HomeMy WebLinkAbout0046 RIDGE ROAD - Health 46 Ridge Road
' W. Barnstable
----------------
A = 21 0023 /
s � !
c
,
����b��Vr �r �M I Fee
No. THE COMMONWEALTH O(4AiSACHUSETTS 1 Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE MASSACHUSETTS
01ppliCation for MispoBal Opstem Construction 3pPrmit
Application for a Permit to Construct( ) Repair(upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. W R J9 4 ?V Owner's Name,Address,and Tel.No.
wesf f3arn�s
Assessor's Map/Parcel a Atoc„i/t-G 6p/,q
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
,t �r�/ lsS�✓
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 jQ gpd Design flow provided ` y gpd
Plan Date (3 —��-`�(' Q6 Number of sheets Revision Date—r/'%, 74.
,
Title
Size of Septic Tank /5W A/eAQ Type of S.A.S. I TOC2r Jfa� f� o7C)
Description of Soil
Nature of Repairs or Alterati ns(Answer when applicable)�zs�c � � �/�,�,� ��► � � /"/c
C2 JOA
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 this Board of Health.
Signe Date / L
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. a y .7-® —3 Date Issued C,
�i,.a z.. r ' ' ,..:.,. . ..--....tL -.. r^...yam �i P. .. ..:•;.' r• � .y�. �T.h nqe+�. '. _ .. � F yy•A• ..c� ^r^'q '�j=.
stf,
�- • •42_.
IVA
Fee J i
THE COMMONWEALTH OF IGIAS ►CHUSETTS Entered in computer:
ter
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Yication forfsosaYpsterrt Constructio�cerntit
f Application for a Permit to Construct( ) 'Repair(ellupgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. yG ;?K4 v �v Owner's Name,Address,and Tel.No. ,
West'I�rNs�bk_ t.Tl
Assessor's Map/Parcel j 1,r /g 410CW/70-0 0/0S rat
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Type of Building:
Dwellings No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ).Cafeteria( )
Other Fixtures
Design Flow(min.required) 3�� gpd Design flow provided gpd
Plan Date 6 ' a10 QQ Number of sheets j Revision Date /u/)Tf j- -
Title
Size of Septic Tank /'5()() N'AC.) Type of S.A.S. .2 soonr,1161 /4•d(')r'1yr I
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) ��t� i 4L,a, /50 Ae,/�140S-Al¢j� IeAdf
:• •aU iJ Dc)x Soo cr`1/cn1 tom- r�i�.M l` �� y' rt� rr✓r° �� �n,1
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 this Board of Health.
Signed w Date
Application Approved by ( Date ►� //��/,t �,
Application Disapproved by Date
for the following reasons L
Permit No. d Q l7 t/ Date Issued /hi.b 6
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Y) Upgraded( )
Abandoned( )by
}C hj-e has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 7Gydated
Installer (. _ fri,-R)nj AIC Designer -LJCGe) r) }�tr,c n_.��
#bedrooms 1). Approved•design flow gpd
The issuance of this pe.:„tt shall not be construed as a guarantee that,the s}{tem will f dfationPas designed' .
Date ��d �-' j,. -. , r Inspector,
No. d 1, �� Fee fJr)
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS {
`vV\/✓� Misposal 6vote Construction ertnit
Permission is hereby granted to Construct( ) Repair( (/ Upgrade( ) Abandon( )
-----Syst located at �/ 1�iC�G iP I��� ( .C�(ac �h �`�c1 N)!r,yn)?p
w
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completedwithin three years of the date of this permit. t
Date a 1 ! (1 r}d Approved by 1, , —,
r ,
Town of Barnstable
Board of Health
DAMSTABMASI`erg 200 Main Street, Hyannis MA 02601
� 1639. A�0
Office: 508-862-4644 John Norman,Chaimnan
FAX: 508-790-6304 Donald A.Guadagnoli,M.D.
F.P.(Thomas)Lee,P.E.
Daniel Luczkow,M.D.Alt.
March 10, 2022
Mr. David B. Mason, R.S.
28 Powder Hill Road
Barnstable, MA 02630
RE: 46 Ridge Road, West Barnstable A= 216-023
Dear Mr. Mason,
You are granted variances on behalf of your clients, Dimitrios and Gretchen Arvantopolos, to
construct an onsite sewage disposal system at 46 Ridge Road, West Barnstable,
Massachusetts.
The following variances were granted:
310 CMR 15.211:. To construct a soil absorption system six (6) feet away from a
property line, in lieu of the minimum ten (10) feet separation distance required.
Section 397-8(E) of the Town of Barnstable Code: To construct a soil
absorption system 115 feet away from a private well located at 71 Spruce Street,
in lieu of the minimum 150 feet separation distance required.
Section 397-8(E) of the Town of Barnstable Code: To construct a soil
absorption system 116 feet away from a private well located at 46 Ridge Road, in
lieu of the minimum 150 feet separation distance required.
These variances were granted because the physical constraints at this property restrict the
design and placement of the new septic system components due to the locations of existing
private wells in the area. The submitted engineering plan appears to meet the maximum
feasible compliance standards contained within 310 CMR 15.000, State Environmental Code,
Title V.
Sincerely,
J n Norman, Chairman
Q:\WPFILES\Mason 46RidgeRoadWestBarnstable Variances Oct 2020.docx
L
DATE: d /.
$95.00 FZZ*:
Town of Barnstable REc.BY:
Board of Health
scHED.DATE:
S
OtBce: 508-862 T' 200 Main Street,Hyannis MA 02601
John T.Nom an
FAX: 508490.63 Donald A.Guedagnoli,M.D.
Paul J.Canniff,D.M.D.
