The URL can be used to link to this page

Home My WebLink About0012 PARKER ROAD - Health (2) 86 PARKER RBp�� WEST BARNSTABLE A = 197 006 I I ` Commonwealth of Massachusetts /97- 001-003 p Title 5 Official Inspection Form Fni Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Parker Rd. Property Address t ALLEN,CAROL M TR Owner Owner's Name information is W Barnstable ✓ MA 02668 3/1/21 required for every page. City/town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, use only the tab Robert Paolini key to move your Name of Inspector cursor-do not Robert Paolini use the return key. Company Name r v r ar;:era .. r -1 Company Address Marstons Mills MA 02648 City/Town State Zip Code (508)280-9499 S14454 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails I� 3/1/21 InspectdFs 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp:doc•rev.7/28/2018 Title 5Ofracial Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Flo Subsurface Sewage Disposal System Form- Not for Voluntary Assessments v< 86 Parker Rd. Property Address ALLEN,CAROL M TR Owner Owner's Name information is required for every W Barnstable MA 02668 3/1/21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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. *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): I ,t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •u 86 Parker Rd. Property Address ALLEN,CAROL M TR Owner Owner's Name information is required for every W Barnstable MA 02668 3/1/21 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due g P g 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 0 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): 3) 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. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Parker.Rd. Property Ad&ess ALLEN,'CAROL M TR Owner Owner's Name information is required for every W.Barnstable MA 02668 3/1/21 ipage. City/Town State Zip Code Date of Inspection C. Inspection Summary (cunt.) ❑ 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 b. '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. c. Other: 4 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 t f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments . 86 Parker Rd. Property Address ALLEN,CAROL M TR Owner Owner's Name information is required for every W.Barnstable MA 02668 3/1/21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than%day flow ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . El ® 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 water supply well. El ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® 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. 1 5) 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 CA. 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 tSnsp-ioc•rev.W2612018 Title S OfWal Inspection Form:Subsurface Sewage Disposal System•Page S of 18 i Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Parker Rd. Property Address ALLEN,CAROL M TR Owner Owner's Name information is required for every W Bamstab'le MA 02668 3/1/21 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for af/inspections- 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: ❑ ia 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)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 L I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 86 Parker Rd. Property Address ALLEN CAROL M TR Owner Owner's Name information is required for every W Barnstable MA 02668 3/1/21 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes 0 No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Parker Rd. Property Address ALLEN,CAROL M TR owner Owner's Flame information is required for every W.Barnstable MA 02668 3/1/21 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 86 Parker Rd. Property Address ALLEN,CAROL M TR Owner Owner's Name information is required for every W Barnstable MA 02668 3/1/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑, Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)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): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): ' Depth'below grade: 1 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.): Joints appear tight. No evidence of Ieakage.System vented through house vents. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 I - Commonwealth of Massachusetts @ Title 5 Official Inspection Form fi; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Parker Rd. Property Address ALLEN,CAROL M TR Owner Owner's Name information is required for every W Barnstable MA 02668 3/1/21 !sage. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 6. Septic Tank(locate on site plan): Depth below grade: 2'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: 1500 GI. Sludge depth: 4" Distance from top of sludge to bottom of outlet tee or baffle 38" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 8» Distance from bottom of scum to bottom of outlet tee or baffle 101, How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump every two years.Inlet and outlet tees in place.No signs of leakage. t5ins .doc•rev.726/2018 p Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form FI Subsurface Sewage Disposal System Form- Not for Voluntary Assessments u 86 Parker Rd. Property Address ALLEN,CAROL M TR Owrer Owner's Name information is required for every W Barnstable MA 02668 3/1/21 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Parker Rd. Property Address ALLEN,CAROL M TR Owner Owner's Name information is required for every W Barnstable MA 02668 3/1/21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Dat-of last pumping: Date Comments(condition of alarm and float switches, etc.): ' Attach --opy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): Box is level No signs of leakage.Box has one outlet laterals. M t5insp.d'oc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form I; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 86 Parker Rd. Property Address ALLEN,CAROL M TR Owner Owner's Name information is required fo every W Barnstable MA 02668 3/1/21 r page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 10. Pump Chamber(locate on site plan): Pumps ii 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 C � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 86 Parker Rd. Property Address ALLEN,CAROL M TR Owner Owner's Name information is required for every W.Barnstable MA 02668 311/21 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): f t5insp.doc-rev.W26t2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Dis posal sposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 86 Parker Rd. Property Address ALLEN,CAROL M TR Owner Owner's Name information is required for every W Barnstable MA 02668 3/1/21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I . .... .... . . Commonwealth of Massachusetts Title 5 Official Ins ecti p on Forme Subsurface Sewage Disposal System Form Not for Voluntary.As 86 Parker Rd. <._ Pr°Pe►N Address` _,:. Owner ALLEN,CAROL M IR Owners Name " information is required for every. W.BaMSt8ble MA P89e• Gity/Town State: Zl2 C 3f1/21 Code P. Date of inspection D. system information:(Cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the..sewage disposaksystem, inciuding.ties to at least two permanent'reference landmarks or benchmarks. Locate all wells within 100 feet: Locate where public wate the'buiiding. Check one of the boxes below: r supply enters ❑ hand-sketch in the area below O drawing attached separately 13 .d 13- 1 of ztr�n 't z•�� c Commonwealth of Massachusetts Title 5 Official Inspection Form F�! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Parker Rd. ,V Property Address ALLEN,CAROL M TR Owner Owner's Name information is required for every W Barnstable MA 02668 3/1/21 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 11above adj. groundwater 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: As- Built ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Used USGS observation well data.Used technical bulletin 92-0001 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.ioc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form vFIA Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 86 Parker Rd. Property Address ALLEN,CAROL M TR Owner Owner's'Name information is required for every w Barnstable MA 02668 3/1/21 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist pp Complete all applicable sections of this form inclusive of: P ® A. Inspector Information: Complete all fields in this section. ® 'B. Certification: Signed & Dated and 1, 2, 3, or 4 checked W, C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 TOWN-OF BARNSTABLE LOCATION b �fl V'.�r�u� �� -J, - SEWAGE # VE LLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 411,1_2 r-Art 2k,�2 /� L � SEPTIC TANK CAPACITY 0 LEACHING FACILITY: (type) (size) NO. OF BEDROOMS n BUILDER OR OWNER Di jr m 'Ahl PERMUDATE: 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 r R l:3 I tY t �1 _ S 7SZTeo, Fee � THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS application for )Digozal *p5tem Cow5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) P<Omplete System ❑Individual Components Location Address or Lot No. 1P<1 V_1:1e._ Owner's Name,Adnndress d Tel.No. (( Assessor's Map/Parcel ,�'�?