Loading...
HomeMy WebLinkAbout0040 PERCHERON WAY - Health 40 PERCHERON WAY, W. BARNSTABLE A=174-1-54 LOT 146 No. 4210 113 BLU SS- sm ESSELTE Q%a l a a ° ° r y -�z Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments E Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for evey West Barnstable MA 02668 6/1/2018 ; page. City/Town State Zip Code Date of Inspection r r� 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:out When fillip out forms A. General Information f Ion the computer, use only the tat, 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services r� Company Name. 350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 6/8/2018 inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. ` t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form R' X Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M g Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2018 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System in working condition. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r Keith Powell M Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): ❑ o'bstruction.is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °« Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than.100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground.or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 'h day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments b M Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for eery West Barnstable MA 02668 6/1/2018 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 0 E] the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate ' regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 17 Commonwealth of Massachusetts : F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Keith Powell Property Address 40 Percheron Way Owner Owners Name information is required for every West Barnstable MA 02668 6/1/2018 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x3= 330gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 0 G Kei th th Powell Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 4 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2016=326gpd g ( Y g (gpd))' 2017=186gpd Detail: Note irrigation system in use Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/2 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, 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): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 2011 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 26' feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from. +10'private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 1411 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: 1000Gal Sludge depth: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 211 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000Gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Inlet cover 16" below grade with outlet at grade. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �Ar SVBV`' Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable . MA 02668 6/1/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid.levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts -- — W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Keith Powell wM SVey`e Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 DB-3 with 1 line in and 3 lines out in good condition. Box is clean and level with minimal solids carryover. Outlet inverts equal. No sign of overloading or hydraulic failure. Cover is at grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 18-Arc units ❑ 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.): 18-Arc 36 chambers with no stone in a 8.6'x32' Field. No standing effluent in chambers during inspection. No sign of overloading or hydraulic failure. 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 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Keith Powell M e Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable . MA 02668 6/1/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth.of Massachusetts d Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' M Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/201.8 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells +12' Estimated depth to high ground water: 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: 2011 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data per plan on file at BOH. No water at 12'. Max bottom of leaching is 3'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Keith Powell Property Address 40 Percheron Way Owner Owner's Name information is required for every West Barnstable MA 02668 6/1/2018 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ` I rage i or L TOWN OF BARNSTABLE LOCATION �o -�ed�cil/E41o.v ki.Y`SEWAGE# VILLAGE • eWXA" ASSESSOR'S MAP&PARCEL 1o1 41-- INSTALLER'S NAME&PHONE NO.t�/� ZG3�O�yf 77S'o�o) SEPTIC TANK CAPACITY d7 /000 LEACHING FACILITY:(type) eP-d Af 3X NO.OF BEDROOMS OWNER 4�f PERMIT DATE: -�/ COMPLIANCE DATE: Separation Distance Between the: ivo vim?