F.P.ffhom)Lee,Alternate
VARIANCE REQUEST FORM
LOCATION
Property Address: -lt� (� '-f�v •��
Assessor's Map and Parcel N be 2-1(, d212 Sine of Lot:
Wetlands Within 300 Ft. Business Name:
Subdivision Name:
APPLICANT'S NAME: �T� Phon O � e
Did the owner of the property authorize you to r present hirfi or her? Yes No
PROPERTY OWNER'S NAME �Q 1,�'�(�'�jCOONNjTACTTPPERSON `ten
Name 2211MOb �C"�" ' "`V ,'�'"'"Ni[rtfe ^�,vt�/
Address: 1d (ZM pmv Address:
Phone: Phone:
EMAIL: —
VARIANCE FROM REGULATION tlndReg.Code u) REASON FOR VARIANCE(May attach��eeAt�if spax needed)
Ig
NATURE OF WORK: House Addition U House Renovation U Repair of Failed Septic System
Checklist (to be completed by office staff-person receiving variance request application)
Please subnW Jlrst four on Ilse as S collated packets
_ A. Five(5)copies of the completed variance request form
B. Five(5)copies of MA DEP approval letters for Innovative/Alternative septic system(when proposing an I/A system or
secondary treatment unit(S.T.U.).
_ C. Five(5)hard copies of engineered plan submitted(e.g.septic system plans)and one(1)electronic version submitted to email:
health(Atown.barristable.ma.us *(Pool Plan-5 hard copies)
_ D.Five(5)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans)and one(1)electronic
version.
A completed seven(7)page checklist confirming review of engineered septic system plan by submitting engineer or RS.
Signed letter stating that the property or business owner authorized you to represent him/her for this request
Applicant must notify abutters by certified mail at least ten days prior to meeting date at applicant's expense(for Tide V and/or
local sewage regulation variances only).
Full menu-Five(5)copies of full menu submitted(for grease trap variance requests only}.
Fee Submitted*$95.00 for the following variances: 1)New construction, 2)Septic repairs&A increase in flows,and 3)New
owner/new lessee applying for food,pool or body art variances. Exemptions from Variance Fee: 1)Septic repair without an
increase in flow and variances granted at the counter,2)Monitoring Plans,and 3)Temporary Food(not a"variance").
_ Variance request submitted at least 15 days prior to meeting date
VARIANCE APPROVED John T.Norman
NOT APPROVED Donald A.Guadagnoli,M.D.
REASON FOR DISAPPROVAL Paul J.Canniff,D.M.D.
0:\Application Forms\VARIREQ Rev Jan 1-2020.docx
Y
Variance Request Summary
Variances are being requested for the upgrade of the existing cesspools at 46 Ridge Road,West
Barnstable, MA.
The proposed Title V system is designed to be placed in the exact location of the existing cesspools as
this location maximizes the distance to surrounding wells.
It should be noted, as shown on the plan,the groundwater flow is towards Barnstable Harbor thus away
from the well at 71 Spruce Street.
The Lots in this subdivision were never intended to provide for a 150' separation between the private
wells and septic systems. The design maximizes the distance from the identified wells that require a
reduction of the 150'
Specifically;
71 Spruce Street; 150' required between the well and SAS. 115' is proposed.A variance of 35' is
requested.
46 Ridge Road;The applicants property is 116' proposed between the well and SAS. A variance of 34' is
requested.
A Title V Variance is requested from Section 15.211, Property line to SAS. 10 ,req uired 6 proposed,ro osed, a
variance of 4' is requested. There are no water lines in the roadway layout because area is only served
by private well.
_ _I_ �iob►2 .
P
o I �
S
I� Z7'
r -
Town of Barnstable
' .� Inspectional Services
Public Health Division
Thomas McKean, Director
t6J9.
+ ° 200 Main Street,Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: Sewage Permit# Assessor's Map\Parcel
IVIL 1 V4, ft— -
J f�'a 4 _
Design
Address: Address: T
T
On was issued a permit to install a
4dat installer
septic system at i i� " based on a design drawn by
(address)
' dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or:septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required) was inspected and the soils .
were found.satisfactory.
I certify that the system referenced above was constructed in compliance with the to rms of
the I1A approval letters (if applicable)
0!:A4gs�9
DAVID
c
staller's Nigature) ASQNNo.108fi �Aa
(Desfg er's Signature) (Affix'. §Vf Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
VtoaldeptAHEALTMEWER connedSEPT[Msigner Certification Form Rev&14-13.DOC
r+
{i
.� � CERTIFICATE OF ANALYSIS Page: 1
Barnstable County Health Laboratory
Report Prepared For:
Report Dated: 01/28/2003
Order Number: G0318733
Lisa Sheehy MAP
40 Joby's Lane PARCEL . 2
Osterville, MA 02655
LOT
Laboratory ID#: 0318733-01 Description: Water-Drinking Water
Sample#: N518 519 520 521 Sampling Location: 46 Ridge Road W Barnstable MA Collected: 01/22/2003
Collected by: L Sheehy Received: 01/23/2003
EPA 524.2- Volatile Organics by GUMS
ITEM RESULT UNITS MDL MCL Method# Tested
LAB: GC/MS
1,1,1,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 01/27/2003
1,1,1-Trichloroethane BRL ug/L 0.5 200 EPA 524.2 01/27/2003
1,1,2,2-Tetrachloroethane BRL ug/L 0.5 EPA 524.2 01/27/2003
1,1,2-Trichloroethane BRL ug/L 0.5 5.0 EPA 524.2 01/27/2003
1,1-Dichloroethane BRL ug/L 0.5 EPA 524:2 01/27/2003
1,1-Dichloroethene BRL ug/L 0.5 7.0 EPA 524.2 01/27/2003
1,1-Dichloropropene BRL ug/L 0.5 EPA 524.2 01/27/2003
1,2,3-Trichlorobenzene BRL ug/L 0.5 EPA 524.2 01/27/2003
1,2,3-Trichloropropane . BRL ug/L 0.5 EPA 524.2 01/27/2003
1,2,4-Tric hlo robe nzene BRL ug/L 0.5 70 EPA 524.2 01/27/2003
1,2,4-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 01/27/2003
1,2-Dibromo-3-chloropropan BRL ug/L 0.5 EPA 524.2 01/27/2003
1,2-Dibromoethane (EDB) BRL ug/L 0.5 EPA 524.2 01/27/2003
1,2-Dichlorobenzene BRL ug/L 0.5 600 EPA 524.2 01/27/2003
1,2-Dichloroethane BRL ug/L 0.5 5.0 EPA 524.2 01/27/2003
1,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 01/27/2003
1,3,5-Trimethylbenzene BRL ug/L 0.5 EPA 524.2 01/27/2003
1,3-Dichlorobenzene BRL ug/L 0.5 EPA 524.2 01/27/2003
1,3-Dichloropropane BRL ug/L 0.5 EPA 524.2 01/27/2003
1,4-Dichlorobenzene BRL ug/L 0.5 5.0 " EPA 524.2 01/27/2003
2,2-Dichloropropane BRL ug/L 0.5 EPA 524.2 01/27/2003
2-Chlorotoluene BRL ug/L 0.5 EPA 524.2 01/27/2003
4-Chlorotoluene BRL ug/L 0.5 EPA 524.2 01/27/2003
Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
r
-i
tlAp r
CERTIFICATE OF ANALYSIS Page. 2
i 1 M
Barnstable County Health Laboratory
yrr'�<•t[use^�.
