Loading...
HomeMy WebLinkAbout0010 CONCORD LANE - Health 10 CONCORD LANE MARSTONS MILLS A = 122105 LOT 23 4 Commonwealth of Massachusetts Title 5 Official Inspection Fora J Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name f information is �� a��, �- // _ n / required for �(/1 �-1ii(,�'" i�l�tJ MA 02655 1/31/07 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. 'p°'l"t When filling out A. General Information W forms on the C computer, use 1. Inspector: . only the tab key to move your MICHAEL DEDECKO cursor-do not Name of Inspector use the return key. COMPASS REALTY DEV CORP Company Name + _ P.O. BOX 2384 — 3 Company Address MASHPEE MA 02649 'e°0J City/Town State Zip `ode 508-221-5003 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 5(310 CMR 15.000). The system: R/Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Ilk Qs` W.,c J -1/31/07 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of,the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. r I ' I 281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: /1have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.30..4 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 j i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07 every page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 i supply well. 281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No Elm// Backup of sewage into facility or system component due to overloaded or www clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters / due to an overloaded or clogged SAS or cesspool El / Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ �,y'/ Required pumping more than 4 times in the last year NOT due to clogged or ❑ [� obstructed pipe(s). Number of times pumped: Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owners Name information is required for OSTERVILLE MA 02655 1/31/07 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ � Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ L/ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ LW Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000g pd. ❑ 3/ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 40.0 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 281 OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 15 } Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M y` 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07 every page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ N Were any of the system components pumped out in the previous two weeks? ❑ Ell"*' Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? 19/ ❑ Were as built plans of the system obtained and examined? (If they were not / available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? [� ❑ Were all system components, excluding the SAS, located on site? M ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on:. ❑ Existing information. For example, a plan at the Board of Health. 17/ ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] i 4 i 281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1131/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): —I> Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): c— Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes M<No Laundry system inspected? ❑ Yes M No Seasonal use? ❑ Yes No I Water meter readings, if available last 2 ears usage d V� 9 ( Y 9 (gpd)): Sump pump? ❑ Yes M/-No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 281OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M sye,� 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes VNO If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping.- Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Priv ❑ Y ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: .� ago Were sewage odors detected when arriving at the site? ❑ Yes No 281OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): t Depth below grade: feet Material of construction: ❑ cast iron � PVC ❑ other(explain): Distance from private water supply well or suction line: feet W` � Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: V ncrete El metal ❑ fiberglass ❑ polyethylene El other(explain) i If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ------------------------------------------------------------------------------------------------,-------------------------- I Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 30 �t Scum thickness 6f Distance from top of scum to top of outlet tee or baffle t 1� 1 Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? 281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 i r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07- every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): (� CT Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade. Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): I 281OLD MEETINGHOUSE•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M r 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site.plan): o Depth of liquid level above outlet invert 111 A- UI,]CA �0-- �' °U '� 4 dvve.vt,l 5 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.): i Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 281OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: [� leaching chambers number: LA ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: L Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): i aw 281 OLD MEETINGHOUSE-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): i Materials of construction: I Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 281 OLD MEETINGHOUSE•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 10 CONCORD N C LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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. V aL 3 i lot 3g' i 281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 i t i r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 10 CONCORD LANE Property Address C/O DAVID HOLT ,TODAY REAL ESTATE,1533 FALMOUTH ROAD ,CENTERVILLE ,MA 02632 Owner Owner's Name information is required for OSTERVILLE MA 02655 1/31/07 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: heck Slope Surface water Check cellar Shallow wells �4 t Estimated depth to ground water: feet . Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design Ian reviewed: g p Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) [(� Accessed USGS database-explain: You must describe how you established the high ground water elevation: 281 OLD MEETINGHOUSE-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 <.t mousse -Pj, ?�(31��. B /�, e�7— ad��� ��� r.-- G olV.rT�rccrfo,* 2Wo- 1000 C�r r - ctloi'77 _ ...__ - --� - ►v © � 4 I f S ry S � To� y� S COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS kiwi' DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 10 Concord Lane Osterville. Owner's Name: Amy St. James Owner's Address- Date of Inspection: Name of Inspector:(please print) W i 11 i am . •Robinson Sr. _ . Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5081 775-8776Mft CERTIFICATION STATEMENT ` ' fco m I certify that I have personally inspected the sewage disposal system at this address and that the inform tion reported below is true,accurate and complete as of the time of the inspection.The inspection was performed b ed on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant7prasses Setion 15340 of Title 5(310 CMR 15.000). The system: Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: _ , Date:- --© S The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Concord Lane Osterville Owner. Amy St. James Date of inspection: G ^9^0 S Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. !Syst Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repair d.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer es,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally . unsound, khibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing is replaced with a complying septic tank as approved by the Board of Health. •A metal s ptic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating at the tank is less than 20 years old is available. ND explain Obs rvation of sewage backup or break out or high static water level in the distribution box due tabroken or _ obstructed ipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with a r v pp o al o Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND exp in: The system required pumping more than 4 times a year due.to broken or obstructed pipe(s).The system will pass in cction if(with approval of the Board of Health): broken pipe(s)are replaced obs truction is rttMvcd ,. .. ND cxpla n: Page 3 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Concord Lane s ervi e Owner._Amy St J mes Date of Inspection: G ^ 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 fail' to protect public health,safety or the environment. 1. stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the s tern 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. Syst 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: _ e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surf a 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 front a private water supply well** Method used to determine distance jhilure This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform cteria and volatile organic compounds indicates that the well is free from pollution from that facility and - e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other criteria are triggered.A copy of the analysis must be attached to this form. 3. (her: M 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 10 Concord Lane Osterville Owner: Amy St James Date of Inspection: —6 D. Sy stemind Failure Criteria applicable to all systems: You ust icate')es"or"no"to each of the following for all inspections: Yes o Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged'SAS or cesspool Static liquid level in the distribution box above.outiet invert due to an overloaded or clogged SAS or- cesspool - Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. .