- vo /oZ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility Of any wells exist on / site or within 200 feet of leaching facility) / Feet Edge of Wetland and Leaching Facility Of any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY £�� �..o fib'•!/� y 9 -r -7// rgV,;;9Arh1�,9 S 9 iyy 0 r i http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=l 74001054&seq=1 5/30/2018 TOWn of Barnstable - ' ' Regulatory Services Thomas F.Geiler,Rector Pubhe HeAth Division Thor"s McKean,Director 200 Main Street,ldyamis,MA 02601 Office:.508-862-46". -Fax: 503-790-6304 llAstaaer&DgSigner Ceram' icatio-O Form. Date: � r Zc-111 6 Deslg�aer: �W10 �• � ��� �talier: a!- � G Address: . NA Address: —T (�j 1 MA .T 3 I'd/ii�1� was issued a permit to imstall a (date) (installez) septic system at based on a design drown by (address) I Ll�' dated (designer) �-.eerify that-the septic system refemced above was installed substau�ally acc. at. design,, which may include na appxaved changes such as Ian,reloration,of the digttrbution box and/or septic tank... I cea-Eify 4hat the septic system'Teferenced above was i�A.�d'•ar"itb' •changes (i'.e, •greater tl mg`I0' lateral reloea "of the SASS oz•any aML.y campR� of the.septa64Vst .)but in akcorclaidce with State.&LocaY,R.egdl,astiops, Plan revidou ox ceai£ied as bt t*designert8 foIIvw. s • (Installer's Signature) SbNji (J)&i4EeFs Sipature} fi ez' ; taiiap here} P 7E BET RN �Q TR OF-.C ' ('t '94ria..�' . ': '.' �UEI3= ram. O3'la,''lE"��s�• rM (A��ST� AR AEC9 Q:T�balti5/SepiiclDeaignerCerti$cs�ioxitFo� �`��.•.. •.>•'' _ ;''.�;}',< ,� . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,3 �rc-�ef'oki (,✓4-4 Property Address / a✓(�jG�/G1 �1 CiGi S Owner Owner's Name information is ("les ���✓I s�q��� Da b 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 A. General Information n forms or.the (f/ computer,use 1. Inspector: only the tab key / to move your ✓ D e usetf cursor- et Name of Inspector not use the return - ���� key. EA10 D Q Company Na e Company Address .'L-n' -A., 1C J City/Town State Zip Code .So3 r7 7.S- 1�1f Telephon umb r 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 -= Fails:m w ❑ Needs Further Evaluation by the Local Approving Authority a t --n .t 9 Inspe rs Signature Date f t9 The system inspector shall submit a copy of this inspection report to the Approvi',Putho ity(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of i6spection 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. I 15ins•09108 Tide 5 official Inspection Form:Subsurface Sewage Disposal System•Page t of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address I/� I Owner Owner's Name �j7� requinaEon is / /PS1 ✓v1S �G�/� L--�— a" � required for lam✓ / every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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): r5ins.09r0e TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Syst m Form -Not for Voluntary Assessments UIV Property Address n Owner Owner's Name i -1 information is / /es�— � � cz—9^l/requirec for W `� every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09108 TiOe 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 640 V1 Property Address /t Owner Owner's Name information is required for �vles-�- every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes o ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded, or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow i5ins-io9io8 rifle 5 Official insp ection form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o,, (✓G Property Address I Owner Owner's Name information is required for �/jam!