Report Prepared For:
Report Dated: 01/28/2003
Order Number: G0318733
Lisa Sheehy
40 Joby's Lane
Osterville, MA 02655
Laboratory ID#: 0318733-01 Description: Water-Drinking Water
Sample 1$: N518 519 520 521 Sampling Location: 46 Ridge Road W Barnstable MA Collected: 01/22/2003
Collected by: L Sheehy Received: 01/23/2003
Benzene BRL ug/L 0.5 5.0 EPA 524.2 01/27/2003
Bromobenzene BRL ug/L 0.5 EPA 524.2 01/27/2003
Bromochloromethane BRL ug/L 0.5 EPA 524.2 01/27/2003
Bromodichloromethane BRL ug/L 0.5 EPA 524.2 01/27/2003
Bromoform BRL ug/L 0.5 EPA 524.2 01/27/2003
Bromomethane BRL ug/L 0.5 EPA 524.2 01/27/2003
Carbon tetrachloride BRL ug/L 0.5 5.0 EPA 524.2 01/27/2003
Chlorobenzene BRL ug/L 0.5 100 EPA 524.2 01/27/2003
Chloroethane BRL ug/L 0.5 - EPA 524.2 01/27/2003
Chloroform BRL ug/L 0.5 EPA 524.2 01/27/2003
Chloromethane BRL ug/L 0.5 EPA 524.2 01/27/2003
cis-1,2-Dichloroethene BRL ug/L 0.5 70 EPA 524.2 01/27/2003
cis-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 01/27/2003
Dibromochloromethane BRL ug/L 0.5 EPA 524.2 01/27/2003
Dibromomethane BRL ug/L 0.5 EPA 524.2 01/27/2003
Dichlorodifluoromethane BRL ug/L 0.5 EPA 524.2 01/27/2003
Ethylbenzene BRL ug/L 0.5 700 EPA 524.2 01/27/2003
Hexachlorobutadiene BRL ug/L 0.5 EPA 524.2 01/27/2003
Isopropylbenzene BRL ug/L 0.5 EPA 524.2 01/27/2003
Methyl-tert-butyl ether BRL ug/L 2.0 EPA 524.2 01/27/2003
Methylene chloride BRL ug/L 0.5 5.0 EPA 524.2 01/27/2003
n-Butylbenzene BRL ug/L 6.5 EPA 524.2 01/27/2003
n-Propylbenzene BRL ug/L 0.5 EPA 524.2 01/27/2003
Naphthalene BRL ug/L 0.5 EPA 524.2 01/27/2003
p-Isopropyltoluene BRL ug/L 0.5 EPA 524.2 01/27/2003
sec-Butylbenzene BRL ug/L 0.5 EPA 524.2 01/27/2003
Styrene BRL ug/L 0.5 too EPA 524.2 01/27/2003
Superior Court House, PO.Box 427, Barnstable, MA 02630 Ph: 508-375-6605
Page: 3
CERTIFICATE OF ANALYSIS
"sS^�FtLsw Barnstable County Health Laboratory
Report Prepared For: Report Dated: 01/28/2003
Order Number: G0318733
Lisa Sheehy
40 Joby's Lane
Osterville, MA 02655
Laboratory 1D#: 0318733-01 Description: Water-Drinking Water
Sample#: N518 519 520 521 Sampling Location: 46 Ridge Road W Barnstable MA Collected: 01/22/2003
Collected by: L Sheehy Received: 01/23/2003
tert-Butylbenzene BRL ug/L 0.5 EPA 524.2 01/27/2003
Tetrachloroethene BRL ug/L 0.5 5.0 EPA 524.2 01/27/2003
Toluene BRL ug/L 0.5 loon EPA 524.2 01/27/2003
Total xylenes BRL ug/L 0.5 10000 EPA 524.2 01/27/2003
trans-1,2-Dichloroethene BRL ug/L 0.5 100 EPA 524.2 01/27/2003
trans-1,3-Dichloropropene BRL ug/L 0.5 EPA 524.2 01/27/2003
Trichloroethene BRL ug/L 0.5 5.0 EPA 524.2 01/27/2003
Trichlorofluoromethane BRL ug/L 0.5 EPA 524.2 01/27/2003
Vinyl chloride BRL ug/L M 2.0 EPA 524.2 01/27/2003
Approved By:�iz�� —
(Lab Director)
'Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
Page: 1
CERTIFICATE OF ANALYSIS
K Barnstable County Health Laboratory
Report Prepared For: Report Dated: 11/25/2002
i
Order Number: G0218204
Barbara Breisky
P O Box 807
Sandwich, MA 02563
Laboratory ID#: 0218204-01 Description: Water-Drinldng Water
Sample#: 18204 Sampling Location:�46 Ridge Road, _ W Barnstable Collected 11/20/2002
Collected Breis by: B 216/023
Y kY Received: 11/20/2002
Routine
ITEM RESULT UNITS MCL Method# Tested
LAB: IC Lab
Nitrates 1.6 mg/L 10 EPA300.0 11/20/2002
LAB: Metals
Copper 1.5 mg/L 1.3 SM 3111B 11/21/2002
Iron 0.2 mg/L 0.3 SM 3111B 11/21/2002
Sodium 19 m1 20 SM 311113 11/21/2002
LAB: Microbiology
Total Coliform Absent P/A Absent 307 11/20/2002
LAB: Physical Chemistry
Conductance 382 umohs/cm EPA 120.1 11/20/2002
pH 7.2 pH-units EPA 150.1 11/20/2002
Note: Based on the results of the parameters tested,the water is suitable for drinking,but may present aesthetic problems(taste,
odor, staining)due to Copper.