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%-Ater supply well with no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEI certified laboratory.,for coliform bacteria and volatile organic compounds indicates that(lie well is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] , (Yes/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 now of 10,000 gpd to 15,000 gpd. Yop must indicate either"yes"or"no"to each of the following: (71 a following criteria apply to large systems in addition to the criteria above) Yes no _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "ye "in Section D above the large system has fatiled.The a%mer or operator-of airy large system considered a sigr ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.104..TThe system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B CHECKLIST Property Address: 10 Concord Lane Osterville Owner: . Amy St J mes Date of Inspection: S� Check if the following have been done.You must indicate`yes"or"no"as to each of the following: Yes No _ Pumping information was provided by the owner,occupant,or Board of Health LI/Were any of the system components pumped out in the previous two weeks? _✓ _ Has the system received normal flows in the previous two week period? }lave large volumes of water been introduced to the system recent) or as art of this inspection?. Y Y P Pe Were as built plans of the system obtained and examined?(if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? _�_ Were the septic tank:manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffl/es or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?. V 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 X— IDetermined _ xisting information.For example,a plan at the Board of Health. in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 10 Concord Lane s ervi e Owner: Amy St, JaEes Date of Inspection: FLOW CONDITIONS RESIDENTIAI. Number of bedrooms(design):. 3 Number of bedrooms(actual):3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x it of bedrooms): Number of current residents: Does residence have a garbag grinder(yes or no): Is laundry on a separate sewage system(yes or no):/ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):LL U Water meter readings,if available(last 2 years usage(gpd)): 2004 - 179, 000 Sump pump(yes or no):Lt,0 2003 - 1 3, 0 0 0 . Last date of occupancy: - -� COMMERCIA&ent.: USTRIAL Type of establis Design flow(b ed on 310 CMR 15.203): gpd Basis of desi flow(seatslpersons/sgft,etc.): Grease trap resent(yes or no): Industrial aste holding tank present(yes or no):— Non-tan' waste discharged to the Title 5 system(yes or no):_ Water eter readings,if available: Last to of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: 20 c> -o A✓cri.,, ,�� S' Was system pumped as part of the inspection(yes or no): h d If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP F SYSTEM eptic 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: ;�-zic v ,5.o s 1;L(5 6-41 Were sewage odors detected when arriving at the site(yes or no):jjFC) 6 r I'agc 7 of I I OFFICIAL INSPECTION FOIW—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIII PART C SYSTEM INFORMATION(continued) Property Address: 10 Concord Lane Ostery Flle Owner: Amy St. James Date of Inspection: —g—d BUILDING SEWER(locate site plan) Depth below grade: / Materials of constructi cast iron _40 PVC_other(explain): Distance Gont priva r supply well or suction lute: Comments(on co of joints,venting,evidence of leakage,etc.): SEPTIC TANK: _(locate on site plan) r� Depth below grade:A — Material of construction._✓concrete metal fiberglass___polyedtylene _odtcr(explain) —' If tank is metal list age:_ Is age confinned•by a Certificate of Compliance(yes or nu):—(attach a copy of certificate) � 'V, Dimensions: &- e, a �" L Sludge depth� Distance Gom top of sludge to but►ont of outlet ice or bafllc: C-/r Scum thickness: i A, Distance from top of scum to top of outlet tee or baffle: , Distance Gorn bottom of sour,to bottom of outlet tee or battle: I low were dimensions determined: 0 P6- - e-V e, Comments(on pumping recommenJatwns, inlet and outlet tee or baffle conditi(;n,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): / GREASE TRAP:—(Io' to on site plan) - Depet below grade: Material of cons tion:_concrete metal fiberglass_polyethylene._other (explain); — Dimensions: Scum thickn s: Distancc G n top of stunt to top of outlet tcc or baffle`. Distance ont bottom of scum to bouorn of outlet Ice or baffle: Date of ast pumping: Conul nts(on pumping Ieconunendations,Wd and outlet Ice or baffle cunditiu:t,structural integrity, liquid levels as rc led to outlet invert,cvidcncc of leakage,etc): 7 'age 8 of 1 I OFFICIAL INSI'ECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SMENTS SUBSURFACE SEWAGE DIS1 OSAL SYSTEM INSI LCTION FORM I'ART C SYSTEM 1NFOR1IIATION(continued) Property Address: 10 Concord Lane Osterville Dwncr James Date of los cctloo: — -0 TIGHT or HOLDING TANK: tank must be pumped at titne of inspection)(locate on site plan) Depth below grade: Material of construction: oncrete_metal fiberglass_polyethylene olher(explaut): Dimensions: Capacity: allons Design Flow: gallons/day Alann present(yes o no): Alarm level: Alarm in working