�+ /ll/rl j�a uG A4 OoZ-(6-e "-e yr" every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ Required pumping more than 4 times in the last year NOT due to clogged or bstructed pipe(s). Number of times pumped: ❑ Qv 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 utary to a surface water supply. ❑ ,L�f/ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.) ❑ �� The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. L�' U The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection ❑ ❑ Area — IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•OW8 Tide 5 Official Inspection Form:Subsurface Sewage Disposat System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal UV Syst em Form -Not for Voluntary Assessments �Q (,✓a Property Address -- - -- ----- Owner Owner's Name formation is �jt/ Q�+ /�5;��y(G -- 1Ti squired for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes ❑ P mping 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? Z o Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Existing information. For example, a plan at the Board of Health. �❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t5 s 09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address I Owner Owner's Name information is required for �/�/�, /es, - /hS�G l 0 a-)-6 y every page. City/Town State Zip Code Date of Inspection D. System Information Description: / // a`///0 Ll SP tC_ ah �✓ Is 44/to it D CA/ t6x ,� ,off Number of current residents: Does residence have a garbage grinder? Yes ❑ No Is laundry on a separate sewage system? (if yes separate inspection required) ❑ Yes No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes No GU�Yer. Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins•09V08 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 7 0!17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments D Property Address 1 Owner Owner's Name / ^� informabon requiredte for ��eS �G/✓1 �� /�� ��6�� oZ — ! / every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: rO Was system pumped as part of the inspection? -, ❑ Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of Syst r 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): (Sins•0908 Title 5 official Inspection Form!Subsurface Sewag e Disposal System•Page 8 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments arc Xeol-a4 t.161 Property Address Owner Owner's Name�Ies r/ /� required fo is � G/v1l a lJ U D�6�� requiredfor every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) an ource of informatio : Were sewage odors detected when arriving at the site? ❑ Yes Z� Building Sewer(locate on site plan): Depth below grade. / feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet. Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material +.onstruction: 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: Xg Sludge depth: t5ins•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposai System•Page 9 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ZZLO A-C hero 0 j i/a Property Address Owner Owner's Name information formation is � _ eS /� required for V" ST�.`j _ f 04r.6� every page. City/Town State" Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) l Distance from top of sludge to bottom of outlet tee or baffle Scum thickness p Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 11) lam. v- r N o / f 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 15ins•M08 Title 5 Official Ins pection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name Q information is required)for W every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Dare Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins•C•9/m T lle 5 Official inspection Form: .Dec6 Subsurface Sewage Disposal System Page 11 of 17 Commonweal- � th of Massachusetts I U1WTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments Property Address n l Owner Owner's Name information is (�! �s rvtfT"6!� Q� 6� required for _ every page. City[Town State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box (if present must be opened) (locate on site plank.— Depth of liquid level above outlet invert C-� Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Tithe 5 Official liftPection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Q lirG 4el-oll-I tvcc Property Address I Owner Owner's Nameinformation is required for I 7/ /_/ (2 every page- City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: 6 X leaching pits number: � � / `��� ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): p 0 Cil Till 1-e W� (DWI :e� A�-14— ✓t� Pv�lOti , 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 t5ins-C9'08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments 4r-4"4'0f'90 a Property Address 57 Owner owner's Name l /� �✓J�7 information isrequired for O—Z6 60 / every page. City/Town State Zip Code Date of Inspection f D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t&ns•OSM Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form W Subsurface Sewage Disposal System// Form -Not for Voluntary Assessments q0 a/'C, hero Property Address Owner Owner's Name/ information is I n required for """lll„ every page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where is water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately c� R ISlns•04'08 Title 5 Official Inspection form:Subsurface sewage Dlsposel System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments q(q OC�r�G G►e�e t vr' Property Address Owner Owner's Name I information is required for �Ies� 6�;(66e every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high round water: - p g g feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: � � l�� !