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HomeMy WebLinkAbout0029 WAYSIDE LANE - Health 29 WAYSIDE LANE WEST BARNSTABLE y A = 110 017 0 RECEIVED No.-- - BOAJ - Fee---- --------------- U 5 20RDLOFU HEALU[TH TOWN H" � �5 A B L E 0(ppiicat ion,I.orVell Congtructionijermit \ Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: Location — Address Assessors Map and Parcel Owner Address. - - -------------- -- Installer — Driller Address Type of Buil YP _ welling _----- --------- Other - Type �of Building--=------------------ No. of y Type of Well—��'P���/�---- Capacity— --- Purpose of Well-- --- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed — ` date Application Approved By ;L date Application Disapproved for the following reasons: -------- ---- _---____-- —_ - — - ----------------------date -- Permit No.�2 6`0 Z y -- Issued --- __ __--------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by- - �� � lop/Z// _C_'_a_. —Installer --------------------------- ---------- ---- at has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. wou� 'Y-Z Dated—;1,Ua--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-- Inspector d ' No.— ---------- Fee--- BOARD OF HEALTH TOWN OF BARNSTABLE 2 App[icat ion-for V ell Construct ion Permit Application is`hereby made for a permit to Construct ( ), Alter ( ), or Repair (-' )an individual Well at: Location — Address Assessors Map and Parcel Owner _ � Address Installer — Driller Address Type of Buil r ---------_----------- welling Other - T',.y2pe''o f Bu-aei.l=di ng --�-' i' _•# :¢.,..,rY :�°::�:' ;j_ t..`�x No. �of Persons [ — -_ • : ,. ,�- ' t[ c =4.; F.. .-. Q � Type of Well ---------- Capacity------------_—__--__.— Purpose of Well--- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed �a date X Application Approved By — --- ---- a-, 7 date ' ' Application Disapproved for the following reasons. k date Permit No.w 2 002 — Issued _�' ! --date ;BOARD. O F�H .-LTK *� _ TOWN OF BARNSTABLE Certificate Of Compliance. THIS IS TO CERTIFY, That the Individual'Well Constructed ( ), Altered ( ), or Repaired C ) b _Installer — .— — has been installed in accordance with the provisions of,the Town of Barnstable Board.of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. W 4!/1 y 2!Dated—_742-- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL . SYSTEM WILL FUNCTION SATISFACTORY. DATE--- — Inspector—__----- -------—--—-- BOARD OF HEALTH _ TOWN O F ;B"A R N"STA S L E, ..Y �_ • .� . __ � Veil Contruct ion Permit No. Fee '- Permission is hereby granted—�- � to Construct (. .,),,Alter ( ), or Repair ( ) An Individual Well at: mE'v No. W'2,uo2 y ` .�J/y/ AAA-- -- `__ ' streeta_� ; as shown on the application for a Well Construction Permit• ; No.- l 2 y Dated -— -- -------- -- . a: 1 - — — } 4''' _ A DATE 741 Board of Health � K` GUI/l S�" /rI,9��sr�%r�t/��r9 s�f6�� - - -------------- --- -------- ----- --- .. TOWN OF BARI�STABLE E ° C, LOCATION 99 \/✓Qy s de. 1 die n e SEWAGE # ca`t000" 3'Y Y VILLAGE W unrr,g$AbkQ- ASSESSOR'S MAP & LOT 0 ""0 7 INSTALLER'S NAME&PHONE NO.W,t- Rod nwr� SEPTIC TANK CAPACITY 1, 000 M� LEACHING FACILITY: (type) �• C. N/-,fm�e—,5 (size) DO e 1 NO.OF BEDROOMS BUILDER OR OWNER B errq t rl PERMIT DATE: —7"3'O® COMPLIANCE DATE: o �® iSeparation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by O Jkc y�� No. Fee/ / � D — �- , Fee 5 0 -�L�� THE COMMONWEALTH OF MASSACH SETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ZIppfication for Miopooal bpotem Conotruction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) O Complete System ❑Individual Components L cation Address or Lot No. Owner's Name,Address and Tel.No. Wayside Lane , W Barnstable Charles Bergin Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand at 5 ' jA Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system, consisting of n n—box nnrd 2 H2O cozi +rate leach Gb2-Mbors with stone all around Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B and Health. Signed Date Application Approved by Date Application Disapproved for the following reaso Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS Bergrin BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( ) Abandoned( )by Wm E. Robinson Septic Service at 29 Wayside Lane , W Barnstable h n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N dat¢d Installer Wm. E. Robinson S r. Designer + �� The issuane is pe it al {got be construed as a guarantee that the s's tuncti n r des Date ) Inspector I '!: C No.