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HomeMy WebLinkAbout0096 PARKER ROAD - Health 96 PARKER ROAD, A= 117-129 'I i I Commonwealth of Massachusetts ■ i1001.50124 Decal Number . Asbestos Notification Form ANF-001 Impor heal"t When filling out A. Asbestos p •Abatement Desdri tion w forms on the computer,use 1. a. Is this facility fee exempt-city, town, district,.municipal housing authority, owner-occupied only the tab key residence of four units or less? ✓l Yes .E]No .to move your _ cursor-do not b. Provide blanket decal number if applicable: Blanket Decal Number use the return key. 2. Facility Location: DOMENICA 96 PARKER ROAD a.Name of Facility . b.Street Address IBARNSTABLE MA 02655 E v a . � c.City/Town d..State, e.Zip Code f:Telephone Number INSTRUCTIONS '1 WorkSite Location: ACE I 1.,All sections of his + t_fr-BASEMENT/CRAWLSP -- - - � [ form must lie a.Building NameBuilding Location b Building# c.Wing d.Floor e.Room completed in order. to comply with 4. Is the facility occupied? [✓Yes: No . DEP notification: . requirements.of 310. cMR Z.15 5. Asbestos Contractor: th e he Division NEW ENGLAND SURFACE MAINTENANC- E! 850 WASHINGTON STREET. an the tibnal s - Safety(DOS) a.Name 'b.Address` notification ! WEYMOUTH € _ requirements-of 453 ; : ..a,, ., 02189 i(7813372117. _,,.•_�� �.��i„�� CMR 6 12 c._City/Town. d Zip Coo e.Telephone Number L AC000196 . g.Contract Type: Written Verdel f DOS License Number Mom--- h.FacilityContact Person i;Contact,Person s Title 1 EE JOHN S BUTTS,J,R } a Name of qfi S e Supernsor/Foreman b:Supernsor/Foreman DOS Certification Number r ILEBLANC r AM061397 �= 7: a Name of Project Monitor b.Protect.Morntor DOS.Certificatron Number_ ' �ENVIROTE$T LABORATORY' , AA000128 a.Name of Asbestos Analytical Lab b.Asbestos Analytical Lab DOS Certification Number 07I0912012 l 07/09/2012 9' a:Project StartDate(mmfiid/ b.End Date,lmmJdd . 8- c.Work hours'Mon-F ri. d.Work hours Sat-Sun. =0 10. a.What type of project is this?' T 0. [1 Demolition El Renovation , -T 0 Repair Other, please specify:' b..Describe ✓ 11 a.,Check abatement procedures.:. • ,moo . .:: , O Glove bag E� Encapsulation o E]'Enclosure u Disposal only _4- [] Cleanup. ❑Other, specify: .: -- � . 0 FUII containment b.Describe Z 12 is the job being conducted M Indoors? [❑Outdoors? a a S anf001 ap.doc•10r02. Asbestos Notification Form•Page 1 of 3■ I Commonwealth of Massachusetts (1001501.24 Asbestos Notification Form ANF-001 Decal Number A. Asbestos Abatement Description;`(cont.) .13. Total amount of each type of Asbestos Containing Materials(ACM)to be removed, enclosed,or encapsulated: 150 -_—"_�- 10 a.Total pipes or ducts(linear ft) o al o her s--u��acce—e--s(square ft c.Boiler,breaching,duct,tank L� d.Insulating cement surface coatings Lin.ft. Sq.ft. Lin.ft. Sq.ft. e.Corrugated or layered paper 50 i f.Trowel/Sprayer coatings I—�— pipe insulation Lin:.ft. Sq.ft. Lin.�ft. Sq.ft g.Spray-on fireproofing h.Transite board,wall board 1—�-��---; S� ft ! 'Lin:ft. Sq ft Li . .. q ft. -_ _ J.Cloths,woven fabrics L - j.Other,please specify: -Lin.ft. S .ft. Lin ft Sq.ft< 77. k.Thermal,solid core pipe _ l.. insulation Lin.;ft. Sq ft. li Specify 14. Describe the decontamination systems)to be used AS REQUIRED :15. Describe the containerization/disposal methods.to comply with'310 CMR 7.15 and 453 CMR 6.14(2)(9) AS REQUIRED ,a 16 For`Emergency Asbestos Operations the DEP and DOS officials who evaluated the,emergency 777, I a Name of DEP Official b.Title c:Date.(mm/dd/yyyyl ofAuthorizafion; ;d:DEP Waiver# P V # f e.Name of;DOS Official` f.DOS Official Title �N g;:Date(min/dd/yyyy},ofAuthorization h.DOS Waiver# ®o :17. Do prevailing wage rates as per M G L.c. 149, §26,.27 or 27A F apply to this project? [],Yes M No B "Facility Description 0 1. Current or prior use of facility. RESIDENCE �o 2. Is the facility owner-occupied residential with 4 units or less? []✓ Yes .Q No T SAME �� a:Facilitym Owner Nae b.Address: 0. c.City/Town d:Zip Code e:Telephone Number area code and extension) emu_ 4' _._� a.Name of Facili Owner s On-Site Manager . b.On-Site Manager Address �Q c.City/Town d.Zip Code e.Telephone Number(area codeand extension) 0 .anfo01 ap.doc•1.0/02 Asbestos Notification Form•.Pa e 2 of 3 E i ` Commonwealth of Massachusetts - 100150124 Asbestos Notification Form ANF-001 Decal Number, B.'Facility Description (cont5. .) a.Name of General Contractor b.Address c.Ci /Town d.Zip Code e:Telephone Number(area code and extension) f.Contractor's Worker's Comp.Insurer g.Policy Number h. Exp.Date(mm/dd/yyyy) 6. What is the size of this facility? � a.Square Feet b. Number of floors C. Asbestos Transportation and Disposal 1. Transporter of asbestos=containing material from site`to temporary storage-site(if'necessary): Note Transfer. a.Name of Transporter. Tb AddressM Stations must i € m__ _ .. ._ k _ complywrth the c Ci /Town d:Zip Code e:,Telep hone Number Solid Waste Division 2. Transporter of asbestos=containing waste material from removal/temporary site to final disposal site: Regulations 310 cMR IRED TECHNOLOGIES a.Name of Transporter b Address ®.��.� c.Ci /Town d Zip Code e.Telephone Number {3 a Refuse Transfer Station and Owner _: b Address. 77 c City/Town �d Zip Code a Telephone Number MINERVA;ENTERPRISES INC, I C y S •_.. ...i_. a.final Disposal Site L'ocation:Name ";b Fin Disposal Site Location Owner's Name a_ 1§000 MINERVA'ROAD I WAYNESBURG: c:Final Disposal Site Address d�Cr /Town_ . OH 44688 L _ _ M. e:State f:Zip Code g:'Telephone Number D. Certification �N The undersigned hereby states, under the KEN FURTNEY j �° penalties of perjury,that,he/she has:read the a.Name b.Authorized Signature �o Commonwealth of Massachusetts regulations i 6L8/0 for the Removal,Containment or Encapsulation of Asbestos,453:CMR 6.00 and c Positron/Title d:Date.(mm/dd/ww) 310 CMR 7.15,and that the information NESM, LLP �T. contained in this notification is true-and correct e.Tele hone Number f.Representing to the best of-his/her knowledge and.belief. ° .Address ALL � h..Cityrrowri` L Zip.Code Z_ �Q o e oa 3 anf0t)1.ap.doc•10/02- Asbestos Notification Form•Page 3 of 'I Commonwealth of Massachusetts Title 5 Official Inspectionection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 96 G { Property Address t Iowner ; owners Name information is l required for LVeS� Gi rh S �,6/e- x4 pd 6 6$ every page. City/Town State Zip Code Date of!Date of! sn�pection Inspection results must be submitted on this form. Inspection foams may not be altered in any way. Please see completeness checklist at the end of the form: Important: 'When filling out A. General Information formsthe computer, r,use 1. Inspector: J f only the tab key /1 /e4l to move your �� d cursor-do not Name of Inspector use the etum _ 'key. Company Name ' �a iC303C 4) YY Company Address r. —.g57 gw, Da 61-12 City/Town State Zip Code Telephone Number- License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and 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 ❑ l= Is c� I I ❑ Needs Further Evaluation by the Local