�► C/(,✓'�`,fie-� Q Before filing this Inspection Report, please see Report Completeness Checklist on next page. tsins-09fW Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1�0 4-P a Property Address Owner Owner's Name information is /Ps� l^f T�1 f�a� required for V y � -��/ every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed 03 System Information— Estimated depth to high groundwater ❑ etch of Sewage Disposal System either drawn on page 15 or attached in separate file t5 ns•0308 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 AsBuilt Page i of 2 TOWN OF BARNSTABLE LOCATION yo /il�c/%razo.v Olii6`SEWAGE# VILLAGE Gti �.4X-*' ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 6 Onoo G.Jl LEACHING FACILITY:(t)pe) (size) Al 3It i NO.OF BEDROOMS 3 OWNER A_-F . '/6:76f-r PERMIT DATE: —��- // COMPLIANCE DATE: Separation Distance Between the: do Maximum Adjusted Groundwater Table to the Bottom.of Leaching Facility a a 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 Of any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �... £? r o f z>'f�?7 • ess rc -� 0 Y16'�2 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=174001054&seq=1 5/1/2017 TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE 46'• 4e,4X " ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO-d��V SEPTIC TANK CAPACITY 6 oOaO 6WZ, LEACHING FACILITY:(type) (size) eP-6- NO.OF BEDROOMS � FAILED �a OWNER � . �/�d'.f INSPE Tlo,�, f PERMIT DATE: ' —/�_ �/ COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility oZ 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 gg—facility) Feet FURNISHED BY V Z G"SOeg/ A � . 3 r„�,s�tc9o��v �oatT 0 BAR G cif'.�nleyEd�1' tic TOWN OF BARNSTABLE LOCATION "V 0 A64 CA/�l0-� �cs�.� SEWAGE# . VILLAGE� A4Ld X d�-cQ ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) . NO.OF BEDROOMS OWNER �� \ PERMIT DATE: ®� PLIANCE DATE: Separation Distance Between the; ��'��� Maximum Adjusted Groundwatera6le 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 No. f O Fee 00 °° _ Z THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplicotiou for Di!5pool &V.temc Cow5tructiou Permit Application for a Permit to Construct( ) Repair O Upgrade( ) Abandon O ❑ Complete System Individual Components Location Address or Lot No. W.,Ay Owner's Name,Address,and Tel.No. Assessor's Map/Parcel JVAI 1911— Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwalling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building ��`„6�. No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(in required) gpd Design flow provided � gpd Plan Date J / I/ Number of sheets Revision Date Title Size of Septic Tanker/�1'T�i��G /OOo�d� Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in,operation until a Certificate of Compliance has been issued by thi and of Health. Signed Date '�� Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. 2—O i l— O 5!1 Date Issued 3116 `� l No. � �= Fee r�O0' U� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I PUBbG HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS? Yes Roplication for �Digoal:*pgtem-construction 'Permit Application for a Permit to Construct O Repair O Upgrade( Abandon - ❑Complete stem U�IndiidualP Components Pg P lete S Y) . Location Address or Lot No.`7�0�G��1�E��� Ay Owner's Name,Address,and Tel.No. 7� �d44 oZ Assessor's Map/Parcel ,17,0 r ,i Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms .3 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building QZ� 1 . No.of Persons Showers( ) Cafeteria( ) "Other Fixtures Design Flow(mi require ) � G' gpd Design flow provided — o gpd Plan Date 70 �/ Number of sheets /, Revision Date Title } ; Size of Septic Tank c��C/1'�'"�/��G /0oo�9�j Type of Description of Soil Nature of Repairs or Alterations(Answer when applicable) i Date last inspected: i Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by thi and of Health. Signed Date -!:!