� o 00 I s Name 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 f� gallons per day. Calculated daily flows, gallons. Plan Date Nu ,ber of sh ets Revision Date Title Size of Septic Tank I AMa&2 MV 11 nK Type of S.A.S. t� r�KsL�'1 rLiNCi�-1ll/ T Description of Soil c Nature of Repairs or Alterations(Answer when applicable) :-: �,y E5VA %!!; ) — h C LMfci• �- 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 Enviro ental o of to ce the system in operation until a Certifi- cate of Compliance has bee ed by this Boaz Signed Date ' Application Approved by Date i Z--- zZw_Z6-" Application Disapproved for the followin reasons Permit No. ?4-00 7Si�, Date Issued 1 Z ` r.w_ __----------------------- ———————————— No.� 7Z ` Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Application for 3M!gpoal 6p$tem Cottgtructiott Permit - Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) omplete System ❑Individual Components Location Address or Lot No. '� G�Ir�C/` t Owner's Name,Address d Tel.No. Assessor's Map/Parcel �q� stall 's Name,Mdres and Tel.No. Designer's Name,Address and Tel.No. t_S t 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 L� L gallons per day. Calculated daily flow Cj gallons." Plan Date Nuf b�er of sheets Revision Date Title Size of Septic Tank 6 A, Type of S.A.S. e ,N � Qv l P YP Q U Description of Soil , a C� Nature of Repairs or Alterations(Answer when applicable) .,t �r /flt. �g+T/1..co ( la•c. `8 �'k�, � �..,L��.LJG�n`�'� .a 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 Environ ental o3e art of to pla a the system in operation until a Cert=fi- cate of Compliance has been=ssued by this B�7 e fit L Signed �. Date Application Approved by Date_f 7. .- T Y— ZO" Application Disapproved for the following"reasons i 1 # Permit No. Zq a " Date Issued'' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of ComplianceYi If THIS IS TO CERTIFY, tha the On-site Sag osal System Constructed( )Repaired Upgraded('< Abandoned( )by o r- 1 . at has ben constructed in accordance with the provisions of Title Sand the for Disposal System Construction Permit No."� -7 Sdated Installer Designer �1 A � The issuance of this permit shallrinot be construed as a guarantee that the syste. will function asAeesignedI' �� Date / (n� I Inspector i.i�l�� 11 �A/ X C�Jl /%fi��` --Ud Ft - _ Na. i�'�� `''---------------------------Fee �g 7 _0U6 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migpoof 6potem Cott5truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(✓)Abandon( ) System located at FCo' and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this rmit. Date: 2 — Z `2—vav Approved by 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT{WITHOUT DESIGNED PLANS) 2, P� _ r C:S , hereby certify that the application for disposal works construction permit signed by me dated JDL—:'�—CD7 , concerning the located at e property ��a�P -� �� ..S`�rneets all of the following criteria: /This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. V/ The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system /There is no increase in flow and/or change in use proposed There are no variances requested or needed. e� The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when r/applicable] ✓• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen 14 feet above the maximum adjusted ( ) J groundwater table elevation, Please complete the following: 7 A) Top of Ground Surface Elevation(using GIS information) 3 B) G.W. Elevation 156 +the MAX. High G.W.Adjustment _ /7/ 7 DIFFERENCE BETWEEN A and B , SIGNED : DATE: [Please Sketch pro ed plan of system on acl< . NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert - a 0 No I Sb�-�-�- TOWN OF BARNSTABLE LOCATION 6 nfl i'', /' 'Z SEWAGE #,4ao VILLAGE wt ASSESSOR'S MAP & LOT 7 INSTALLER'S NAME&PHONE NO. _44 I P r1 SEPTIC TANK CAPACITY i J LEACHING FACILITY: (type) L r11XX117op (size)-. NO. OF BEDROOMS .� / nn h i BIMDER OR OWNER i PERMITDATE: COMPLIANCE DATE: (� Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ' Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of_leaching facility) Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching,facility) Feet . PDX, I T, rI/ I j Iq 41 4. i I 3.�` No.- Fee- --- BOARD OF HEALTH TOWN OF BARNSTABLE Application-ftlVell Con.9tructionpermit Application is hereby made for a permit to Construct ( , Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel _�3-N P�_i_p------�o M,+rj -------------- - f-A�-adLt '-' = - ner re ��.4r1 __! 