—� —�y�-------------------------Fee $50 I, THE COMMONWEALTH OF MASSACHUSETTS Bergin PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ligool bpztem Congtruction 3permit Permission is hereb anted to Construct( )Repair )Upgrade( )Abandon( ) System located at Wayside Lane, W Barnstable and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: tructi n must be completed within three years of the date o 's e . ' . 1 Date: ©� Approved b PP Y �' � � � pB�c. iQ' .,� � � • � 4 � � I' a G ��, �,I J � � � ti � 1 - - -- s. . TOWN OF BARNSTABLE LOCATION :49 VloY 5 i de. i P,n o- SEWAGE # aa;O-39 T f VILLAGE, W 3aCn5Aab�Q- ASSESSOR'S MAP & LOT JO INSTALLER'S NAME&PHONE NO.W,t. PoE6 mcn "71 S- `M (c i SEPTIC TANK CAPACITY 1, 000 LEACHING FACILITY: (type) a e5%zM b=-rS (size), ti c7o m 1 NO.OF BEDROOMS BUILDER OR OWNER Qe-ra t r1 PERMITDATE: -7-3-00 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet >.....:... Furnished by r I Fk . .. r I o J — RECEIVED - t Massachusetts Department of Environmental Management 115352 Office of Water Resources J U N 16 2003 I TYPE OR PRINT ONLY Well Completion Report 1.WELL LOCATION GPS (OPTIONAL) LATITUDE Address at Well Location..— Property,Property,Owner: Subdivision Name.' : Mailing Address. City/Town; CirylTown 44: ��sA: s Assessors Map Assessors Lot#: NOTE: Assessors Map and Lot# mandatory rf no street address available Board of Health permit obtained: Yes Q -Not-Required .❑ Permit Number:�a� �', �D teassue`d ©a r� 2.WORK PERFORMED 3. PROPOSED USE 4. DRILLING METHOD ❑ New Well ❑ Abandon L1 Domestic ❑ Irrigation ❑ Cable ❑.:Auger El Deepen El Recondition El Monitoring El Municipal El Air Ham er—;❑ Direct Push LI 'Replace ❑ Other ❑ Industrial ❑ Other [9 Mud`Rota ': -❑ Other 5.WELL LOG cr Unconsolidated Consolidated 6. SITE SKETCH (use permanent:tandmarks with distances) Permeability T y m n a ro From (ft) To MY_ High Low U m Other Rock Type 20 k —t �7 s 7.WELL CONSTRUCTION 8.CASING s Total Depth"Drilled �Q7� Frorn:(ft) To`(ft) _ Casing Type and Material size.O.D."(in) Well Seal Type s' j bate Drilli mplete 9.SCREEN From (ft) To (ft) Slot Size w Screen.Type and Material Screen Diameter 10.FILTER PACK/GROUT/ABANDONMENT MATERIAL 1#, ADDITIONAL WELL INFORMATION y ' ' Developed? 0 Yes ❑ No From (ft) To (ft) Material Description ,? Purpose Fracture Enhancement? El Yes ❑ No y j r Method Disinfected? 0 Yes ❑ No 12,WELL TEST DATA(PRODUCTION WELLS) 13.STATIC WATER LEVEL(ALL WELLS) Yield ``Time Pumped Drawdown to Time Recovery to Depth Below . Date Method (GPM '(hrs-&min) (Ft. BGS) (hrs & min) (Ft. BGS) Date Measured Ground Surface (FT) -71 ,`-, 14. PERMANENT PUMP IF AVAILABLE),) - : t .NA�IFJADDRSS OF PUMP INSTALfATION CURQPANY K Pump Description - �✓ El Horsepower ,Pump Intake Depth t�```- ' (ft); Nominal Pump Capacity (gpm). 16.COMMENTS' 17.WELL DRILLER'S STATEMENT This well was drilled and/or abandoned under my supervision,'according to applicable rules { and regulations, and this report is complete and-correct to the best of my knowledge.. p Driller: i/� '�ry� Supervising Driller Signature: ��� �Registration #:I f� Firm: i% /�l •�/ N . Date: Ri Permit#: NOTE: Well Completion Reports must be filed by the registered well driller within 30 days of well completion. - - ,e . r:'i.'•ti . 5 t 1^ T s5 i V V Y!V %'It 4& .4#r [ •.�: . s r. a -..n �V{S.( {�? R i}i`t.4'f Y- f'q FAY ts-r Yv X M V.t�..��;� i.a 1 S Y t-'j.. 4 F'-e. T S-4 i q�t.: 1 i S� i i i#•sy 1♦ 1 i i a i k. , f - - 3# No. Fee 5 0 THE COMMONWEALTH OF MASSACH SETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpp[ication for Migogal bpgtem Conelruct%on .permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components L cation Address or Lot No. Owner's Name,Address and Tel.No. �i9 Wayside Lane , W Barnstable Charles Bergin Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. at 5 ' Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system, consisting of a n—*hox and 2 H2O concrete TlganIq GI?2mb€rs with stone all armind Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B and Health. Signed Date Application Approved by Date Application Disapproved for the following reaso Permit No. Date Issued TOWN OF BARNS-TABLE LOCATION W ak`t_S► d.2. 