�7'�� � � J Application Approved by Date { Application Disapproved by: Date for the following reasons i Permit No. ZO I(' 05 t Date Issued 3116111 { THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance s� THIS IS TO CERTIFY,that the On-site�Sewaage Disposal System Constructed ( ) Repaired (!/) Upgraded Abandoned( )by G T at lr�� �cG©l G'i��G�oi✓ l�i+<y d'y 4�, eX.v has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ,701 1-o5q dated 3 1 I/ InstallerZ/yJ � �l��l//� Designer4g!24/i/,Q /JfAJ77 G�.J`. i #bedrooms .3 Approved desi 2n flow -��� _ gpd The issuance of is peg it shall not be construed as a guarantee that the system wfun ti as design Date U iI Inspector ------------ No. + Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Xitpofsal 6p5tem ConfStruction Permit Permission is hereby granted to Construct ( ) Repair (4-< Upgrade ( ) Abandon ( ) System located at _I,I,- G1/ a 4",- I ; and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: on truction must be completed within three years of the date of this perm Date Approved by i f i i Town of Barnstable p# 13 ?c) Department of Regulatory Services Mxetar,►eM : Public Health Division Date 3 1639. �e� 200 Main Street,Hyannis MA 02601 Date Scheduled Cy Jam ' Time Fee PdzzPo o yo Soil Suitability Assessment for Sewage Disposal Performed By:_�� a/ 6 Witnessed By: dA LOCATION& GENERAL INFORMATION Location Address �e��Gl�G�Q'��/ Ctii(+/ Owner's Name Address Assessor's Map/Parcel: Engineer's Name c�_C'G/O NEW CONSTRUCTION REPAIR `' + Telephone# J�,J 3 �>> Land Use Slopes(%) Surface Stones Distances from: Open Water Body ft Possible Wet Area + . . ft Drinking Water Well ft - _ Drainage Way ft Property Line ft Other r a ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) I I V3 Parent material(geologic) Depth to Bedrock f Depth to Groundwater. Standing Water in Hole: Weeping from Pit Race '" Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: _ in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adl,factor- Adj.Groundwater Level PERCOLATION TEST bate Flare Observation 41 Hole# Time at 9" Depth of Perc 1 Time at 6 Start Pre-soak Time @ 01 i lime(9"-0) t End Pre-soak Rate Min,%ch ' Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Heailtl Division Observation Hole Daia To Be Completed on Back----------- 'T f + ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1)week prior to beginning. Q:\SEPTIC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture .Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistencv.% ravel r e� � ♦ V J DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. '?.� Consistency,% e � ^ J 6 DEEP OBSERVATION HOLE LOG , Hole# Depth from Soil Horizon Soil Texture Soil Color j' ..-Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi to c Gravel a. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten Flood Insurance Rate Map: Above 500 year flood boundary No— Yes .1 Within 500 year boundary No Yes Wiibin 100 year flood boundary N Yes�. . , ♦ `` —' Depth of Natura11 v Occurring Pervious Material .. Does at least four feat of naturally occurring perv' terial exist iri all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of n urally occurring pery ous material?` Certification a I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environ IntI Protection and that the above analysis was performed by me consistent with . the required training,expe se a pe ience described in 310 CMR 15.017. Signatu� Date Q:\SBPTICIPERC'FORM.DOC 3 THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiou for Divi-pooal Workii Towitrurtiort ramit Application is hereby made for a Permit to Construct ( Vfor Repair ( ) an Individual Sewage Disposal System at: / / Z16 ddressn No. _ ) dress _ .... � n •----•--- - - .ot............................................... Installer Address c UType of Building ��// Size Lot___-_LYO0_....Sq. feet Dwelling— No. of Bedroo>m'�'s�/________ _____________ _______________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building(N ✓1 -No. of persons______________________-_-_- Showers ( ) — Cafeteria ( ) 04 Other fixtures -------------------------------------- Design Flow--------------------- g p pd e p y. y gallons. W ��_�_____________gallons per per day. Total daily flow_-______��d___.-__._______ _____.. WSeptic Tank—Liquid capacity SWgalIons Length________________ Width---------------- Diameter................ Depth__._________---- x Disposal Trench—No_ ____________________ Width.................... Total Length:`___...____________ Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing t ~" Percolation Test Results Performed by----------- 4Z4Date........ ......... Test Pit No. ..........minutes per inch Depth o Test Pit____________________ Depth to ground water- -fro Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 66 Description of Soil -�� --------------------------•--------------------------------- x w UNature of Repairs or Alterations—Answer when applicable................................................................................................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Com i nc as een issued y the board of health. Signed - .._.... ._. . ......�t�... .. - ........................_ Date Application.Approved By ............!aen.....,- Application Disapproved for the following reasons: ........................ ..............-................. . . . ........... ............ Date ��Permit No. ............7-J- -. Issued .................3...-' 6 ..I&.......... Daze J a T THE COMMONWEAX' TH OF MASSACHUSETTS BOARD OF HEALTH TOWN 6F BARNSTABLE A lirati�au f/iffl' imal Workii C owitrttrtion' rrntit Application is hereby made for a Permit to Construct ( V�or Repair ( ) an Individual Sewage Disposal System at: _ . ` �... ( ..g).......... !.------.... -•-•---- ._ .D .................................... Lor .ion•:lddress or ^ot No ` ---------------------------- •.Q ----_----------_ .......... ...................... vie, r Address __. �.... ---._ _... - Installer Address � C Type of Building Size Lot----- feet I-. Dwelling—No. of Bedrooms --- ------•___-_--_.__-_-__.-_._-Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Buildiiig(N(l — No. of persons____________________________ Showers ( ) — Cafeteria ( ) Other fixtures ----- // -�o p - -- L/�� gallons. W Design Flow--------------------- _____ _____________gallons per person per day. Total daily flow-._____. ,__.... .......................... WSeptic Tank—Liquid capacity_!-9(UzalIons Length---------------- Width________________ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width..................--- Total Length................... Total leaching area....................sq. ft. Seepage Pit No________ __________ Diameter-------------------- Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank WPercolation Test Results �,Pe wormed bY-------�--�---'�'-.................................................. Date------------- .......... ,.4 Test Pit No. 1�_.---..___.___lntnutes per inch Depth of Test Pit._______--__-_-____ Depth to ground water..._ .. _ ( , Test Pit No. 2a .' .___....minutes per inch Depth of Test Pit-------------------- Depth to ground water.,...................... Description of Soil. - �� ha-�._... ..... --•------------- U --••----------------------------------•--•-----------------....--------------...-------------------------------------�----------------------.------------------------------•---------••-------------- W ---------------------------------------------------------------------------------•-------------------------------......------•-----------------------...-•-----•--••-•-------------•-•----••-•-•••---- U Nature of Repairs or Alterations—Answer when applicable.................................................................................................. ..----•---------•-••--•--.•--•-----....-•--•-•------•----------••--•------•---•-•---•--•-•--•----------•..........:..•-----.....---••-•-•------•-•••---------•-----------•--------•--••......_....-•---• Agrreeement:id s r ,,f The underslgned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to`place the system in operation until a Certificate of Comp'lilnc as Peen issued by the board of health.t Signed 1 ... !-c�c�.a--------/��(.fl--- /l?�i/G��si ..................../ /. .. .. ��... , 4 / Daze Application.Approved BY ......... - - Application Disapproved for the following reasons: -------------------------------------------------------------------f�.....................�n.....!n....j............. fi + q Daze Permit No. �� ........... Issued G - .� i Date ,pl..iharl THE'COMMONWEALTH OF MASSACHUSETTS f, t¢ 'BOARD OF HEALTH TOWN OF BARNSTABLE' ' w_ - C- �;Jhat the ndi id al Se age Disposal System constructed ( L ) or Repaired ( ) � - J by --t , � Gi= % .._........_........ ..... ......................_... � Installer w =s aGr t ( . / , -- - f -(�rf .. ......... ... ........... ..... .. _.... 1 has been installed in accordance with the provisions of TITf E 5c�f The State Environmental Code as described in the application for Disposal Works Construction Permit No. -._.../--5..'-3 L .._7.._.-- dated .-__3--.---- I a_- .:..... THE ISSUANCE OF THIS-CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. j 9�` DATE.........-...../......`. � --'------_..-- ....---- -- Inspector ................ -------.--------���.- ----- ----------------------------- ------ ———— ------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE FEE....... a..- ........ RopuBal� � orkii Tangtrrutiaan rermit Permission is hereby granted------:�J.�l: - - ; C -- C4U - ....................... to Construct (✓) or Repair an Individual Sewage Disposal System at No...k.0-T-----4-L(12-------- lr/2_C t._� '_U ....--W ��------- --------------------------------- Street /')�� —7 as shown on the application for Disposal Works Construction Permit No._.____________ ___//_ Dated____..._._..__-_._____.._.__..._........... � I 9 / -------------••--•------------------------------------------------------•-------------------------------- / Board of Health DATE------. // .................... FORM 36508 HOBBS&WARREN.INC..PUBLISHERS N FAMIL-( .3 $EVVa-2W' /z ..-PAIL-( F-01 SE?rf C T AtJ� 3�OK1 Sn 7�' A�iS�__ � f— �' 1 pI5FMA L� I o T1 T 1 lc�d../►'sretil& \\ l81°lOO 5iDe%V4LL ARC ISO SF J� 1 I,Z7oS=X n•� = 'r15CeP'D o, 1�'�'� °� 'I 1 \ BOTTOM AZA 50 5f ► I r \ 50 r. I -7cT-AL t)E616W = A-25 I `TOTAL VA I L-y FUV = 339D. � TEI2,GaC.A'-nON ¢ATE c ('III 2m,i /LzSS T3 j G¢A w 51102'r PE 'Aft 0 PETER ;; SUITl I+ AN � � l L � � M i auTrM f No. 29733 s� No.24= ONAL ,P-,L-73( ; WP-( TLsr lof�la� ' i P V.C. IaJ .. SuBSorc. �„ ��•G• � �vc� ,u MKT IwV GAL Izag Z'Z logy IN ris Z.. 0CK 120 Iry rAAN f: Z= cCj Ivle� GAL o I Wl t't{ z® vs e ( 3/4- ALL- SrzvcrU zo s,✓,r ri s � m c' -To9 MOM Tam q! vUE-F m - �, I.I4-s+4AcL Me 14-20 MAr' lid- 1'e-l. 1-Sd- 8 6ez-rEI® ELVE FZA IJ VCRV .OPQ PPOCFI Lam- Loamol.i t�o SGd L� ? -- 14 L-lot 4G ;Lam% � �4Q 1, 14gSto do WAT. ZW. May IA•,"9b opo�� PLAN QeFEREWCE- 1 CE TIF'l . 7444T T14S sldowN NEZeo,N CXM'PL S WITµ -ME 5(PEUWE �'0T !4-L :F, 7-a-01 or TDWN OF '»AR*17&�Ua A{•1'D 1�� Lo�dT�-> u/tl�I T�1 TLoov T�-oI�1 ,4 Pc "8L 43�. -... 5•IG•9L QP4F�`f(pi.14r_ Ld►J� Suev�yo�5 7W-5 FLA0 (-� HOr 'F3A/,p oN AN M-PLVA VE r z��I L � E+J(;I N EEL5 SL)Wt-: j Ml rNiE OFSETS li 1400l.) Q aT" BE o 5TEIzv I( LG MA44 . U5e1:--) T"o Uwe5 '�a s iAe� '+3uIi-AinJb �a �uG I dPPLICAW7 , �( ASSESSORS MAP 71 NOTES: TEST HOLE LOGS PARCEL: b/ - 1 1 The installation shall comply with Title V and Town of Yarmouth Board-of SOIL EVALUATOR: , ' �; ) P Y FLOOD ZONE: / �1��L,� G - WITNESS ; C'" _ Health Regulations. ,tl,D z �b # 2) The installer shall verify the location of utilities, sewer inverts and septic -1 REFERENCE: �/ � � `�-- DATE ..._ -�- components prior to installation and setting base elevations. J PERCOLAT I N RATE: ? 1'�, 3 All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first C' �Fit�' Go/ 0#X� ) g �' p P p g - - ` �4 I `IZ� 'b�V two feet out of the d-box to the leaching shall be level. - — - - �� 1� TH- I TH-2 4 This plan is not to be utilized for property line determination nor any other 1€3 purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. `o 6 Parking shall not be c over Hl h1L L ) Pa king constructed o 0 septic components. CS �� 10 ,� ,_ /�?-� 7) The property is bounded by property corners and property lines. I ���w✓ 8) The property owner shall review,design considerations to approve of total LOCATION MAP j9j) design flow and number of bedrooms to be considered for design. Receipt r I !o of payment for the plan and installation based on the plan shall be deemed . P Y P I�)w approval of the design flow by the owner. I 2D. f 40 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall i I ',,• , be removed along with contaminated soil and replaced with clean sand per I � & _ - ol� Title V specs. b a 10)System components to be 10 feet from water line. Sewer lines.crossing� g the __.. -.. _ ..._. ._..._ water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if applicable. The proposed SAS is being installed below the water service C SYSTEM DESIGN line. The line is to be sleeved as aforementioned and maintained in place. SEPT 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if such exists. BEDROOMS AT GAL/DAY/BEDROOM - GAL/DAY 13)The installer shall verify the location, quantity and elevation of the sewer lines exiting the dwelling prior to the installation. EP r I C TW v GAL/DAY x 2 DAYS - GAL USE J GALLON SEPTIC TANK td �N a Mqs \� SOIL ABSORPTION SYSTEMDAVID _ _ oCP \ AIASON - ►k i _._� s , -- X -- ,�_y,� �F 3Z, SEPT I C SYSTEM SECT _ .. q 1Lo Efi ` I DOC GAL I I�a�� "f _.. _ W � SEPTIC TANK Cl S I TE AND SEWAGE PLAN LOCATION : �I✓ PREPARED FOR : S ALE: o _ b o a DAV i D B . MASON19�7- DATE: 3 l ZbI( ry DBC ENVIRONMENTAL DESIGNS F f - EAST SANDWICH . MA Wj .m -• DA E EALTH AGENT W _.. ( 508 ) 833-2177 -- ------