of a septic system if the existing naturally occurring soil is classified as Class I(sand or loamy sand) in the most hydraulically restrictive layer included within the five foot zone beneath the proposed soil absorption system. If the soil conditions are not Class I within this above described zone,a professional engineer or registered sanitarian is required. SIGNED : DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER i 1 Please complete the following: A)Elevation at top of ground in the location of the proposed soil absorption system �y B)Elevation of groundwater 3 3 [Attach a sketch plan of the proposed system. Also if the licensed installer possesses a certified plot plan, this plan should be submitted]. q:health folder:Cert2 r , 0 T3 - J2c;p� 1 >Z : I I ,.�� - I 1 I � ; I i I I 1 13 v _ 1 I � r I : : 1� I , I I I I 1 I ; ' I I BORTOLOTTI CONSTRUCTION, INC. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address Prop /U// do d 10 Date of Inspec} Map Parcel Owner 5g P *4 PART A — CHECKLIST ' CHECK IF THE FOLLOWING HAVE BEEN DONE: PUMPING INFORMATION WAS REQUESTED OFTHE OWNER,OCCUPANT,AND BOARD OF HEALTH. NONE OF THE SYSTEM COMPONENTS HAVE BEEN PUMPED FOR AT LEAST TWO WEEKS AND THE SYSTEM RECEIVING NORMAL FLOW RATES DURING THAT PERIOD. LARGE COLUMES OF WATER HAVE NOT BEEN INTRODUCED INTO THE SYSTEM RECENTLY OR AS PART OF THIS INSPECTION. AS-BUILT PLANS HAVE BEEN OBTAINED AND EXAMINED. NOTE IF THEY ARE NOT AVAILABLE WITH N/A. THE FACILITY OR DWELLING WAS INSPECTED FOR SIGNS OF SEWAGE BACK-UP. 6,�THE SITE WAS INSPECTED FOR SIGNS OF BREAKOUT. ✓ALL SYSTEM COMPONENTS,EXCLUDING THE SAS,HAVE BEEN LOCATED ON THE SITE. THE SEPTIC TANK MANHOLES WERE UNCOVERED,OPENED,AND THE INTERIOR OF THE SEPTIC TANK WAS INSPECTED FOR CONDITION OF BAFFLES OR TEES,MATERIAL OF CONSTRUCTION,DIMENSIONS,DEPTH OF LIQUID,DEPTH OF SLUDGE, DEPTH OF SCUM. HE SIZE AND LOCATION OF THE SAS ON THE SITE HAS BEEN DETERMINED BASED ON EXISTING INFORMATION OR i APPROXIMATED BY NON-INTRUSIVE METHODS. THE FACILITY OWNER(AND OCCUPANTS,IF DIFFERENT FROM OWNER)WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SSDS. PART B — SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL 12 No of Bedrooms C12 No of Current Residents Garbage Grinder Laundry Connected to System A/6 Seasonal Use i i NON RESIDENTIAL: Calculated flow WATER METER READINGS,IF AVAILABLE: i GALLONS I Pumping Records and Source of Information: ZeQ 19 C_3— I SYSTEM PUMPED AS PART OF INSPECTION? Q IF YES,VOLUME PUMPED = GALS Reason for Pumping: TYPE OF SYSTEM: Septic tank/distribution box/soil absorption system Single Cesspool Overflow Cesspool Privy Shared system (if yes, attach previous inspection records, if any) Other(explain), Ap oximate age of all componentJs. Date ins led,if known. Source of information. SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE? D SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SEPTIC TANK: Depth below grade: /3 p Dimensions: O 1' / , / Material of construction: oncrete Metal FRP O Other) CD Sludge Depth Z!� Distance from top of sludget o..pottom of outlet tee or baffle Scum Thickness ! Distance from Top of cym to top of outlet tee or baffle Distance from bottom of Scum to bottom of outlet tee or baffle/5—! Commen /L? C, P DISTRIBUTION BOX: DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT Comments: PUMP CHAMBER: Pumps in working order? Comments: i SOIL ABSORPTION SYSTEM-(SAS): IF NOT PRESENT,EXPLAIN: TYPE: — /000 CoWents: ; Cl r- Ve Lk—Al— ( �j /`��j� / 'ICJ v /71. I CESSPOOLS: Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimension of cesspool Materials of construction Indication of groundwater inflow(cesspool must be pumped) Comments: I PRIVY: Materials of construction Dimensions I Depth of solids Comments: i I _ . J SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B — SYSTEM INFORMATION (Continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCES,LANDMARKS OR BENCHMARKS. LOCATE ALL WELLS WITHIN 100' O DEPTH TO GROUNDWATER: /4 DEPTH TO GROUNDWATER METHOD OF DETERMINATION OR APPROXIMATION: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C — FAILURE CRITERIA (Indicate Y—yes N—no ND—not determined.Describe basis of determination.If"not determined",explain why not.) / Backup of Sewage into Facility? Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the districution box above outlet invert? Liquid depth in cesspool, 6"below invert or available volume, 1/2 day flow? Required pumping 4 times or more in the last year? Number of times pumped Septic tank is metal?cracked?structurally unsound?substantial infiltration?substantial exfiltration? tank failure imminent? Is any portion of the SAS,cesspool or privy, below the high groundwater elevation? Within 50 feet of a surface water? Within 100 feet of a surface water supply or tributary to a surface water supply? Within a Zone I of a public well? Within 50 feet of a private water supply well? Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools &privies only, not the SAS)? 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,amonia nitrogen and nitrate nitrogen. PART D — CERTIFICATION INSPECTOR: ROBERT J. BORTOLOTTI ADDRESS: 765 WAKEBY ROAD, MARSTONS MILLS COMPANY: BORTOLOTTI CONSTRUCTION INC. MA 02648 (508) 771-9399 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE PERSONALLY INSPECTED THE SEWAGE DISPOSAL SYSTEM AT THIS ADDRESS AND THAT THE INFORMATION REPORTED IS TRUE,ACCURATE AND COMPLETE AS OF THE TIME OF INSPECTION. THE INSPECTION WAS PERFORMED AND ANY RECOMMENDATION REGARDING UPGRADE,MAINTENANCE AND REPAIR ARE CONSISTENT WITH MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEMS. CHECK ONE: ZI HAVE NOT FOUND ANY INFORMATION WHICH INDICATES THAT THE SYSTEM FAILS TO ADEQUATELY PROTECT PUBLIC HEALTH OR THE ENVIRONMENT AS DEFINED IN 310 CMF 15.303. ANY FAILURE CRITERIA NOT EVALUATED ARE AS STATED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. I HAVE DETERMINED THAT THE SYSTEM FAILS TO PROTECT PUBLIC HEALTH AND THE ENVIRONMENT AS DEFINED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS PROVIDED IN THE"FAILURE CRITERIA"SECTION OF THIS FORM. INSPECTOR'S SIGNATURE: DATE: Ca�o/ 7b ORIGINAL TO SYSTEM OWNER,COPIES:BUYER(if applicable),APPROVING AUTHORITY r