31_ _ � __ -_ �— �_— •- 1 lam_-�---- Installer — Driller Address Type of Building Dwelling-----—--- —- - - ------- - Other - Type of Building----------------------------- No. of Persons---------------------------- Type of Well Capacity—- - _ +rs/_kz=------------- Purpose of Well--0(Y11u_-A_ -'- -� - Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed--Yq _ " C� date —— Application Approved B date _------_—� Application Disapproved for the following reasons: 9.,✓ date Permit No. - ill__"�-�--- " - — Issued — ��- date BOARD OF HEALTH TOWN OF BARNSTABLE . (Certificate Of (Comphance THIS IS TO CERTIFY, That the Individual Well Constructed (V), Altered ( ), or Repaired ( ) by - y --s N. _ ►'/�. r - - --- Installer at has been installed in accordance with the provisions of the Town of Barnstable B,o,a/rd of Health Private Well Protection Regulation as described in the application for Well Construction Permit N��'v--"�-C�-"_—f ated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE—--- ----- ----- —— —-- — - - Inspector- - --------------------- ---- - - - -- BOARD OF HEALTH TOWN OF BARNSTABLE Veil Con5tructionpermit No. -------------------- Fee------------------ Permission is hereby granted----�.Ifp07'X`S--!�- __�_✓__,f 4�t127 - -- -- - to Construct ( � Alter ( ), or Repair ) an Individual Well at• �- No. — �_G__ ' 1�,��--- _ --------G__ � r --- - -- ------ Street I as shown on the application for a Well Construction Permit No. d - --- ---------- Dated------ -------------- ---- -- --------------------------------------------------- Board of Health DATE --—-------------------------------------- ------ — q No.-------------------- Fee BOARD OF HEALTH TOWN OF BARNSTABLE z1pplicatiotij rWell Con5tructionPermit Application is hereby made for a permit to Construct ()4-),Alter ( ), or Repair:'( )an individual Well at: ---__--------------- Location — Address Assessors Map and Parcel Owner `' Address �— Installer — Driller —�—�. Address Type of Building Dwelling- - ------------ - ---- -- Other T ' e`of Building _-______._._____'=` No. ofPersons=------------____—_._______________ YP g --== Type of Well-_--- - - vi - --- - -- Capacity- - —C =-- Purpose of Well---Domt�'5T cl VOA-re2'-= - Q Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to . place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed-!� -�,------ — date Application Approved B - / GG2 date Application Disapproved for the following reasons:- — -- 3 date Permit No.---�"---� _�''_'_.✓� — -- - Issued-------- -`5 " date BOARD OF`HEALTH ' p# TOWN OF BARNSTABLE ! f T Certificate Of Compliance THIS IS TO CERTIFY, That th Individual Well Construe ( ), Altered ( ), or Repaired ( ) Installer has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No�"--K-•Da ed-�� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------------------------------------------- - -------------- Inspector - BOARD OF HEALTH TOWN OF BARNSTABLE , Well Con,5truct ion Permit No.------------- -------- Fee----------------- Permission is hereby granted--- / l -�`--------- - to Construct ( Alter ( ) or Re it ) an Individual Well a ,�j -/ Street + as shown on the application for a Well Construction Permit No. -------- -- -- ------------------ Dated--- ___—__—_------------ ------ Board of Health DATE------- '=-- -- --------___— U CERTIFICATE OF ANALYSIS Page. j Barnstable County Health-Laboratory Report Prepared For: Report Dated: 08/27/2002 Order Number: G0216870 David W.Allen 27 Parker Rd. Osterville, MA 02655 Laboratory ID#: 0216870-01 Description: Water-Drinking Water Sample#: 16870 Sampling Location: 86 Parker Rd.,West Barnstable Collected: 08/19/2002 ollected by: Buyer 197-001 Received: 08/19/2002 Routine ITEM RESULT UNITS MDL MCL Method# Tested LAB:IC Lab Nitrates 0.1 mg/L 0.1 10 EPA 300.0 08/21/2002 LAB: Metals Copper <0.1 mg/L 0.1 1.3 SM 3111B 08/23/2002 Iron _ 0.1 mg/L -.. 0.1 ..0.3 SM 3111 B_ .. _....-08/23/2002 Sodium 11 mg/L 1.0 20 SM 3111B 08/23/2002 LAB:Microbiology Total Coliform Absent P/A 0 Absent P/A 08/19/2002 LAB: Physical Chemistry Conductance 127 umohs/cm 1 EPA 120.1 08/20/2002 pH 6.3 pfl-units 0 EPA 150.1 08/20/2002 Note: Water sample meets the recommended limits for drinking water of all above tested parameters. Approved By: a,...,.....,_ (Lab Director) y�isr�i�Z i Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605 /�QF AA/tl�` j� CERTIFICATE, OF ANALYSIS Page. 1 y' Barnstable County Health Laboratory \'iyssActtU ,�c, Report Dated: 12/9/2005 Report Prepared For: Order No.: G0533905 David Allen P O Box 296 W Barnstable, MA 02668 Laboratory ID#: 0533905-01 Description: Water-Drinking Water Sample#: 33905 Sampling Location 86 Parker R id.W.Barnstable,MA Collected: 12/l/2005 Collected by: D.W.Allen Received: 12/l/2005 Test Parameters ITEM RESULT UNITS RL MCL Method 9 Tested LAB: IC Lab Nitrate as Nitrogen BRL mg/L 0.10 10 EPA 300.0 12/1/2005 LAB: Metals Hardness 29 mg/L as CaCO 0.1 SM 2340B 12/1/2005 Iron BRL mg/L 0.10 SM 311113 12/1/2005 LAB: Plgsical Clreniistty pH 6.6 pH-units 0 EPA 150.1 12/1/2005 W te%.sample meets the rec6m—mended limits for drinking water of all the'above tested parameters_ Approved By: ( a Director) c 0 o N `! J - - , rn RL = Reporting Limit MCL=Maximum Contaminant Level Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605