Approved By: -
(Lab Director)
If/Z4/ZoOL
1
1
i
{ Superior Court House, PO. Box 427, Barnstable, MA 02630 Ph: 508-375-6605
COMMONWEALTH OF MA AFFAIRS
ACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL
DEPARTMENT OF ENVIRONMENTAL PROTE �- �Rar--'CEIVED
M F
= w
d NOV 2 7 2002
veW� TOWN OF BAtirq:;TABLE
O�M s�0 HEALTH DEPT.
TITLE 5
L INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
OFFICIAL �-
SUBSURFACE SEWAGE DISPOSAL SYSTEM ;
PART A MAP
CERTIFICATION PARCEL
ert Address: 46 RIDGE RD W. BARNSTABLE,MA 02668 'L t,Q;(�`Z3 LOT
Prop y
Owner's Name: MELVA JIMERSON
Owner's Address: 46 RIDGE RD W.BARNSTABLE,MA 02668
Date of inspection: 11/12/02COPY
lease print) JOHN GRACI
Name of inspector: (p p SEPTIC INSPECTIONS 11
Company Name: P.O. BOX 2119 TEATICKET,MA.02536
Mailing Address:
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT sewage disposal system at this address and that the information reported below is
I certify that I have personally inspected thetheinp performed based on my g
true,accurate and complete as of thetime int maintenance on site sewage dispection.Tile posal systems. I am a DEP approved system
experience in the proper function
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
a,
X Passes
_ Conditionally Passes rovin Authority
_ Needs Further aluation by the Local App g
_ Fails
Date: 11/12/02
Inspector's Signature: Board of Health or DEP)within
v j J of this inspection report to the Approving Authority( d or greater,the
The system inspector shall submit a copy
e appropriate regional office of the DEP.The original should be
completing this inspection. If the system is a shared system or has a design flow of 1000gp
30 days of p
owner and copies sent to the buyer, if applicable,and the approving authority.
inspector and the system owner shall submit the report to
sent to the system
Notes and Comments
LE V INSPECTION.RECOMMEND PUMP[
SYSTEM PASSED TIT
NG EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
of use at that
e.
****This report only describes conditions at the time of inspection and under tile ile ,o edit different conditions�of use.
inspection does not address how the system will perform in the future under t
V
Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 46 RIDGE RD W. BARNSTABLE,MA 02668
Owner: MELVA JIMERSON
Date of Inspection: 11/12/02
Inspection Summary: Check A,B,C,D or E/ ALWAYS complete all of Section D
A. System Passes:
X 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 PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain.
n/a 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 exf Itration 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.
ND explain: n/a
n/a 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: n/a
n/a 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: n/a
r
.( age 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 46 RIDGE RD W. BARNSTABLE, MA 02668
Owner: MELVA JIMERSON
Date of Inspection: 11/12/02
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
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 n/a
"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.
3. Other:
n/a
I
Page 4 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 46 RIDGE RD W. BARNSTABLE,MA 02668
Owner: MELVA JIMERSON
Date of Inspection: 11/12/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped Wa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ X 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 forma
(Yes/No)The system fails. 1 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.
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
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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
"ves" 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.
A
Page 5 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 46 RIDGE RD W. BARNSTABLE, MA 02668
Owner: MELVA JIMERSON
Date of Inspection: 11/12/02
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period
X Have large volumes of water been introduced to the system recently or as part of this inspection '?
X _ Were as built plans of the system obtained and examined?(if they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up `?
X _ Was the site inspected for signs of break out'?
X _ Were all system components,excluding the SAS, located on site'?
X _ 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 ?
X _ 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
X Existing information. For example,a plan at the Board of Health.
X _ 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)]
S
Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 46 RIDGE RD W. BARNSTABLE, MA 02668
Owner: MELVA JIMERSON
Date of Inspection: 11/12/02
FLOW CONDITIONS �-Q
RESIDENTIAL N"
m (design): 2 Number of bedrooms(actual): 2
Number of bedrooms ( )
DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): 220 7 dMS as
Number of current residents: 1
Does residence have a garbage grinder(yes or no): NO Fug
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] J
Laundry system inspected(yes or no): NO A 0°l-'
Seasonal use. (yes or no). NO Y
Water meter readings, if available(last 2 years usage(gpd)): n/a 0t5 3 ��1�O°'r`S•
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes, volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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): n/a
Approximate age of all components,date installed(if known)and source of information:
EARLY 1960'S, LEACH PIT 1990 BY OWNER
Were sewage odors detected when arriving at the site(yes or no): NO
A
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46 RIDGE RD W. BARNSTABLE, MA 02668
Owner: MELVA JIMERSON
Date of Inspection: 11/12/02
BUILDING SEWER(locate on site plan)
Depth below grade: 14"
Materials of construction:_cast iron _40 PVC other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
WELL WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 8"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 6' X 6' BLOCK CESSPOOL"
Sludge depth:3"
Distance from top of sludge to bottom of outlet tee or baffle:31"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
7
• Page 8 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46 RIDGE RD W. BARNSTABLE, MA 02668
Owner: MELVA JIMERSON
Date of Inspection: 11/12/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: _(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
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.):
NO D-BOX
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
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: 46 RIDGE RD W. BARNSTABLE, MA 02668
Owner: MELVA JIMERSON
Date of Inspection: 11/12/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
6' X 6' BLOCK CESSPOOL overflow cesspool, number: 1
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
OVERFLOW AND LEACH PIT APPEAR TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
SYSTEM SHOWS NO SIGNS OF FAILURE. DID NOT EXPOSE OVERFLOW. LEACH PIT HAD I' OF LIQUID
IN IT AT TIME OF INSPECTION. STAIN LINES INDICATE PIT HAS NEVER HAD MORE THAN 2' OF LIQUID
in it . t3ottonl it at
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.):
n/a
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46 RIDGE RD W. BARNSTABLE, MA 02668
Owner: MELVA JIMERSON
Date of Inspection: I1/12/02
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.