Approving Authority JIna & Inspect s Signature Date The system inspector shall submit a copy of this inspection report to the Approving ��-AuF ri ward 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. '***This report only describes conditions at the time of inspection and under the conditions of use r at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. i l isms•o9ioe �:f i, 7iUe 5 Ofida)Inspon Form:SuGsurrace Sewage posa!S •Page t or 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form R Subsurface Sewage Disposal System Form=Not for Voluntary Assessments ' Property Address 90 W/A Y7 Owner Owner's Name 2 information is VI/'e Y /J ct�nS a Z le- 1&,4 Qo)6 6� �� el,T required for every page. City/Town State Zip Code Date of pe n ti i B. Certification (cost,) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 1 have not found any information which indicates that any of the failure criteria described fr in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are E indicated below. Comments: d I I! B) System Cond'ationally 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 i ! ! the Board of Health, will pass. i Check the box for" es","no"or"not determined" "y (Y, N,ND)for the following statements. If not I t 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. a( ❑ Y ❑ N ❑ ND(Explain below): i,, ►, ; i : R 1 t x , t5ins•09/08 Title 5 Official Irmpettion form:subsurface Sewage Disposal system•page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 f Ge Property Address y►'ef� g� Owner Owner's Name informs is for W 1 'es �,„s /l� ®a 669 required fo �'� every page. Cityfrown State Zip Code Date of In ectlan B. Certification (cont.) I B) System Conditionally Passes(cunt.): ❑ 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): i' ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): , , I' I ! i I r iq + ❑ 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: I ' ❑ 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 { i t5ins•oa os Title 5 Otfiaal kspedon Fomr.Subsurface Sewage()isposaj system•Page 3 of 17 i � Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owners Name information is t-le S /*t required for every page. cityrrown State Zip Code Date of I e B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) ,' {i �` ► determines that the system is functioning in a manner that protects the public health, IJ, `I �i 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. f j i ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water j supply. j ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water I supply well t ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well"'. Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria 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: l You must indicate"Yes" or"No"to each of the following for all inspections: 1 Yes No ❑ ; Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ondin of effluent to the surface of the round or rf❑ � 9 p g g surface waters (' E due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded i or clogged SAS or cesspool ❑ ❑/ Liquid depth in cesspool is less than 6"below invert or available volume is less ; than %day flow t&ns•osroe rae 5 ofioal trupecf1w Form Subswfaw Sem*P DISMW system. 4 of 17 : Commonwealth of Massachusetts Title 5 Official Inspection Fora' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `,�. Il� �r�er �c✓ I Property Address /20 04 C, ` Owner Owner's Name ) /information is �IeS T— 'nJ b �/� ' �o��� 1+� S 07 n— �. required for every page. City/Town State Zip Code Date of nspecrion B. Certification (coat.) 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. El I Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 2" Any portion of a cesspool or privy is within 50 feet of a private water supply well. j ❑ Irk 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 1 i system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ The system is a cesspool serving a facility with a design.flow of 2000gpd- 10,000gpd. - ❑ The system fails. I have determined that one or more of the above failure criteria exist as described In 310 CMR 15.303,therefore the system fails.The i# system owner should contact the Board of Health to determine what will be necessary to cored the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 d to 15,000 d. 9 gP gP r i _ I For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the i 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 i system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 1!. t5 ns•09ro Title 5 Official tnspec6on form:Subsurface Sewage Disposal System•Page 5 or 17 A 11 1 ! � ''`� ' Commonwealth of Massachusetts Title 5 Official Inspection I'orrn Subsurface Sewage Disposal System Form Not for Voluntary Assessments I 1 ` ►l; Property Address f Wl R vJ Owner Owner's Name / information is '/✓e5 ��r�s�w 6� Oa66 a`� �o� I$ 09 required for every page. City/Town State Zip Code Date of hispeeton C. Checklist Check if the following have been done.You must indicate"yes"or"nd*as to each of the following: j . Yes No 5 ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ 2 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? j �,/ Have large volumes of water been introduced to the system recently or as part of j ❑ l� this inspection? ®/ El available 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? 1 Ly' ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank ;i inspected for the condition of the baffles or tees, material of construction, i. ! 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 i been determined based on: [� ❑ Existing information. For example,a plan at the Board of Health. li I ®�❑ 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)j D. System information Residential Flow Conditions: ( Number of bedrooms (design): Number of bedrooms(actual): f DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 70 'j.� g _ ���► t5 ns•09l08 Title 5 Official � InspecUvn form:Subsurface Sevmge Dsposal System•page 6 of 17 ' l Commonwealth of Massachusetts Title 5 Official Inspection Form , p , Subsurface Sewage Disposal System Forme Not for Voluntary Assessments g C Property Address �.O WI R✓1 Owner Owner's Name information is arras a/ / required for every page. City/Town State Zip Code Date Inspection D. System Information ' ' I Description: A 1^ !i opt-5- 1- o� I rVloW �✓��><i.3p.s Number of current residents: Does residence have a garbage grinder? ❑ Yes (D"Nio i Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes [E No Laundry system inspected? ❑ Yes 2eNo ,i Seasonal use? ❑ Yes U40 Water meter readings, if available(last 2 years usage(gpd)): I Detail: ,ram Sump pump? /� ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): t, it i Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes ❑ No 1 ,1 Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No c. 'Water meter readings, if available: 15irts•09/08 Tine 5 offfdld tnspecWn Form:Subsurface Sewage Disposal System•pap 7 of 17 f �e I . i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not/for Voluntary Assessments i Q !