ordcr Oyes or no):_ Date of last plum tng: Comments(co dition of alarm and float switches,ctc.): DISTRIBUTION BOX: 7✓ if( present must be opcned)(locate on site plan) Depth of liquid level above outlet invert: Conuncnts(note if box is level and distribution to oullcts equal,any evidence of solids carr),over,any evidence of - leakage into or out of box,ctc.): Q K PUNIP CHAMBER: /, ,)) ite plan) Pumps in working ordcr _ Alarms in working ordc Conuncnts(note coedit' amber,condition of pumps and alipurtcnanccs,ctc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Concord Lane Osterville Owner:_ Amy St. James Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): y (locate on site plan,excavation-not required) If SAS not located explain why: Type r �� eaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CES/nn S: (ce pool must be pumped as part of inspection)(locate on site plan) Numconfig tion: Deptof liqu' to inlet invert: Deptids 1 er:Deptm ayer.Dimcesspool:Mateconstruction:Indic groundwater inflow(yes or no): Comote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on lan) Materials of constructio Dimensions: Depth of solids: Comments(note ondition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 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: 10 Concord Lane Osterville r' Owner: Amy St- James Date of Inspection: t;-7-0 S' 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. LU 11,12�C, s36 Ara � ul v K,_ G6-3 10 I Page 11 of 11 OFFICIAL INSPECTION FORM-NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 10 Concord Lane Osterville Owner: Amy S t. James Date.of Inspection: — O 6✓ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 1? feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Qhecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Ci$ 11 c€ TOWN OF BARNSTABLE LOCATION O SEWAGE # MO a VILLAGE aE&3f3t �, J ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Ieo O LEACHING FACILITY: (type) /f Toe-C (size) NO.OF BEDROOMS BUILDER OR OWNER 1 0 PERMITDATE: L/ 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 k f No.4?" Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for Migpozar *pztem Con.5truction permit ��\Application for a Permit to Construct( )Repair(grade( )Abandon( ) O Complete System kndividual Components 9 Location Address or Lot No. /D Owner's Name,Address and Tel.No. Assessor's Map/Parcel ! ^��_ /O 2;dor_ Inst s e,Address,anf No. Designer's Name,Address and Tel.No. f f t YC-r1/� Type of Building: Dwelling No.of Bedrooms_ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures e 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. i` G Description of Soil &0 Nature of Repairs or Alterations(Answer w en applicable) _`1 , L _4 cyr. / l y fI uA- 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 ha sued by d of H It Signed - Date Qd Application Approved b -Date./A' Application Disapproved for the following reasons Permit No. 22 Date Issued ��'' No. �.� "��G- Fee s THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ti. PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Tipprication for Oigogaf *poteut Con!aructiort Permit Application for a Permit to Construct( )Repair(grade( )Abandon( ) ❑Complete System PMdividual Components Location Address or Lot No. !>/,,Coa Owner's Name,Address and Tel.No. Assessor's Map/Parcel /^ "1 InstallerFNeAddress,;gtNo. Designer's Name,Address and Tel.No. la_o- tl I Type of Building: Dwelling No.of Bedrooms- Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures tt rr 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. r 7 a-. o .j Description of Soilt.0 S T A Nature of Repairs or Alter t ns(Answer when applicable) G`44O 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 een�issued by'this-B d of H th. Signed - Date Application Approved b Date Application Disapproved for the following reasons Permit No. fJ oe �" i�� Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CER t the -site Sewage Dis sa System Constructed( )Repaired( )Upgraded Abandoned( )by v o i- A � at QA,16 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N;e'�,�bW r'l��°r dated�/��' • �� Installer Designer .-� /�I 'D A G l 1,l i.11 r' rX_, The issuance of this pe Its/hall not be construed as a guarantee that the syste .11�function pa/s designed.V �����,Date / r,) Inspector I(PP] )JAI' Yl-, a a i � 0 --------------------------------------- No. Fee 41,7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Digpo!6ar *potem Conotruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at 4:�24 (!'a 40 144 Kd,Vhr f and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this pd$nit. Date: ��"' C""�r— a r�T1 Approved b 1 TOWN OF BARNSTABLE LOCATION �y l��t/G' Lr/ SEWAGE # (/ t/ VILLAGE 0-= TZhr 1Z. ASSESSOR'S MAP & LOT I� INSTALLER'S NAME&PHONE NO. /Wii)c�inc� 4 SEPTIC TANK CAPACITY /ao 0 LEACHING FACILITY: (type) 'I A/�f7A/97U/t' (size) NO. OF BEDROOMS BUILDER OR UWNhK c PERMIT DATE: 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 y f i S j I , r v 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) 4 hereby certify that the application for disposal works construction permit signed by me dated �/" �/—� , concerning the, property located at LO C_v rk co AQ [Vu M'. M'k meets all of the following criteria: /. This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. "• The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system y There are no private wells within 150 feet of the proposed septic system VThere is no increase in flow and/or change in use proposed 61 There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) 3r B) G.W.Elevation 0J the MAX. High G.W.Adjustment= DIFFERENCE BETWEEN A and B c SIGNED : DATE: [Please Sketch proposed plan of ack]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert �. �.,. d TOWN OF BARNSTABLE LOCATION SEWAGE.