Ab-d
,�. A
U
G
r999AA
r/
A(f
rJr�
bb
in
Page I I of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 46 RIDGE RD W. BARNSTABLE,MA 02668
Owner: MELVA JIMERSON
Date of Inspection: 11/12/02
SITE EXAM
_Slope
_Surface water
_Check cellar
_Shallow wells
Estimated depth to ground water 20+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked, date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER-20+ FT.
TOWN OF BA NSTABLE
LOCATION Ed SEWAGE 1
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.��
SEPTIC TANK CAPACITY
LEACHING FACILITYAtype) ��" (size) la �
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
ire
Irey�
iie&e
No.. :� __*�� Fizs..............0.00
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliratilau for Disposal Works Tonstrurtinn Prruti#
Application is hereby made for a Permit to Construct ( ) `or Repair �X4 an Individual Sewage Disposal
System at:
46 Ridge Road West Barnstable
................______.................--•---.......... .. ........_..... ......-------- -----
Location-Address or Lot No. ---
Mark Jimersen
......................--._......... -- ................................................. ------------...........................................-..........................................
W
J.P.Macomber Jr.Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms........3.................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
04 Other fixtures ---------------------------------------------- ----------
.el
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity._..._......gallons Length_:.............. Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width------------------_ Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No----------------_-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................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......................................Sand & Gravel
x
U
W
V Nature of Repairs or Alterations—Answer when applicable... -ga
._llo-•-___l eac-----h p---------i--t---.-•------•-------•--......
.
1-IG0�- n
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 Complian e has b e iss ed by th oar of health.
Signed --- �-�-�-- -A...................-------- (/9/2..I-/9�-----..
Date
Application Approved By ... .......... .. ..... . '� �[ �
Application Disapproved for the following reasons- ............................................. ----- ----------------------------------------------------- --- -----------------
--- --------------------------------------- ---------------------------------------------------------------
�/ _ Dale
Permit No. .... ` r 1 Issued
Date
t THE COMMONWEALTH OF MASSACHUSETTS
J
BOARD OF HEALTH
TOWN OF BARNSTABLE y
Appliratinn for Disposal Works Tonstrurttun trrmit
Application is hereby made for a Permit to Construct ( ) or Repair ,(KXl)s an Individual Sewage Disposal
System at
46 Ridge Road West Barnstable �
Location-Address or Lot No.
Mark Jimersen
__.................• •----------.....------------------------....... ..........-----.._..------......•••--------------••--...........---------------------.............
w
J.P.Macomber Jr owner Address
Installer Address
UType of Building Size Lot-----------------------------Sq. feet
Dwelling y No. of Bedrooms.........�1....................._..........Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons.................:.......... Showers — Cafeteria
QIOther fixtures -----------------------------------------•---- ---------------------------------------•-•-------•--
W Design Flow............................................gallons per person per day. Total daily flow__._........._........._...._............_..gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter--------.-......\Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
a
Test Pit No. I................minutes per inch Depth of Test Pit..................... Depth to ground water--__--_____-_--_---___-.
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 •-••----••---------•----. --•----------------------•---•-•--------................_._.._....._.._...---------•-----------........-•••-•-•----•--•------
D Description of Soil....................................... and `�= -Grn.trP 1
U •--•.................................••-••---•---------------•----------------------•••••--•••--•-•-.....--•••••---•----------•----•---------•---•••--------------•......-••---••.---...••......
W
U Nature of Repairs or Alterations—Answer when applicable......................................•._......................................._.._....___....
1-1000 gallon leach- Pit.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has b-en-issued by the boardbof health.
Signed ----- •---- --- '� ./�✓.. �I---------------------------- --�.�9/� /9�------
Date
Application Approved BY "'�-- .. �� - ---��--�/t -------------------------------------
lDa[e
Application Disapproved for the following reasons: ---------------------------------------------------------------------------------------------------------------------------------------
-------------------------- ---------------------------.----------..............
� Dare
Permit No. ... `r` �''`----17.7----- ----------- Issued ----------...-!r ? 1�
Dace F
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Q-1ertifira a of 101,nmplianc.e
THIS IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX)
by J .P.Macomber Jr.
------------------- ....... -------------------------------------------------------------...................------------------------------.....-------------------------------------------------- ..
Installer 4
at .......4.6 Ridge Road West Barnstable f
- - -- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------- --
has been installed in accordance with the provisions of TITLE 5 of The State EnvironmentalrCodefas described in
U.-
,
the application for Disposal Works Construction Permit No. ... ./.• ..... ..' ' dated/.._
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED�AS A GUAif'"NTEE THAT THE
SYSTEM�� /WILL FUN�CTIONfSATISFACTORY.
q it
DATE.... r--; &2-(v--'-- ..b...... .......----..----------------------------------------- Inspector ......... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Id--ram17 TOWN OF BARNSTABLE
Disposal Works Tunutration Fermi#
JP Macomber Jr. ....................................................
Permission is hereby granted...... '••......................... ..... -
to Construct_( ) or2epair O an Individual Sewage Disposal System
at No....................idge Oad est Barnstable.
Street
as shown on the application for Disposal Works Construction PermitN �' Dated.._... .• -�.,�I?....
DATE-------- --- .................................. Board of Health
FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS
sf
BARNSTABLE COUNTY
a
z y DEPARTMENT OF HEALTH, HUMAN SERVICES AND THE ENVIRONMENT
tU SUPERIOR COURT HOUSE
0 BARNSTABLE,MASSACHUSETTS 02630
V Phone: (508)362.2511 Ext.330
• •
Environmental Health 383
A 5 S Community Health Nursing 330
Water Quality Analysis 337
Children's CI nic 520
Human Services 330
May 12 , 1992.
Norman and Melva Jimerson
334 N Street, SW
Washington, D.C. 20024
Dear Mr. and Mrs. Jimerson,
On May ,11, 1992 I inspected your property located at R dqe
Rd. , West Barnstable, MA for the presence of lead based paint-.
This inspection was performed at the request of your tenant, Ms.
Wendy Kapp. I did not perform a full lead inspection in which all
painted surfaces are tested. Instead, I performed a procedure
known as a lead determination. In this procedure only a few
selected surfaces are tested to determine if lead paint is present
in the dwelling. The results of my inspection are enclosed. Lead
was found at the dwelling, primarily on exterior surfaces.