1 r1 Z SEWAGE # 20CX-)"39 VILLAGE W i3arnt'tAblg- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0.W,t Rod rt5o+� 71 J' `' � 6 i SEPTIC TANK CAPACITY 000 LEACHING FACILITY: (type) + 3fe-AN- mb;-r5 (size). E OO m/'r l j NO. OF BEDROOMS II BUILDER OR OWNER PERMTTDATE: -7'-3'O0 - a0 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist I on site or within 200 feet of leaching facility) Feet Edg-.of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by Rackf i fi - r ' Q x � j i o V v No. Fee $5 0 THE COMMONWEALTH OF MASSACHUSETTS.- Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for Diopozal broem Construction Permit Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components L!atio,,,N Ce�ssl rdleot r Ov�ger's Nyme,Address and Tel.No. 7 vyay Lane W Barnstable titlarles Bergin Assessor's Map/Parcel InstalM 's ame„Q 0%ss,and Tel.Ng, Service Designer's Name,Address and Tel.No. WW H0 inson Septic P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan_Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand. at 5 ' Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system, consisting of a D-box` and 2 H2O concrete leach chambers with stone all around. n Date last inspected: 1 r Agreement: V The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i ed by,th' ar Health. Signed l c Date v Application Approvedby, r e Date Application Disapproved for the following reas s _ - t .f` Permit No. Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Bergrin BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( X )Upgraded( ) Abandoned( )by Wm E. Robinson Septic Service at 29 Wayside Lane, W Barnstable AW-h n constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N dated Wm. E. Robinson Sr. Installer Designer - f it f !11�1 The issuancerof F�.per&clall_not be construed as a guarantee that the sy�sttE m wallfunction.as design d.,,tC..�� ' ————————————————————————————— No. _:? Fee $50 /// THE COMMONWEALTH OF MASSACHUSETTS Bergin PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS l ligo!gar bpotem Construction Permit Permission is hereb ranted to Construct( )Repair� )Upgrade( )Abandon( ) System located at �� Wayside Lane, W Barnstable and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to PP P Y PP comply with Title 5 and the following local provisions or special conditions. Provided: tructi n must be completed within three years of the date oqs ,eel k. Date: ©� Approved by 4 116/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT(WYMOUT DESIGNED PLANS) h W i 11 iain E. R o b ins on,S Thereby certify that the application for disposal works construction permit signed by me dated concerning the property located at 29 Wayside Lane , W Barnstable meets all of the following criteria: The ' ed system is connected to a residential dwelling only. There are no commercial or business associated with the dwelling. soil is classified as CLASS I and the percolation rate is less than or equal to S minutes per inch. Ther are no wetlands within 100 feet of the proposed septic system — Ther are no private well,within 150 feet of the proposed septic system ` re `no increase in flow and/or change in use proposed • there are no variances requested or needed. • The bottom of the proposed leaching facility will p_t be located less than five feet above the maximum adjusted groundwater table elevation: [Adjust the groundwater table using the Frimptor method when applicable[ • If the S.A.S.will be looted with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be looted less than fourteen(14)feet above the maximum adjusted � groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX High G.W. adjustment._ - rj-� DIFFERENCE.BETWEEN A and B C/ SIGNED : 4/� 6 G 1✓ 1 DATE: [Sketch proposed plan of system on back). y:health folder cent .N' //ryry e c tiL U� p OJ L /�( r A Ago&—,-, CO\L�10. -E.ALTH OF MASSACHLSETTS £ _ ' RO\ ETAI AFF.AIP�ExECunw OFFICE OF E:�V % \ DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE%%T\TER STREE_.BOSTO\ XA 0210r 1617 t 292.55IIV TRl DT CO.lr Secre:a-y ARGEO PALL CELLtiCCI DAVID B STP_uS Governor Comm ss:oner SUBSURFACE SEWAGE DISPOSAL SYSTEM RISPECTION FORM PART A CERTIRCATION Property Address W9Barnside Lane Nameofowner Charles Bergin/ Peter Pr inc i Address of Owner- Date of inspection: 7—,/— Name of Inspector:(Please Print)Wm. E. Robinson Sr. 1 am a DEP approved s en)inspector to Section 15.340 of Title S(310 CMR 15.000) Company Name: Wm Rob ins on Septic Service MaMngAddress: PO Box 0 9. Centerville MA Telephone Number: 7 7 5-R 7 7 CERTIFICATION STATEMENT I certify that 1 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 inspection. The inspection was performed based on my training and•experience in the proper function and maintenance of on-site Zew" ge disposal systems. The system: es Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails atu ,f Inspector's Signre: lf, s t�..