� la Property Address •,i �o 01 G!d/ Owner Owner's Namel ' tnfonnae on is G�/es,T E7��ns7��� �.� �— �I`'^` requirefor ! every page. City/Town State Zip Code Date of pectin D. System Information (cunt.)_ Last date of occupancy/use: Date Other(describe below): a I ,l General Information j ! Pumping Records: L lF1(,i of information: �� u Source t16 Was system pumped as part of the inspection? ❑. Yes t, 1 If yes, volume pumped: gallons ;3 How was quantity pumped determined? Reason for pumping: Type of S tem:. Septic tank,distribution box,soil absorption system ' ❑ Single cesspool � t ❑ 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 t , maintenance contract(to be obtained from system owner)and a copy of latest 4 inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): tsins•09r0a - 'i Title 5 Offidat Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 f i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Property Address Mum Owner Owner's Name infonn�tion is� f ,eS required for W ✓nt 7`al� �{ / dd 666 `a / 1 l every page. City/Town State Zip Code Date ciAnspelion D. System information (cunt.) Approximate age of all components,date installed(if kno )and source of inform tion:YO Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: teat i Material of construction: ❑ cast iron 40 PVC ❑other(explain): Distance from private water supply well or suction line: feet t 1 Comments (on condition of joints, venting,evidence of leakage, etc.): � I a Septic Yank(locate on site plan): Depth below grade: r feet Mater' f construction: ` concrete ❑metal ❑fiberglass ❑polyethylene yl ❑other(explain) r ; If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: ro X 0 Sludge depth: — 6 isins•09+08 I. + Title 5 Official inspection Force Subsurface Sera System. 9 17 J Sewage tTsposal S em It f I . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �o vyl G vI Owner Owner's Name l information is �e S� ...s �,� � �61(dp laLl$ Q�' required for „ every page. Cityfrown State Zip Code Date ofinspedbon D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle $411 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Ole �"5 C 1.4 e-e- l Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): fI h IM t N �10 T Aer_�C/ Gi T L 4-A 1 s` -�—j*+7-e i 1W� 1 IIi!i71 I ( C>z a,,, S ±3t90 c'.C//to , 4110 i Grease Trap(locate on site plan): 1 Depth below grade: feet Material of construction: ' ❑ concrete ❑ metal El fiberglass ❑polyethylene . ❑other(explain): 1 ' 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 t5lns•09/08 Tittle 5 Official fn spection Fame Subsurface Sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts r Title 5 Official Inspection Form I I, i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4�i Property Address I Owner O wner's Nam information is �/. , f I required for cif e S r��f Tee every page. City/Town State Zip Code Date of lifspectron ! r 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.): i n ti i' i! I` Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): I Depth below grade: II r Material of construction: ` ,. ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Dimensions: Capacity: f � � gallons f Design Flow: I I t gallons per day 'rt : 1I1 I Alarm present: ❑ Yes ❑ No I i Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping. Date i {Comments (condition of alarm and float switches, etc.): i I , Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No r . ;;; 11 t5ms•OW08 l iTitle 5 Official Inspection Form.Subsurface Sewage pisMsal System•Page 11 or 17 y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 6 `re Property Address O JAI)G ✓I �yi I Owner f Owner's Name Gci ✓� /� 02 ' ' } information isA 9— i required for ! „ every page. Cityfrown State Zip Code Date of In pection D. System Information (coot.) I' I Distribution Sox(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Ve� , 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.): &0 C6 i I A9 F 1 i 4, J Pump Chamber(locate on site plan): t Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No j Comments (note condition of pump chamber,condition of pumps and appurtenances,etc.): } i. i Soil Absorption System (SAS)(locate on site plan, excavation not required): �t If SAS not located, explain why: l i 1151ns-09/08 Title 5 Official Inspection Form:Subsurface yst Page 12 of 17 SeWa9e Dispose S em i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments : l Property Address Owner Owner's Name information is /. le-5•� /l �� / J �j� ©a2 6� required for �" s.SG S�6/� every page. Cityfrown state Zip Code Date of Ihspectibn D. System Information (cunt.) 1,,nr � 0 Type: Row�i-S©rf' � S4 (, ❑ leaching pits number st ;li i I' � E ❑ leaching chambers number: .1 � fir• ► � ❑ leaching galleries number: I i ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ fnnovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,etc.): 611 / i ✓�10 o 51 s' �c , 1ur-e a s Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration '. Depth—top of liquid to inlet invert ii Depth of solids layer ;l ! Depth of scum layer i Dimensions of cesspool { Materials of construction Indication of groundwater inflow ❑ Yes ❑ No 15ins•09108 ! q: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 1 f , �s Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �j Property Address Owner owlc� Owner's Name information is is / ,fore / / �� �ryda9e Gtyfrovn W 7' �'�1fY� /9 4$ an— k State Zip Code Date nspection T D. System Information (cost.) Comments (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, 4 i etc.): t t Privy(locate on site plan): Materials of construction: Dimensions ' i z Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t i ! I 15ins.oe/o® a Title 5 Offidal fnspecbm Fomr.Subsurface Qlsposal system Page 14 of 17 it/t L9E91 s i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0/' C�r� Property Address Owner I Owner's Name ,/� information is �e S ¢ / jns�c 669 h$required for /0 every page. CitylTown State Zip Code Date of 16specfion { D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.Check one of the boxes below: 2--ddrawing d-sketch in the area below attached separately ! cl e , i r �i 1! r, r, i r a lilt.( 3 ' ns,osoa TiBe 5 Offiaal hspeclan Form %b5Wf'1W Sewage Disposal System•Page 15 of 17 1 F= � Commonwealth of Massachusetts ; y l ' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 96 Property Address ® Owner Owner's Name j information is f ,ems required for !N �v►5 1. /e 0OU 6$ /J, j 8 e f every page. City/Town State Zip Code Date offnispeCton j" D. System Information (cons) i 1 Site Exam: ! ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells o� Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: t I ❑ Obtained from system design plans on record •a t! 1• k f I checked,date of design plan reviewed: Data f 1 ! ❑ bserved site(abutting properiylobservation hole within 150 feet of SAS) Checked with I cal Board of Health-explain: 1 ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 7eS 1- 40/G 04 �� a o Before filing this Inspection Report, please see Report Completeness Checklist on next page. i 15ins-09108 E Title 5 Official inspection Farm.Subsurface sew Disposal system•Page 16 of 17 A 1 I Commonwealth of Massachusetts Title 5 Official Inspection Form Ij i Subsurface Sewage Disposal System Form v Not for Voluntary Assessments iv- Property Address — j Owner'tion is O wnet's Name / informa �,✓�s T e ®ot b 6`� required for _ rnS � • ,I, every page. Cityrrown State Zip Code Date of Infipectibn E. Report Completeness Checklist inspection Summary:A, B, C, D,or E checked (Inspection Summary D(System Failure Criteria Applicable to All Systems)completed i. ERI-**S,-ystem Information-Estimated depth to high groundwater } ketch of Sewage Disposal System either drawn on page 15 or attached in separate file 4ij ' ! t t is r 1 ' j ;i I"s•osuoe Title 5 Offidat k+spection Form:Subwrfae Sewage tksPoeal System•Page t 7 of 17 i r i i 5" ge 10 of 1 I I INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS CIAL IriSPE OFFI SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " u PART C ,i SYSTEM INFORMATION(continued) 96 Parker Road Property Address: West Barnstable,ILIA Donald Roman Owner:, 200� Date of Inspection: (/ i SKETCH OF SEWAGE DISPOSAL SYSTEM Pr�v►deL ,a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or a Ali b'emc marks. Locate all wells within 100 feet. Locate where public water supply enters the building:. II + E ` ! l� i �j r i t r ®-7 4 1 CO-Il11O-NIAj LUTH OF AtksSACH =SE T TS ExE-c- 7-p OFFICE Or E owl 4 J DEPARTMENT OF E�'V?ROlvrvrE-\-1Ar PFOTECT10_\ /l is 4�- TITLE 5 OFFICIAL INSPECTION FORM—'SOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FOR1T PART A CERTIFICATIO l�7'wl Oo/ kProperty address: rr'— es a,�s Crvner's\ame: o v� Owner's Address: �-✓�s�- A.�s�a� e /J� O�b � 4 Date of Inspection: o ame of Inspector: pPlease print) aYhr %0 4f.B��j E Company lame: C/l/l/I'a — EG _ N'lailing Address: o C->( a s f a✓h /J Q� 6�e1 - Telephone Number: p� CERTIFICATION STATE'lVIENT -- I certify that I have personally inspected the sea-aae disposal system at this address and d at e die=�fo na~on ro or''.ea below is true. accurate and complete as of the time of the inspection.The inspection;;-as Here med based on training and experience in the proper fumct'on and maintenance of on site seivace disposal sysre_:ls. I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 C1IR 15.000). lne sysrem: '- i'asses Conditionally Passes Needs Further Evaluation by the Local Appro;-^_Q Aur 0,i Fails Inspector's Signature: 60ecADate: g/01�� The syste.._inspector shall subrn:t a copy of this inspection report to the Appro; �A:1t �,- DEP) ;:thin-0 days of completing this inspection. If the sv + Dot a o= `- p stem is a shared s;�sre or=as a `�, znt'os., C. �. gpd or greater; the inspector and the system ovmer shall submit the report to the An01_ oo_L renien=l o`=.e o= DEP. The original should be sent to the sv_stem o�mer and copies sent to the bu er. annlic_ a _�„_, a„rhorin% - .� otes 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 NQi perform in the future under the same or different conditions of use. Title ;Inspection Form 6.'1 5'2000 naQe i Pa-at 2 of i 1 OFFICLA-L INSPECTION FORM—\OT FOR VOLI,TNT--!�RY ASSESS-MENTS SUBSURFACE SEWAGE DISPOSAL SYSTRII IN—SPECTION FORM PART A CERTIFICATION(continued) Property Address: j Gr���- Owner: / Cowlcyr Date of Inspection: Qi6 Inspection Summary: Check A.B,C,D or E I ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure c_..eria desct bec .m=_? CMfRI 15.=03 or in 310 C'VM 15.304 exist. Any failure criteria not evaluated are indicated beio7°. Comments: B. System Conditionally Passes: /V !Dne or more system corTonents as described in the"Conditional Passe section need to be replaced of repairea.. The system upon completion of the replacement or repair,as approved b the Board of Health, ,-ill pass. Answer yes, no or not determined(Y,\?ND)in the for the folioair_g statements. If"not deter-,=fined please explain. E) Tile septic tank is metal_and over 20 years old*or the septic tank(whether metal or not) is s-mucturally unsound, exhibits substantial infiltration or exfiltration or tank failure is im- nen. SvsTenl v,i i pass inspection if the existing tank is replaced,tiith a complying septic rank as approved by The Board of Healif-t. *A metal septic tank will pass inspection_if it is structurally sound.not leaking and if a Cep care of Compliance indicating that the tank is less than 20 vears old is available. ND explain: Observation of sewage backup or break out or high static water level in the dis.-ibuon box due-o broken o- obstructer pipe(s) or due to a broken,settled or uneven distribution box. System Rill pass nspec-ion if approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than='. tL-nes a year due to broken or ebsT�eted pipe;s:;. i n= pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed \71)explain: Page 3 of I I OFFICIAL nTSPECTIO\FORM- NOT FOR VOLI�TA-Rl ASSESSAIEtiTS SUBSURFACE SEWAGE DISPOSAL SYSTUNT TN-SPECTIO1 FORM 4,RT A CERTIFICATION(continued) Property Address: �& tt/--XJLGrnS a�/r �� ow, 6 G� Owner: O VI 1 G✓J Date of Inspection: as pU C. Further Evaluation is Required by the Board of Health: /" Conditions exist which require further evaluation by the Board of health in order to Cdete.-rime if the s stem is failing to protect public health; safery or the erg-:romnent. I. Svstem will pass unless Board of Health determines in accordance'vsith 310 C:�IR 155.303(1)(b)that the system is not functioning in a manner which will protect public health. safer-and the environment: — Cesspool or is thin 0 feet of a surace water Cesspool or privy is%within 50 feet of a bordering vegetated l etaland er a salt naa_sh 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the systFm is functioning in a manner that protects the public health.safety and environment: The system has aseptic tank and soil absorption system(SAS)and tn_e SAS is surface water supply or tributary to a surface water supply, _ The system has a septic tank and SAS and he SAS is v=thin a Zone i of a Tpublk wa:e-suu_l r. _ The system has a septic tank and SAS and the SAS is Rzthin 50 feet of a private water supp _ r•:e '. _ The system has a septic tank and SAS and the SAS is less than 100 feet but f' feet o-_Lore -Eon:a prvate water supply well". Method used to determine distance ""This system passes if the well water analysis;performed at a DEP cerified labo=o v. for colifo_--n bacteria and volatile organic cornpounds indicates that the well is free from poll zt:on from hat and The presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppry n_ro-iced that no ether failure criteria are triggered.A copy of the analysis must be attached to this 3. Other: T;rol� II Page 4 of 11 OFFICIAL INSPECTION FORIM—NOT FOR N7OLU,NTARY AS SE S SATE N TS SUBSURFACE SEWAGE DISPOSAL SYSTEiNI INSPECTION FORM SKr A CERTIFICATION(cony rued) Property Address: �� G G r 4.0Y /� 2 5�►— a..1 uS�r � ��� O� c 6� Owner: /t o V-1 A V1 Date of Inspection: D. S-%-stem Failure