In accordance with Massachusetts General Law Chapter 11, Sec.
190-199, any lead based paint detected in a residence where a child
under six years of age resides must be removed. No child under the
age of six presently. resides with Ms. Kapp but, as you know, she is
expecting a baby in July.
I am writing to inform you of your responsibilities once a
child under six becomes a .resident of the dwelling. You will be
required to have a full lead inspection performed by a licensed
lead inspector to identify all lead violations. You will also be
required to hire a licensed deleader to abate these violations
within specified time guidelines. Although I cannot order you to
abate the lead paint at present, I am enclosing all the relevant
legal notifications which I am required to send to an owner when I
order them to abate lead paint. This paperwork summarizes what
your responsibilities will be once Ms. Kapp' s baby becomes a
resident of the dwelling. You are also required at this time to
provide written notice of lead paint to all occupants of the
building. "Notice to Tenants of Lead Paint Hazards" is enclosed
for that purpose. You are also required to send a copy of the
inspection report to all mortgagees and lienholders of record.
I_ .
f�
You might also consider performing the deleading voluntarily
before the baby arrives. Ms. Kapp will likely have to remove most
of her possessions from the dwelling while deleading is in progress
and it might be more convenient for all involved if this were to
occur before she has the baby.
I am enclosing a list of licensed lead inspectors and licensed
lead abatement contractors. I would be happy to work with you to
get the deleading accomplished as smoothly as possible for everyone
involved. Please contact me if I can be of any further assistance.
Sincerely,
Susan G. Rask, R.S.
Licensed Lead Inspector A1239
cc: Wendy Kapp
Barnstable Board of Health
l
O Asa BARNSTABLE COUNTY HEALTH AND ENVIRONMEN-TAL DEPARTMENT
SUPERIOR COURT HOUSE
O
BARNSTABLE, MASSACHUSETTS 02630
J
ly
o ° '
MASS PHONE: 362-2511
EXT. 330
Date of lnslxX:UOn:-5/11 ' �� . LAB 337
CLINIC 340
Inspector: JLl`_�gtil
License: Z3 q —--
Method used: Sodium Sulfide Expimlion elate:
X-flay Flouesmice m(Xkl: xK 3
scritila: 24�c�
1'rolwity Address: �� i C� G e.
Description of Property:
Single Family Z
Multi-f-ainily a units
Garage
1.Cnce
01.11cr struclures
Age of Property: V� Pic-19]8 e Lt:l f—e 4�(i(�
Post-1918
Occupant. ti/en �� K _
()c cupants under six ycals of ag"c:
l zz1 7�
We�c1�, 15 UU13:
1X)13:
PGft: ------
(X:Cupwits,Ulephone: j )3 Lo " 2 to U
I'rvpet(y0wncr s): r'-ton Q V e) . -J r :5o
Owner's Ad(tress: N Wit., S tnl
n G 1-1) -D-- 2 002-4-
owners uiephone: (.201Z)4e54 - 2lo 1 -7
An X-ray flouresceme reading greater adman 1.2 mg/cijO or a gray or black reaction to sodium sulfide indicates an
illegal level of lead arid,constitutes a lx-)sitive detctmination.
Any removal replacemenl,or covering of Ic Rl paint n-s a result of this repuit or siibselluenl iwpecfior must be
performed only by a dcleading conuactor licerlsed by tl►e DeIntunenl of labcx and Indusli ies.
BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT
SUPERIOR COURT HOUSE
BARNSTABLE, MASSACHUSETTS 02630
Q Phone: (508)362-2511 Ext.330
V `7 Environmental Health 383
Community Hoallh Nursing 332
G • Walor Oualily Analysis 337
q 5"� - Children's Clinic Services 3d3
LOCATION S OUP,CE Pb
1. Child ' s bedroom Window parting bead/=hv1-cV
exterior sill area 3
2 . Child ' s bedroom Window -sill- ---------- ---
3 . Living room rig�ea � --
exterior sill area +
4 . Kitchen W.indoc-, parting bead/
e;-_terior sill area
5 . Interior Flaking paint
6. Exterior Flaking paint
7 . Exterior Cellar window units
8 . Exterior Window sills below 5 4- _L14 Gt�
9 . Exter}or Hain entry door or
door casing 2. b T"+6c
10 . Interior Outside corner of
baseboard
11. Kitchen or Bathroom Cl?airraii -
12 . Bathroom -� iilaoa sill- ---- --- ---------
13 . Exterior TtiresFi�olu -- — -- --
14 Common area hallway . Stai_r trey _ _ - --- --------
15 . Common area hallway FJalust^rs ----- - ---- -
16 . Common area hallway { Dcor casing -
17 : Porch r S to r tread_ ---- -18 . Porch F.�i l ir)a cam ---- - -- --
19 . Porch -_ a u s t n r s _ --- --- ---- --- - ---- -
20 . Porch I Support colu) 1is ----- ------
C 6 11-d i a rl e t e r l---- --- --
21. Porch Staircase stringer
22 . Exterior I Biil',=-ad
23 . Garage Doer casino or ja^ --- — - ---
24 . Interior Closet door or . — ----
_ � "bass=board (tncao ed __ __
25 . Interior �G4t� �� - Capinet door, shelf,
.6ti , Ci�a� wall. _ Y._ o•54-
26. (ivi-I l:iinAD(OfY n drd
28 . Q ' rs�-_ 0
No.-- .......... ................._
THE COMMONWEALTH OF MASSACH-gU-SETTS
BOARD RF H�P_
_4�............. OF....... ..
Apphratinn for Biliposal Works Tonfi#rurtinn Vanfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: /l
�1 .......kt'U el.' 4 r .Vt........ ................................ 0 ����. ........................................
.
Location•Address r Lot No J/
. .,T�.4... r £...��rG::............................................. �/77.. 0rr7� � .....................
Owner / Address
W ... -
Installer Address /
Type of Building Size Lot../ -L�.o.......Sq. feet
Dwelling—No. of Bedrooms._......:��.................................Expansion Attic ( ) G;bage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
G" Other fixtures ---•----------•-••.............•--•--• .
W Design Flow................0 .....................gallons per person per day. Total daily flow........s14®..........._......._.....gallons.