-�✓�- Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty 130)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 Department of Environmental Protection. The original should be sent to tfre system owner and copies sent to the buyer, if applicable. and the approving authority. NOTES AND COMMENTS 11000 ��EP r • r revsed 5/2/9E Parriorll o-Reaiord Panr• r�� I ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (condrared) 'rowWAddress: 29 Wayside Lane , W Barnstable awnK: Bergin / Princi Date of Inspection: s7 WSPECiION SUMMARY: Check, C, o/ D: A. SYS PASSES: 71 have not found any information which indicates that*any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. YSTEM 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. Indicate as,no, or not determined(Y. N,or NO).' Describe basis of determination in all instances. N"not determined'.explain why not. _ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance!attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection: or the septic tank, whether or not metal,is cracked,structurally unsound. shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if Iwith approval of the Board of Health). broken pipets)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more then four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed re'viseQ 5/2/98 Page 2oril SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Property Address: 29 Wayyside Lane, W Barnstable Owner: Bergin / Mnc i Date of Inspection: 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 the ublic health, safety and the environment. 1) S STEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM IS OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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..Method used to determine distance (approximation not valid). 3) THER V� '_"0e%r-; se-- Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Icontinued) Property Address:29 Wayside Lane , W Barnstable owner: Bergin / Princi Date of Irmpection: D. SYSTEM FAILS: You m st indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes o Backup of sewage into facility-or system component due to an overloaded orebgged 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must inificale either "Yes" or "No" to each of the following: Th following criteria apply to large systems in addition to the criteria above: Th system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public he lth and safety and the environment because one or more of the following conditions exist: Yes N the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone 11 of a public water supply well) The own r or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of a Department for further information. ;ev: sed 5j2,/5C Pagc4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address:29 Ways id.e Lane , W Barnstable 0--: Bergin/ Princi Date of Inspection: 2_ s Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner,occupant, or Board of Health. None of the system components have been pumped for at least two weeks and•the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _ As built plans have been obtained and examined. Note if they are not available with N1A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. v _ The site was inspected for signs of breakout. v _ All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: V _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) / 115.302(3)(b)1 _ The facility owner (and occupants,if different from owner) were provided with information on the propermaintananrj.of SubSurface Disposal Systems. Page 5 or n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION ►rop"Address: 29 Wayside Lane , W Barnstable Owner: Bergin/ Pr inc i Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow: O g.p.d./bedroom. Number of bedrooms (design):_:5 Number of bedrooms (actual): Total DESIGN flow.-- ?