# VILLAGE i $b CQfVC6(ZQ .1-M& ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. �b�a,�5can.) 7 75-'%7?(6 SEPTIC TANK CAPACITY ) 0oo. v LEACHING FACILITY:(type) J 6ACk- t(,26yuGk (size) 2-'x4 "4 (-,0 ' NO. OF BEDROOMS- .�j PRIVATE WELL OR PUBLIC WATER ro 1 �- BUILDER OR OWNERSSrAu,,,p A �B "y y DATE PERMIT ISSUED: g 9 q5 k k DATE COMPLIANCE ISSUED 9T b 19S VARIANCE GRANTED: Yes No 'X j� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching Facility Pe of Wetland and Leaching Facilit 64&, O.t ff wsc- k GA S axy;K44 s . oc� ' �.�.rfriJ �.ii - E 2005 AN -2 AM 10: 44 I'4lSION THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/replaced( on by W_jz_ Reb-nsen SeptIE for } c— --Geneerd-rune--(Z 1 as has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated � Use of this system is conditioned on compliance with the provisions set forth be ow: Ate- �^ ------------------------------------- lot 16 �i ss9 LOCATION SEWAGE PERMIT NO. Cn" co VIILAGE ////�f ///Grd 4 15 INSTA LLER'S NAME i ADDRESS JOHN A. AALTO B.ACKHOE SERVICE Walnut ree West Barnstable, Mass. 02668 6 U I L 0 E R OR OWNER -- GOhf��f�tih� DATE PERMIT ISSUED 7 _87 DATE COMPLIANCE ISSUED - _ �� __ � ,� ���� � , . , � �. �- ,�y � �� ,- �� , , � 3`7 ��� q- " � f ,% �® 5�� f � ./ %! 1 \ j Cjf' � / SdJ� V y� .�; } �_. r No.C /.-.25 e Fics.Z...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............. ..........................OF.........................---- ....... App irFation for Disposal Works Tonstrurtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ...............© ..... ° .........L° ---------- - Coca ion-Address or Lot No. •- `Y /�O ner np � /ey^�Add�es�s S tWa ©--•�..._..... !..L-� o.....-•............................••. ......\ 5'. .........AA..k-- t7...... ............................. M Installer Address - Type of Buildinn Size Lot�� 1 .---.._..Sq. feet Dwelling No. of Bedrooms............N_.__..........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a Other—Type g ---------------------------- P ( ) — Cafeteria.(...__>. Otherfixtures ------------------------------------------------------••-•--•----------•---••--•-----------••--•-------- w Design Flow.................!�_Q..................gallons per person per day. Total daily flow-------------.....�-�__�.........._......gallons. WSeptic Tank—Liquid capacity 1 ..gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No.......... ......... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......... Diameter....j.0.......... Depth below inlet.._.._..CP........ Total leaching area.._2.'*O..sq. ft. Z Other Distribution box Dosing tank ( ) `" Percolation Test Result Performed by...... ` �rvlrvt� � �------------------ Date........................................ 1.4 Test Pit No. 1.... ___._.m mutes per inch Depth of Test Pit---- � _�._.._. Depth to ground water___-A-3.. '_.—D_-. 44 Test Pit No. 2....... ..Minutes per inch Depth of Test Pit....PI-ek 11_.. Depth to ground 9 --•-----------------•-- --------------------------------.....--•------.......---•---•---•------.................--•••-----...--•-------•-•--•...........----- Descriptionof Soil. -y - ------------ ------------•-••---------•-•-••-------------------------------... x w --•--------------------------------------•-------------••---- U Nature of Repairs or Alterations—Answer when applicable......................................................................................._.....__. --------------------------------------------•----• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of LIT1,;�. 5 of the State S a y Code— The undersigned further agrees not to place the system in operation until a Certificate of Complianc ha "een issu d by 'e board of health. ned----- -•-- ----•-------- - ----------- .........................99. Date // Application Approved By. = . ...... - •- . �2, —Cil ...... Date Application Disapproved for the following reasons-------------•-----------------------•-----------------••-----------------------------------••----------•-••-••-- .-•---...-•---------- -•-•-•-•------------------•--...---------------•--.....----•---•---------...........---....---•----•---------------------------------------------------------------•-------•-----_. Date PermitNo............................................--••-•....... Issued....................................................... Date No... ..... ............ Flms............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF.......................................................................................... Appliration for Disposal Works Tonstrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal S stem at: ........................................................ .. i ....Address•••........................•--.... .............------......-•-•-----.......... Lot No.- 1...f�C 19la>o S .0 Ltj TOVIIV� O r � �� Addr ............................. ..___---• ----- - ------- ,,f......................................... ti.. Installer Address Type of Building,' Size Lot :•__��.--......Sq. feet U Dwelling No. of Bedrooms.........•... ................. Expansion Attic ( ) Garbage Grinder ( ) ....._..... No. of persons............................ Showers — Cafeteria per., Other—Type of Building ................. p ( ) ( ) QOther fi ures -•----•----•--•-----• ----• . W Design Flow............... ..0....._._._.___..gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity l..........gallons Length_............. Width................ Diameter................ Depth................ x Disposal Trench—N,o. .................... Width.................... Total Length.................... Total leaching area........ -_ sq. ft. Seepage Pit No.................... Diameter... G .......... Depth below inlet.._...'...._._ Total leaching area--- s_...sq. ft. Z Other Distribution box ( Dosing tank ( ) '-' Percolation Test Resul Performed b . W'�k� �C.n a���^ Date............... l Test Pit No. 1...... ..minutes'per inch Depth of Test Pit j------��--...... Depth to ground water. `"' (Tq Test Pit No. 2...___ ..minutes per inch Depth of Test Pit.._=f°�1.R... Depth to ground water,/VO: !�"'�`:. �+ .......... ---=--------------• ••--•-•••--•••----...._......_...--------•-•-..............-•--------.......•---.....--•--••---•--•---...... O Description of Soil.......- �ss__ � o u'�' ..p -•-•-•--•.i.dJ .... ' .................... .................................................�- t. 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 A.i?l:;. 5 of the State S ita Code—The undersigned further agrees not to place the system in operation until a Certificate.qf...Compliancl h een iss d by e board of health. p Ied _ . .. ........ ... ..... .................... .............................. ApplicationApproved BY-•-•-• -•--•• .......................... .. ................................. ----•------- y,. Date Application Disapproved for the following reasons------------------------------------------------------••------•-------------....._._......-•-•-•-------•-----•-- ....................•--------•---------------------•-----•--•---•-•-----.....................----------._._.....-----------------•---------•------------------------------------•----••-----••------••••- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Trrtifirtttr of Tomptiana THIS I TO CERTIFA14 Th t . he Individual Sewage Disposal System constructed or Repaired •••- Swv,. �by - ---------- ------------------------• -------.......---------- ..........--•------....._ Instiller at ._._ ...`�...................Co Ill•G...Y�---------..''-'-�"'... ----------- - _"3 dfs...---------------------- has been installed in accordance with the provisions of " r The State Sanitary Code as described in the application for Disposal Works Construction Permit No....�.�.....�................ dated_........................................... : THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE--------------------------------------------------4.14,.I•41...--•---. Inspector.............................. 9 =----•---------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ✓�''"SJt"q ...........................................OF.............................................................. No......................... FE& .P................ Disposal Works T no#r ion rroti# Permission -hereby granted....1J...0./LNG..-•---•• -.tAATt.0!..------•---•-----•-------------------•--.........---•--...................... to Construct r e air an Individua Sewa a Di s stem P ( ) g Y i- o l�,w. ,v !�► . t1 11 Street as shown on the application for Disposal Works Construction P >;Init No..................... Dated.......................................... ...-•-•------............--•- •-•-•-. ----••-•....................••-•-•. Z B rd Health DATE........................ ......................... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS 9° 3 G'- 38"C M J� ev.Ve I o 0 o Cif4 L. CPO � 0 I,o'4''SoL-,n Pvc fn 3 P�a:t)P-00 99�aa b) ® VEti� h s 3 99x 5 0 �� 99K0 �gx cc)tic o ie D �c�VLl►'el or-- B A pzN s7-N P L4. - MARSToiJ MILLS of Mgss9cyG L.t,) L cT v r i WALTER o E. can SMITH, JR. ,o #15128 (_:.. �FGISTER� �FFSSIONAL s 4 �f �'�.�\I r. ^� i�..•�' ^'�{t7a A/� � � ''lf• `srAGl�` 94, ' . �ioop 9 -7 ba C c. leACNt tG� Ps AA 8 /8 4 ��i'i .mv SOT 7t O' 9 i Q,c4 - i QrJ 2A4 AJ 1IM4W DROP aROOMS K 33(J� � a�a �•�l�so we '.� � !► � 4F �_ o `-�P►cz DtsP05oA OmSE 1 od o GAL. `w 41 R}a G -T4 L 13 C-t>Ep—s ou► S�a a� L-n Co>v Go Q 61 L 'S TIZ Wr A 'emu Y