P� Septic Tank—Liquid capacity.j.4.00.gallons Length................ Width---------------- Diameter................ Depth................
W Disposal Trench—No.................... Width...... _ ... Total Length Total leaching area....................sq. ft.
........ Depth below inlet.... Total leaching area._ .Qrsq. ft.
Seepage Pit No.104v--------- Diameter41X�.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date.................................... '
Test Pit No. 1----- ------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
0�4 Test Pit No. 2................minutes per inch Depth of Tes Pit.................... Depth to ground water___-___-____-...___-__-.
.... .................................••••-........... --••• . •---•• ... ....?
O
x Description of Soil ° �a.y-------:=..........�-G ------------------------------------- -------------------
U --••----------•----------------------------•••---------•---•---•--......--------•-•------......-•••••......•-••-•-•----.-•....---•--...--••••......---••---••-••......................................
W
x ----•-•---------------------•------•----•••-----------•--------------•--••--•....-••-•----------•-•-•...•---•••---------•-------•••-------•---•------•-•-•--••--•-•----•••......----•-•---•-----•-------
V 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance,has been issued>y the board of health.
1
Sig �....
Date
Application
A A _- . -. _
Approved BY �'� -_
Date
Application Disapproved for the following reasons_____________________
-------------•--......_................................. ---••••.......
--------------------------
------------------------•-------
•---------------------
•--------------------
•-----------------
....----------------------------------------------------------
Date
Permit No. Issued. !Z l 2- .
Dat
No.- .. Fps.. ,:G�.. ......
THE COMMONWEALTH OF MASSACHUSETTS
Ap.V iratiou fvr Biupsal Works T.unutrurthm Vantit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
=r' r• ti.......
....... ................................ ........¢V...........................................
Location-Address or Lot No.
s �?..{ r t ^.,,r................................................ �lr.L: �Lt :.+ s CSC 6.r a.�<-i1f ....._...-...._...
W � •' Owner -+�Address
... .............. . ..............................................................
Installer Address
Type of Building Size Lot... ,!..,r.:r __.....Sq. feet
Dwelling—No. of Bedrooms.........ki................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building ............. No. of persons............_............... Showers — Cafeteria
04
d Other fixtures ....._...-••--•••-•................. ---.••••---•----•-••--••--••-••-•-••-•-•--•--•••-•--•---------•.............--------•-•---••----•--
W Design Flow................ : .....................gallons per person per day. Total daily flow..........3. ........................gallons.
Ix Septic Tank—Liquid capacity_,.an.:.gallons Length................ Width................. Diameter................ Depth................
Disposal Trench—No..................... Width....................Total Length...........,........ Total leaching area....:. .....sq. ft.
Seepage Pit No.� ,, ,.______.. Diameter �`�._ ' 1 Depth below inlet..... .......... Total leaching area.-.„. ...sq. ft.
,,,,,, %.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1......V.....minutes per inch Depth of Test Pit.................... Depth to ground water........................
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...-_•____-____--_.____-
-•----------------••-•••••--.........-- ... ..
O Description of Soil..... ,�., .._ .._ ,/ _y..._..._....._ `1.,.�
- :
U ...................• --•----- ......-.......................... --•-------••.............................
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
? Signed ....................... ..... . . '' - .
9 f Date
Application Approved BY � �< "--• ,lrr :,�.,,y � r----.-
...
Date
Application Disapproved for the following reasons:.....................( '_-,-----------------------------------------•-. ...................Da--.--------------
.................•....--•-•-..._.........._...-•-•-•••------......-•••••••--•.........•-----•-•-•............................ -•-•--••-••••-•-•-•-•--••••---•--•-•••••---••--•------•-••-••-••--........
Date
Permit No......................................................... Issued.------1;t'-...
t ......------•--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD/ 9F HEALTH
f f ,g n fr,,�//
v Tatif rate of Tnutplitturr
THIS I TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by..... ,:. ....
., � ,,� � �F� a a11c4 r'
has been installed in accordarfc'e with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..................... .............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............... - ........................... Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD JP,F bEALTH
/d� ;{. r... �..♦:;:............OF....�:� .................No..... -.- .... F EE t� ..................
Disposal orki ntisfrurtion Prruti#
Permission is ereby granted. ........-'? ---'--•..... ...•. --•..................................................
to Constr t ( r R.efppair-( )a an I d;vidu%p�1 Se agq Disposal System
at No. ....t J f f C l ...�j_. __ ` t :.r 4G,,i� r`.✓......X..P........................,�
Street`
as shown on the application for Disposal Works Construction Pe t No.. � Dated._..:%.�!f -- �'-£..:` " ....
..
DATE 3 /IRRIEN.
...... -
........................... Board of Health
FORM 1255 H0985 & INC.. PUBLISHERS
...-•_'7�RQr�Y•,aprr�-.+..-•- iR-•y[a.7.1>f.1r'.Clbf.iNq•.f.eR'hali�^„ r J'gix!.:!..� c.•v'...«+a.2W"yR'{-+T TC.�_•e.CtS.'�.}T+6: . - � ...�•.�,•
T�`. instailation shall F 7.--)P,1 14:ih tn.: ate Envirf7nmenta!!.Ode We • Town(3.
web
-.art+of Health Regu' .
O
ZO
-----------------
' i../ 'L/!4� /+ ('t i ' ' Cf TQ + i
' �t - �,/�� t "�' ...,.� septic system-is P s}3f1 '.:a_3 ar;Y�:!_ ,;:I$ $tali!°i{ t it !t n .It t';ise town inst 3.!cr
� - _. _._...__.. � �'�'� ' e3 � 3 •, n shall not a it+
" - -
J '� ... - -- y!!N� 1 _ _ ,_ :!� s� 1'i�l �Fi?U permit t�3 t'i�r!i!:is Usti
"`1 "�''� �r ton . >_:' ` ,
— '! G" r �� �!• '1St�t�t9flQilr t 'c -S' . .ii '.�i ++ :a�riN the'fo ation W, i!.';.5!?:.•. '3Y'i'?�r $2iltiP' Fr 3�.
—Tt �.�.} S' �v lr 1 ;: { i :,rd existingseptic cur oc e is_�i:*:;s installation,.