� Number of current residents: Garbage grinder(yes or no): v Laundry(separate system) (yes or no)AO; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use lyes or no):A-- e) Water meter readings, if available (last two year's usage(gpd): We 1 1 Sump Pump(yes or no):Q 0 Last date of occupancy: /) —L COM RCIAVINDUSTRIAL: Type of establishment: Design f ow: qpd 1 Based on 15.203) Basis of esign flow Grease tr p present: (yes or no)_ Industrial aste Holding Tank present: (Yes or no)_ Non-senit ry waste discharged to the Title 5 system: (yes or no)_ Water me r readings, if available: Last date f occupancy: OTHER:( escribe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: l/ System pumped s part of inspection: (yes or no),& 6 If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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) VA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed fif known)and source of information: /;0,", A. ,e/ Z tl— G� Sewage odors detected when arriving at the site: (yes or no) 0 re%r s e d G Page 6 of I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'ropertyA ss: �9 W7Princi side Lane , W Barnstable owner: erg in Date of Inspection: 'J-- BUI ING SEWER: (Coca a on site plan) Depth below grade:_ Meter at of construction:_cast iron_40 PVC_other(explain) Dista ce from private water supply well or suction line Diem ter Com ents: (condition of joints, venting, evidence of leakage,-etc.) SEPTIC TANK:_ _ (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: `" •G Sludge depth: f ' Distance from top of sludge to bottom of outlet tee or baffler Scum thickness: 6 Distance,from top of scum to top of outlet tee or baffle:_ , Distance from bottom of scum to bottom ofoutlet tee or baffle: How dimensions were determined: (5 p C''^'�•o +. I� ;omments: (recommendation for pumping, condition of inlet a d outlet tees,or baffles,JJdepth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) �U B d �d7 / "+� �/�e7 log GRF11 TRAP: (locate o site plan) Depth belo grade:_ Material of onstruction:_concrete_metal_Fiberglass _Polyethylene_otherlexplain) Dimension Scum thic •Hess: Distance om top of scum to top of outlet tee or baffle: , Distance from bottom of scum to bottom of outlet tee or baffle: Date of ast pumping: Commel is: Irecomrpendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) '_"et"_—se—C G/2/90 Page 7or11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 'rop"Address: 29 Wayside Lane , W Barnstable Owner: Bergin-Z/'�Princi Date of Inspection: TIG OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) Ilocat on site plan) Dep)he,low grade:_ Matf construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimns: Cap gallons Desiow: gallons!day Alaresent Alarel: Alarm in working order: Yes No_Daterevious pumping: Coms: (con of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert:_` Comments: Inote if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locat on site plan) Pump in working order: (Yes or No) Alar s in working order (Yes or No) Com ents: (not condition of pump chamber, condition of pumps and appurtenances, etc.) reV1seC 5/2 /98 Page 8ofII --a r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(colt wid) 'roperty Add►ess: 29 Wayside Lane , W Barnstable Owner: Bergin / Pr inc i Date of Inspection: ' —0- J SOIL ABSORPTION SYSTEM(SAS): v (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits', number:_ leaching chambers,number: leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of h�d auiii failure, level of ponding, darDp soil�onditi n of vegetation, etc.),/ / /t., 77 CESSPOOLS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert Depth of solids layer: / )epth of scum layer: L� Dimensions of cesspool: Materials of construction. Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Com ents: (note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRI _ (loca a on site plan) Mat rials of construction: De th of solids: Dimensions: Co ments: (no a condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) S;�L,� Pap 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Nop"Address: 29 Wayside Lane , W Barnstable lwner: Bergin / Princi Date of Inspection: �j` ,g C.) SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 3 ' o 3� 1 I f /4;t-0 j� s i Page 10 of 11 • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) roveRy Aad<ess: 29 Wayside Lane , W Barnstable owner: Bergin / Pr inc i Date of Inspection: 0-0 NRCS Report name Soil Type_ Typical depth to groundwater uSGS Date website visited Observation Wells checked Moderate Deep Groundwater depth: Shallow. SITE EXAM Slope Surface water Check Cellar Shallow wells x Estimated Depth to Groundwater_Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site IAbutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators. installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) ,�l 1 ✓G S /V16 revised- 9/2/95 page ilorn