Criteria applicable to all systems: You must indicate "yes" or"no"to each of the follo)v ng for all inspecrions: Ye \o/ III✓ achcip of se«age Into facility or system component due to overloaded or clogged SAS or ce__naci . ✓✓✓Discharge or pond ng of effluent to the surface of the grourd or surface waters due to an overloadee o- -��iogaed SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded o-clog_ed S"A.S or f'sspool T quid depth in cessuoo1 is less than 6"belo=x-invert or avai!abie volli e is less than day'O Required purnpir_a more than 4 times in the last year tiOT due to clogged or obs-ructed piv �f times pumped ny potion of the SAS, cesspool or pricy is below high ground�,azer eieva�on. Any portion of cesspool or privy is within 100 feet of a surface water supply_ or tnbwta--to a surface ter supply. _ Anv portion of a cesspool or privy is within a Zone '_ of a public well. v portion of a cesspool or pri«-is within 50 feet of a prit-ate rater supply v,-eli. Anv portion of a cesspool or privy is less than 100 feet but greater than-�Q feet from a supply well with no acceptable water quality analysis. {This system passes if the well stater analysis. performed at a DEP certified laboratory.for conform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form., (Yes.-N o) The system fails.I have deternined ghat one or more of the above fails-e c--.-ia e_cs-as described in 10 Cti1'R 15.303,therefore the system fails.The system o„ner sl_ould contact t e I3oard 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 Qpd to 14.000 gpd• You must indicate either"ves"or"no"to each of the fol1mving: (The following criteria apply to large systems in addition to the criteria above) ves n 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 orate-sarply the system is located in a nitrogen sensitive area(interim\Vellhead Protec ion ea—i::P_^';;,- Zone II of a public water supply well If you have answered"ves"to any question in Section E the system is considered a si z� 151- a: � _ "yes"in Section D above the large system has failed.The owner or operator of anv large significant threat under Section E or failed under Section D shall upgrade 'e �Y. to stem yn.accord =ce— e` ;04. The system owner should contact the a ropriate regional of ice + h - - PP �.,,. o�t e Deg a-�rnen:.. 4 f Page 5 of i 1 OFFICIAL INS PECTIO-'� FORM-\OT FOR VOL LT -ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM IISPECT70\ FORZI PART B / MECKLIST Property Q Address: 7 6 �✓�e,� // �G1y� Owner: 11�o w7 G Lj Date of Inspection: ola Q� Check if the following have been done. You must indicate` es"or`no"as to each of the follo-:-n�: 1 eso Pumping information was provided by the owner.occupant. or Board ofHeahh / Were any of the system components pumped out in the previous two weeks I v— 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 tins i -ce;.ton:' «%ere as built plans of the system obtained and examined?(If they;were not available note as\ _) Was the facility or dwelling inspected for signs of sewa?e back up Was the site inspected for signs of break out Were all system components, excluding the SAS. located on site ? V — Were the septic talk manholes uncovered,opened,and the interior of - ; r L. .ank L sec eu�o: :i_ co: cie0,of the b ff1_es or tees. material of construction, dimensions,depth o_liq_ud. depth of sludge. and dent'r_of sc;�jr_ ? Was the facility owner(and occupants if different from owner)pro.idea with ink-triaron on the proper maintenance of subsurface sewaQ,-disposal systems? =ne size and location of the Soil_absorption Svstem(SAS)on the site has been det-2_Lired base`on: :'es�ra isting 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;ssue annro=_-!tio_ o_, is unacceptable} f310 CMR 15.302(3)(b)] -i i`i. Tncnort'�n n-w Git c��nnn pas-,- b of I 1 OFFICIAL. I\SPECTIO\ FORM--NOT FOR ZOLU'_'NT-�_RY ASSESS:�IEN T S SUBSURFACE SEW-,kGF DISPOSAL. SYSTEM I-NSPECTION I-OIZNr PART C SYSTEM nT0R C-kTION' Property-Address: 96 ��s.-may /� G/�.s Owner• �o P 1 Ot i Date of Inspection: FLOW CO\-DITIO\S RESIDE\TLAL -Nu:-nber of bedrooms(design): � 'Number of bedrooms(actual): DESIGN,flow based on 310 CMR 15.203 (for example: 110 gpd x�_of bedrooms): Number of cur-,ent residents: dL Does residence have a garbage grinder(yes or no): Is laundry-on a separate sewage system(yes or no):A�iO Fif yes separate inspection required Laundry system inspected(yes or no): IC'V Seasonal use: (yes or no): A"O Water:peter readings, if availab e(last 2 years usage(gpd)): Sump pump (yes or no): Last date of occupancy:tAllll-v� COZNTERCTAF/L DUSTRIA Type of establishment: Design flow(based on 310 Cam. 1 .203): gpCl Basis of design fiokv(seats/persons/sgft,etc.): Grease trap present(yes or no):_ industrial waste holding tank present(yes or no):_ Non-sanitary-waste discharged to the Title 5 system(yes or no):— Water meter readings. if available: Last date of occupancy/use: OTHER(describe): GENERAL I\FORIIATION Pumping Records / Source of information: I0 J� /�c� 11"Y7 e 'i Was system pumped as part of the inspection(yes or no!: If yes, Voj.UMe pumped: gallons--How was quantity pum med detet­rriined" Reason for pumping: TY . F SYSTEM _ eptic tank, distribution box, soil absorption.system —Single cesspool _Overflow cesspool _Privy Sharec system(yes or no) I fyes, attach previous inspection records, if any) —limovative/Alternative technolog};.Attach a cop};of the cu_rent operation and rna-�- an;:e - - obtained from system owner) V `---` Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components. date installed(if knm� )and ource of info_-rat on; 0 Were sewage odors detected when a_-m in?at the site(yes or no):�� Page 7 oil OFFICIAL INSPECTION FORIM-NOT FOR V'OI.U'\T_LRY ASSESSMENTS SUBSURFACE SENVAGE DISPOSATL SYSTEM EcgECTION FOR-Ni PART C SYSTEM INFORIN ATIO'� (con inued) Propertz Address: 9� / �'� /qd Owner: Date of Inspection: rd as p� BUILDING SEWER(locate on site plan) Depth below grade: N,fater'a's of construction:_cast iron _�0 PV C_other(explain): Distance from private water supply well or suction Line: Comments (on condition of joints; venting; evidence of leakage; SEPTIC TANK:_�cate on site plan) Depthbeiow grade: —?