/I 7 _. _
+ t � ° j�,Z ;� .! All gravity, s w r pipu:g;s W bc� 4 irr��: shetlUlp 0 PVC at irii' ',�a= i '. '!;� 2rrSi i{t�E't t�'t!i CJl
the distribution box Ova !;� ir�ae . Tr!t i:�:ing connections to i e s,la:=
a s pti; design Wa. s r r; �p ?t :_ for llr'operty ling r for any othe>'
{ � Ci tt i 1' t, fir{ ,.:,.. t-
Y ' +' �` �j� *i;irpgSE'Cstfisart'ttii l tlsa C+iL}i?;sS��i arf;".t SySt�rte!nsta!latiot!
�� x:li Title V arripoi:ents a:"
'�,1..� i ?ar king shall be p:n:lltftiF f: f ;ite- �: t,c!ri )onent5 flit{E;::•. ,:'rs Ft't':.P. ,iti: Ei�r:loaded,
:
fir;'exist!ng�!eaChingcr�:rr.;,yc,.t;s ,:<tl be Ft:lt:ned and fi!l�-,a �r.rt:�;T;a�.r?ri.rl;�rTit!e b'
is —
1 :=nyrtdonment procec#u, I.:al.!Sir d cesspool(s)and cL=ira rr:rat�c!>r,:i5 within the
►D ��} �� r._'� asec?SAS shall be z r " ;o =-;:.faced with tean sart:j �,e:'r;iF . U—Ci(icat:ons.
t
S t i 3 `iPptic components ara •-, '. ' is :es::: 1`dZtE+f S�rVIC2 line_
! t �`.f't'�J•� ,� � r s r� €_, i 4 rt.3 _; ,` �` !a. IE'@VE tiJltll df1 a27i} 7 s? i 4ltE'dt7lL Q!� Wit!'o ,�;_i �' '_ water Se'1fF'
`•' tDD.OD' 1 `� - x 'ier:. Tl•:e �v r �.i�
rQ �� t V + J�ft(� 's+ . t_ ►i a �'. yr being e,r. F•,th �i ��.
4 2 . 4 L,�Wy/ .r `1e e .c lit h fir¢sl e�te kz�„irr :.3.- := d
t `--- __-- -- i _� 7 ci- ssing the line,
�.
garbage grinder exist.: i 1 Y.:_<<.i�l*n,it is to bca rernee,e_i if:tie se .s �- :�steri is not
� .� ,._.__ i
p � / - `' -.,. .82, � _v , �'- '-itr±ed to ac::r,:-nri�c • •'I�, +,r;r�ar. ... '
~' 'f, ~j�_ C)w� f r`f!'t i.. i"15t31!t?r!S!t'}t 4?r' t r._ Lx-vat; r►arour;: 3i; C. �� :�;' ir+'`. fTj 3slu
w i' " s. :
'r+r't;teCllrlgthe 5ti'E1Ctti?.-F ti�,r #}'!? _ s6tructures during t! e ;=t:yli ,i''11 i,;ivCaSS C1'si'iE 5@lit it
/ p!4CV.vrlly"r@tfr sP.'l:4 :..c _ � ltt�.yyStEii^1 iarl l)a itlst[t! ~''7 t:,":rl' t . (:: y`.y!TrnE`ettC1Q�Title
�y{-85.Q LOT 1 �.,
,' uirPmertts.
..� �c �U -
/ 14 969 S.F. -- --� � '/ T .N '
`yam / r j - property owner : r fi1;u yp�k ,rriteria to approvo i i.-�t i1�i+" n= of bedrooms ant'
} I�r, \ '� j -- , l } ,ci u ,!invent for the 3 sigr
I calt� :c ,;gn#Othl_ tr#stal!a2iC i i ,t:, _;item as proposed a, re i�i. e t e..
' — -- -.,.._ .� ..._. '•::� F�-.^ _ - •-cir7; i-r, ,;i`• T +i-ns.'1,s i .,i L� ..,.:r:t(Jf. -
9 = •l be deemed app " :. ri crlt�ria by the proppr€�, �.e �-
170 I N ` '��' , 1 ` _� f' "x( � f✓ "'_ ._ c .., «;T.,1P validity of ti1is pian.: .ali eif tis::+r:th the expiration of the f:�.>>fr�ir,5t !t t:�J!?permit issue ' 'r:;{
ti iS <plait or the val!di: •� ;+i r 4!04 expire-or,the evir It+`(s of '',•t'fit's riCa3Tf of Ct7mpiiant
ice']L� fo :i
elf
.,/ i -t. Pd sVt i;[: i(i}t.
N � ( �-8$.7 "� � t 4j,.
4..
LJ
EXIST
< a, 1
'DWELLING ��, 1t � _-
--� 1 ,' +87.3 ��� #46 . U 5'7� ___,.v. _ s_._
no
o BRICK PA __.� _s . :. 1�� 1 'ST, � C.�7D l 50 ! 15('�
r O $M. SASEME�y -_ -�
87
�' 6-K11tffi�ib kllio��4
'?
f .
IWu
11 PA j j DRf VE t " i' -�r t j r„ t ,t r lge! i (9907
�r i
�1t-iai '�: t t/f �1
ell
k 9 � �r86.5 FIELDSTONE t _- - - ' t - ;ma's'
-,,
RE7- WALL Ell
l 8g 79.00 `P >x _ N 4 G
_ TRH .. , � �
DAVID
>�tsoly
'� ! t!� _-- --- _ .. . ,n.a .,,�,. . ..: .�.,�.. .�...: .. .:,,.ram.--• �.�.� v�
� � pAra •�rrnv.s-, �q.,•ra�..�—Try
rir
ce '!. � - - .�. it 1
AN
o
r 1
Z,qwo t JJCtt31�.77'i �� LL�
Gl /G l 1� V
-�a:...w�ow,:s+.•,.: ssse..- -u.•�eaa..wa��.a.w►.r - ..r..•Yi��wrrrw�wtnrr�w�r� �.�...,...�e:s�z- -'----___..a.. -t+sw�o s: -ao�r:.�`:. '�9 - -�-- -+;-.._ _�--------- ._ -. _ _ _ - .. ..-, t . . rt,.. ., .
_._"'_ _. r- _+tic'-'o _ Ir•11r"q�rt�arF c
i _ -