� � ii M renal of construction:_cam oncrete_metal_fiberglass oolvethviene Other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance of no;:_(a-z h a con of certificate) 6 Dimensions: Sludge depth: G Distance from top of sludge to bottom of outlet tee or baffle: a 6 / Scum th::ckness: Ze.tS Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom q f9utlet tee or baffle: glow were dimensions determined: Ole Comments (on pumping recommendations;inlet and outlet tee or baffle condi_ion_. strsc rut rai Ty. liquid let ens as related to outlet unvert. evide ce of eakage,etc.): A �hePs i o GREASE TRAP: � (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass Polyethylene et er (explain):_ _ -- Dimensio-s: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments,(on pumping recommendations; inlet and outlet tee or baffle condi on si ,,c u al as related to outlet invert; evidence of leakage; etc.): ` f Pare 8 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTA-RY ASSESSAIENTS SUBSURFACE SEtiKAGE DISPOSAL SYSTEM INSPECTION FORM PART C Q SYSTEM INFORMATION(conr;nued) Property Address: / )� /'G✓�e,�// /�d�J Otis ner -7 Lute of Inspection: TIGHT or HOLDING TA.K: /y (tank must be pumped at time of inspection)(Iocate on site !an) Depth below grade: Mate-'al of construction: concrete metal_fiberslass volvethvlene other;e=pait: Dimensions: Capacity: gallons Design Flow: gallons.day Alarm present(yes or no): y Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches,etc.): DISTRIBti TIO ice �-P--- -N, BOX:_ , rest must be o erred locate on si p )( to plan) Depth of liquid level above outlet invert: '�40/,-V"1": L--- Com ments (note if box is level and distribution to outlets equal, any e��idence of sa"ids car,.over. at 1 e. idence of leakage i / -,g � ;box. etc.)--e(/`C /. 44 PUMP CHAMBER:A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber. condition of purnps and anpt?renanices. e7c.1; I Titio 1 ;''cncrtinn �n-m /lC/'innn I Page 9ofII OFFICIAL INSPECTION FORM—NOT FOR N%OLU'IT AR-1-ASSESSAIEEN TS SUBSURFACE SEWAGE DISPOSAL SYSTEM L\SPECTION FOR T PART C SYSTEM i'_\-FORINIATION(conrmueui Property Address: (/�G✓�-?r /Q� Owner: �o �'� 4i Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan.excavation not required) If SAS not located explain«-hy: Type reaching pits;number: / 'r leaching chambers. number: / /( `C TLt leaching galleries,number: leaching trenches; number, length: leaching fields,number; dimensions: Overflow cesspool; number: innovative;"alternative system Typername oftechnologv: Comments (note condition of soli, signs of hydraulic failure,level of pondhig, damp soil, condi=on of vegeta on. C. Ct/L � Ct CG /_r1_ -� CESSPOOLS: cesspool must be pumped as part of inspecr:on)(locate on site plan Number and configuration: Depth—'-op of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: -Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition_of soil, signs of hydraulic failure.level of pondina con-di o= ege-a-;or_. :tc. PRIVY:&(locate on site plan) Materials of construction: Dimensions: Depth of solids: e= Comments(note condition of soil; signs of hydraulic failure, level of ponding, condli ion ;ece-a �• e Titio � Tncr�ort;nn 1-nr..� lil vnnnn p I r . Page 10 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 96 Parker Road Property Address: West Barnstable,MA Donald Roman Owner: I 200S Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Pr vide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or bearks. Locate all wells within 100 feet. Locate where public water supply enters the building. r �3' i5o0yhu'� Z� J 3z' 60 5 L 1 50 Page 11 of i l a OFFICI_-L INSPECTION FOR1l1-NOT FOR VOLUNTARY ASSESS11ENTS SUBSURFACE SEWNGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM IoIFOR_NTATIO (continued) Property Address: I Owner: Pate of Inspection: �o2a p,(, SITE EYAA11 Slope Surface water Check cellar Shallow wells p* //.� �e �1►sf��3 ti E.,rmaed depth to ground water � eet -- avoa Please:r-dicate (check) all methods used to detebine the high ground water elevation: O�tained from system design plans on record-if checked;date of design.plan rep-lie Aed: Observed site(abutting properry'observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed T 7SGS database-explain: You must desc e ho v you established the high ground water elevation: 9,o o v" o /1/0 ws �, ���o�✓ ice, c�Q 4 .1 wo Sod T41 Inc oro-i n.n T n lil /lnnn TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MZ 02660 COMMONWEALTH OF MASSACHUSETI'S EXECUTIVE, OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION "TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 96 Parker Road West Barnstable,MA Owner's Name: Donald Raman n Owner's Address: 96 Parker Road West Barnstable,MA 02668 Date of Inspection: December 19,2000 O RECEIVED Name of Inspector: Troy M. Williams Company Name: Troy Williams Septic Inspections 1 zQQQ Mailing Address: 19 Hummel Drive South Dennis,MA 02660 TOWN OF BARNSTABLE Telephone Number: HEALTH DEPT. (508)385-1300 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. 1 am a DEP appros ed system inspector.pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system ✓ Passes Conditionally Passes Needs Further Evaluation b) the Local Approving Authority Fails Inspector's Signature: -1--1--� _ Date: i.z//ti The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth or DEP)within 30 days of completing this inspection. 1f 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 Although system meets'the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping.or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.l his inspection does not address how the system will perform in the future under the same or different conditions of use, Title 5 Inspection Form 6/15/2000 �anr I — I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 96 Parker Road Property Address: West Barnstable,MA Owner: Donald Roman Date of Inspection: December 19, 2000 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 anv of the failure criteria described in 310 CM 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N//g One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair,as approved by the Board of Health, will pass. Answer yes. no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicatine that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 i Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 96 Parker Road West Barnstable,MA Owner: Donald Roman Date of frtspection: December 19, 2000 C. Further Evaluation is Required by the Board of Health: lvlg 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 Hill pass unless Board.of Health determines in accordance with 310 CM 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within a Zone I 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 front a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the aresence 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: 3 i f Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) 96 Parker Road Property Address: West Barnstable,MA Donald Roman Owner: December 19, 2000 Date of Inspection: 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 clo�_ged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 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. j/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. vim/ Any portion of a cesspool or privy is within a Zone 1 of a public well. N/A/.o 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.) N (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as de�crihed 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: NIA To be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 96 Parker Road West Barnstable,MA Owner: Donald Roman Date of Inspection: December 19, 2000 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No r--::-,pina information was provided by the owner.occupant,.or Board of Ilealth 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 ;1 _ 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: 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 C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] 5 _ I Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 96 Parker Road West Barnstable,MA Owner: Donald Roman 2000 Date of Inspection: December 19, , FLOW CONDITIONS RESIDENTIAL 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): 33 o ' Number of current residents: 0R Does residence have a garbage grinder(yes or no): YL S Is laundrN on a separate sewage system (yes o no): vu [if yes separate inspection required] Laundry system inspected(yes or no): AMA Seasonal use: (yes or no): .vo Water meter readings, if available(last 2 years usage(gpd)): ,j&t I. Sump pump(yes or no): At- Last date of occupancy: COMMERCIAL/INDUSTRIAL N/,9 Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: A10-af'^P Was system pumped as pan of the inspection(yes or no): ,va If yes, volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe):. . Approximate ate of all components. date installed (if known)and source of information: J-�s•ft,. l..,)t � �28 /8� ���� `� r a t, . ,AS- 6.. t f Were sewage odors detected when arriving at the site(yes or no): A/c 6 Page 7 of'I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 96 Parker'Road West Barnstable, MA Owner: Donald Roman Date of Inspection: December 19,2000 BUILDING SEWER(locate on site plan) Depth below grade: 3 Materials of construction:_cast iron _✓40 PVC other(explain): Dist-ance fton: private water supply well or suction line: i50 •-f- Comments(on condition of joints, venting,evidence of leakage,etc.): rl✓.S L, c d I. H c:..n 76,r.:� G.( C ✓ Gam. '7 1..-i -}-) ar,..� .../- SEPTIC TANK: (locate on site plan) Depth below grade: Material of construction:_[concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 7 ' )c II 'x G Sludge depth: Y" Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ,vo ti% Distance from top of scum to top of outlet tee or baffle: AID s c. Distance from bottom of scum to bottom of outlet tee or baffle: A0. s c How were dimensions determined: - pr_ ,,L, T pf—" - Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet.invert,evidence of leakage, etc.): ?V 4- G n,A c o�c�a.��. 'F'c..S //`` '�- -'----._T�1.r..� .ti .n.iu 1 1•c.....w O.�`:.(c.�. V y�t- c o...�.r�.-�'� f"cc. L/'xS ,...-A 0(c.'t S.IT N �,./�.,.11 o✓,.Jt xT /`,:J"' 41 � 0- %�y ( ✓�,✓r� .ate 4wi�c�j - J•�1 A+✓r,.t %�.. k w... S gnat . ,, 6 GREASE TRAP:Ai/4(locate on site plan) Depth below grade:_ Material of'construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): i 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 96 Parker Road West Barnstable,MA Owner: Donald Roman Date of Inspection: December 19, 2000 TIGHT or HOLDING TANK: kl/,q (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 Foy%: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: — Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): D'-13ox w�. , i.. �..� lc✓s i.� ,sic — I PUMP CHAMBER: AtM(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): a 8 f Page 9 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 96 Parker Road West Barnstable,MA Owner: Donald Roman Date of Inspection: December 19, 2000 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why. Type leaching pits,number:_ leaching chambers,number: 5 - F&u df f{„ 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.): . L kc k c Z _s4b U _ ,,t V✓ i�w b ��rn S Ati J 4 CESSPOOLS: AVA(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY:Aillq (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 96 Parker Road Property Address: West Barnstable,MA Donald Roman Owner: December 19, 2000 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. r\ CIS• �1 a3 IS�oryhti�.. a81 ARM 60 5�, 150' Page I 1 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 96 Parker Road West Barnstable,MA Owner: Donald Roman Date of Inspection: December 19, 2000 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater I.s'feet Please indicate(check)all methods used to determine the high ground «ater elevation: Obtained from system design plans on record- If checked,date of design plan reviewed: 1918 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: S p w .2 S .z t�ti A y, .� 1 "J J You must describe how you established the high ground water elevationJ: s s. (e si 11 t IF-a' 'No. -....---- ` ;: SUBJECT TO Fx$... APPROVAL Op THE COMMONWEALTH OF, MASS cg(AET -TSFABLE L+ONSERVAT10j,4 BOAR® OF HEALTH .O F...................•-.................. q f `q fo lylkppliratiun for Mi'VuuFal Works Tunstrnrtiun Errant Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ............ ..... --lam: c ------------------------------•-•------ --------- ---•---•--......----------- Location-Address r t o. .......... - , --------------••-----•------------•-----•---- ......... -....._.•-.•-__-:-• 0 ........ Owner Address ..... �..... ..!..... .............. ....... Installer Address Type of Building Size Lot...........................Sq. feet Dwelling—No. of Bedrooms..........3.............................Expansion Attic ( ) Garbage. Grinder ()-W p4 Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- d ----------------------------------------------------------------------------------- Design Flow.................�.�.................gallons per person per day. Total daily flow__._.__.....J2..Q...........__._.___gallons. WSeptic Ta capacityl��__gallons Length................ Width._.............. Diameter------- Depth__._.____....._. x Disposal No..................... Width.................... Total Length.................... Total leaching area.... ft. Seepage �gi.quid t i1o____________________ Diameter.................... Depth below inlet. ........... Total leaching area......__.______...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................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---_____----___-_______- �+ --••-----------------------•--------------................-•---.....------------••••----•-••......-........................................................ 0 Description of Soil------------•-------------------------•--------------......._......----•--•----------------------------------------•---•---------------•---......•.....•••••••-•-•-•••. x 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 been issue by the bo d of health. Signed..... . . ......... .............................. ................................ Date Application Approved By..... •__ •• • ••• ............................... ............ Date Application Disapproved for the f oilowing reasons-.............................................................------••-------••••-••--•-•••--••-•-•----••••-••--- ....................•-••--•--•-------•--•--•----......---•-------------------------------..._._.......-----------•-•••••••-•-••--•••------•-•-----------------------------------------------•-••••-•_•-- Date PermitNo.............. Issued........................................................ Date V No .. .. THE COMMONWEALTH OFj MASS/#CHUSETTS BOARD OF HEALTH ,' ............................................O F.....................:.:.............. ,ill,vUration for Uwv sal Oaks Tomitrnr#inn ranit- Application is hereby made for a"Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at .....------ .... ...r ..... ... ! .......... ....... ..... -- .........---•--•---- . Location-Address � rr&ot o . � W....-----•----•-----•---------... .---- Ownez n Add, ss 4 �..... W .. ._ ....... ................................. Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms........... .........::::................Expansion Attic ( ) Garbage Grinder ( / a`. Other—Type of Building ............................";No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------------------------------------------------------------------------------------------- W Design Flow................. .................gallons per person per day. Total daily flow............;, :Q..................gallons. 1:4 Septic Ta � iquid capacityt .gallons Length.............•._ Width................ Diameter..._......_..... Depth................ Disposal No. .................... Width.................... Total Length.................... Total leaching area.... .....sq. ft. — Seepage it No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by --....-•--•........:'.................•--•--•... Date aTest Pit No. 1................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........................ lx ...................................................................................:.................••-•••....•••--•--•--••••••-......•....------..........-- Descriptionof Soil.....................................-----------------------------------------------------------------------•-------.....------------------.................-••._...•... x W --- = -----------------------------------------------•------------------------------------------------------------------------------------------------------------•--- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ---------•-------------------------------------------------------------------------------------------------------------------------•-------------------------------------------.--••••......•-•........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TTT y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been issue by the bo d of li lth. 4 Signed ... .: ............ .... Date Application Approved By..-.. >.- + _ ...........�. ........---•--- Date Application Disapproved for the following reasons--------------- -=-----------------------------------------------------------------------------------------.._ -----------------------------------------•---•-----•-----------------------•••-•••-----.....•••--:--•-•-.---•••--••••-•-••-......-•••-•-•••-•••-•-•••-•----•--••---••----•---•------••----•---•••••..•-- Date PermitNo..........................•-•••......----•-•...... ... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF;......7............... .......*'***........ .................. (9rdifirate of Tompitur THI .IS T ERTI Y That the Individual stem Disposal Sewage S. Repaired constructed or Re air�' ( ) P� ( ) � by . t I talleri { �*at. r ' ` --�A -----------•---1� ,• x t;,, `"�•�.. has been installed in accordance with the provisions of TI T LE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No...... 2_iit-_L2............. dated------------.................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSfiRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTI N SATISFACTORY. DATE..........................(911� _---..-------•-----•---. Inspector.......k t2 ---------------.--------------------•------..-.-..--------•- THE COMMONWEALTH OF MASSACHt SETTS BOARD OF HEALTH .. No... .................. FEE.... ................. Dispood Work U.t-41 ra inn rrnti Permission is hereby granted---------' ? -- - _.... to Construct (C eor ep 'r ( ) Individ 1 Sew is s- System atNo. e ..-----------------------------------------........................................ Street as shown on the application for Disposal Works Construction Permit No.............. ..... Dated.......................................... ....................................... ` �+ B Health DATE.......... a----•-------V-----------•----------------•---------------------- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS Y $v'ttt77{t�,,, r a � � -. .^� '� '� � �,� -�: 4 �' f. ,t '`K f''" '/t/�r e.•. ':` r'a+ lra '`t 1 �' �` ra f +F , N+Yr�/t:4�{_ . � _� ++{��.r r 2 , .a•. . x e W kL 5� '�Civ-��+,V� l•��" '3;ft� 'a 4 f k M•`, a� :.� ��, rJ �°t �rYT y � c ''f jq + 's � rt t'� i '`�1 a• r-.,:5 � :h .. t St.Soh .�. w -4 9 g ftY .:'r`• y `i ,i�3 .�•° •c' ,�_ � �` t 'w„' r,� ,,(^t ti , k4 _ a w -ai r� J,.,* r 2 1,x }. � i� ��+ i` T r.{��r t C;.•', i.' y 1-t, .. .� , �+ � ' December 16�, 1981 ' ! h '4e F 'y +tic � 4•' �{ v s r''�. .x c�x •.t vS • r f �v f r ?� _ F t tr sV � k ` . f M l FT� `� i i :g,� t'r �: 2 �' `. `;`•k v t. + �r � Y .« * r`• � � E t '' ' a s x" t .. r 1 _, t T 4 `. x * ey ,. '. •� •1 t .t a s t2•• a ♦ Y`a t `.n Yf.... " Ya- Ft ham. � 4 y �, �, 4 t -� ' ' � .: 2 4 �,� h Mr :,Josh'.Whitney t Jt. �;. Whi�l�tey,. &` Bassett �� _ �X t satilY ; ra' Nla].n 5 L,r eet - ' `F t. n Yw' ':.'. ,i ii ` v ��''' `�sx �' ••+r S+. �` T r 't� i �� yt +��;/«.,• .` ht •',aYh. q'Hyannx.s, ata`� - -vr' `4, '4 •.~ , i s .: ; ,: h it'`.� _ r �. ,�_ dear Mr: WYitne d_• `, ,t v.� rF K+❑ t2.-.i ta.^ +S :v'"� y- - ' 4 �:"rhe Board of Health.;w�:'11 •consider,granting ,a" var`�:ance tom ut'ili e ` r an existing,-weir �locatecl on ati -:adjacent =lotto• aproposed -new F� dwelling between Parker 'Road and; Main", Street; West Barnstable,• �� 1w - �,, :after; rece pt °the>>r'£o low g; nfarmation: t� f statement from, •the 1'Lcensdd weft`4t_dagger."that it �s 1m � ` ; gossible :to install a'well',an';the pzoperty inva].ve"d.. i + v^V(2 ) A ,statement from a registered profe$siohal engirieer,'certi fying ,tle,�capacty of fthe well ;andelso:rcertificat�on that • r« i ;:the ell 'can- service' - Y t w lothf'dwellings. ;'- P� A complete bac erso],og cal.; and•chemical `'report ,,() the",' duality,of y t1i water perfok*4d: by a:`tcertifi`ed. labmratory. .j `' X�. t� 4�.•: !.. �,. .. � w - ��z£tt 3.I 'r xsy, +''. .,f _-_e { • , f k lts,.. _ .. :.,. '� 5'.•` L ?,kRt a 4) Furnish y proof?.that the t`ownor lies recorded oii the''deed that he w3.I1 A"nod.sell `either of the-:twci' prppert es `involved, d ;,that s they w�.1E remain' under Fhi's;. ownership.,: 1 r .{r'* y4 n'� �' K n r t U..-'F +. E' ,'�-�f r. 1 Y } !• �i:. .x t'5)x_the;exist�;ng well must be`' .50 feet�'frc�m`any.`sep �ic leaching r. facility •v t r ui t V er ru 4 �rr'7 '� * ✓ V M'v�a.a4..a ! x u t ,5 e.y _ a� �.- . Y t t1 n ;•t +�', ♦ ,�"'_ ;.t � ry^ "'r �„y S J` , F • ,, r .a +. .' `' + r s+^h t«fir ':: .. a ttv , ; v i ✓ e. ^�• ,+ *- , y .� S. 'yrf •r .'a i�t' ..�d �5 � °r4 rs `` w. �_- �. 'rh,, w .:.�' tY -r," •a4�t � ;? ya.. i P �?y;,l ` r .,' } �_� ':� � R© ert :L! 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