HomeMy WebLinkAbout0130 CONCORD LANE - Health 13!i;C'0'ord La.nf`
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.] You must first obtain the necessary signatures on this form at 200 Main St., Hyannis.
Take the completed form to the Town Clerk's Office, 1 st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: IVOIOIIZ Fill in please:
D APPLICANT'S YOUR NAME/S: N i o n-S
L,n,r YOUR HOME ADDRESS: !3 CpNcor GN
BUSINESS
s TELEPHONE # Home Telephone Number
NAME OF CORPORATION.
NAME OF NEW BUSINESS I i0 o;nJ n.vo oche /'vice TYPE OF BUSINESS
IS THIS A HOME OCCUPATION? ' . YE NO n� �,n 2�— �2
ADDRESS OF BUSINESS 13J CaNC Oro Cw Z� 'V I'Y I MAP/PARCEL NUMBER [Assessing]
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
2. BOARD OF HEALTH
This individual has bee►�nformed of the permit requirements that pertain.to this type of business. MUST�:OMPLY WITH ALL
L- ry1� fgAZARDOUS MATERIALS REGULATIONS
Authorized Signature**
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
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TOWN OF BARNSTABLE Date: N /Zj/ IZ,
TOXIC AND HAZARDO
US MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: �11 o nN� 401ne �k ey%_E-
BUSINESS LOCATION: 1.30 Conicorol ZO �lf ferdi//l//(,� /0-14 INVENTORY
MAILING ADDRESS: 130 Copvcorof jry 05ter✓r-(.C� ,,fi-A TOTAL AMOUNT:
TELEPHONE NUMBER: 4qj-Soll 32 82-
CONTACT PERSON: 5o8- o253 o5 4+
EMERGENCY CONTACT TELEPHONE NUMBER: 606-a83 o5 62 MSDS ON SITE?
TYPE OF BUSINESS:
INFORMATION/RECOM MEN DAT ONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
?j Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform,formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers A1
Windshield wash �
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS App icant's Signature Staff's Initials
a w)
-.a COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL P -REMN�D
tnm
MAY 3 0 2003
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 130 Concord Lane
rvYp�s�T�+S Osteroi)le, MA 02655
Owner's Name: M John Duffy
Owner's Address:
Date of Inspection: April 30, 2003
Name of Inspector: (Please Print) James M. Ford
Company Name: .lames M. Ford Map: 122
Mailing Address: P.O. Box 49 Parcel: 121
OsterviUe,MA 02655-0049 Lot: 14A
Telephone Number: (508)862-9400
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
NeedsTurther Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: May 4, 2003
The system inspector shall sub " 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.
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
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Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 130 Concord Lane
Osterville, MA
Owner: John Duffy
Date of Inspection: April 30, 2003
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
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
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:
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Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 130 Concord Lane
Osterville, MA
Owner: John Duffy
Date of Inspection: April 30, 2003
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 15303(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 unkss the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
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Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 130 Concord Lane
Osterville, MA
Owner: John Duffy
Date of Inspection: April 30, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z 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 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. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for col form bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`eyes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
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Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 130 Concord Lane
Osterville, MA
Owner: John Duffy
Date of Inspection: April 30, 2003
Check if the following have been done: You most indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)13 10 CMR 15.302(3)(b)].
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Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ,
SYSTEM INFORMATION ,
Property Address: 130 Concord Lane
Osterville, MA
Owner: John Duffy
Date of Inspection: April 30, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No {
Seasonal use(yes or no): No
Water mew readings,if available(last 2 years usage(gpd)): 2002-8.000 gals.:2001 -11,000 Qals. {
Sump Pump(yes or no): No i
Last date of occupancy: Unknown {
COMMERCIAL/INDUSTRIAL
Type of establishment: i
Design flow(based on 310 CMR 15.203): gad i
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records {
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 130 Concord Lane
Osterville, MA
Owner: John Duffy
Date of Inspection: April 30, 2003 t
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BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line: i
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
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Depth below grade: 12" i
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 1" 1
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffler 12"
How were dimensions determined: Measuring stick 1
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels ;
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid revel was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade: ,
Material of construction: _omcrete _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: I
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,eviderce of leakage,etc.):
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Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) i
Property Address: 130 Concord Lane
Osterville, MA
Owner: John Duffy
Date of Inspection: April 30, 2003
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: Qallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: {
Comments(condition of alarm and float switches,etc.): i
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DISTRIBUTION BOX: None (if present must be opened)(locate on site plan) 1
Depth of liquid level above outlet invert:
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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
1
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 4
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Page 9 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART. C
SYSTEM INFORMATION (continued)
Property Address: 130 Concord Lane
Osterville, MA
Owner: John Duffy
Date of Inspection: April 30, 2003
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SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
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Type
✓ leaching pits,number: 1-6'x 6'- 1000 gal.
leaching chambers,number:
leaching galleries,number: y
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number: +
Innovative/alternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
The pit was dry. The scwn line mw approximate&2'up from the bottom. There were no signs of failure. The bottom to grade
was 8'. The cover was 16"below grade.
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CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: i
Depth-top of liquid to inlet invert:
Depth of solids layer: +
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no): 1
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
1
Materials of construction:
Dimensions: l
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
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Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART C
SYSTEM INFORMATION (continued)
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Property Address: 130 Concord Lane
Osterville, MA
Owner: John Duffy
lil Date of Inspection: April 30, 2003
Map: 122 ,
Parcel: 121
SKETCH OF SEWAGE DISPOSAL SYSTEM Lot: 14A
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.
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Page I 1 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 130 Concord Lane
Osterville, MA
Owner: John Duffy
Date of Inspection: April 30, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- 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: topographic and water contours maps y
Checked with local exzavators,installers-(attach documentation)
Accessed USGS database-explain: j
You must describe how you established the high ground water elevation:
The bottom ofthe leach pit to grade was 8. Using the Barnstable topographic map and the Cape Cod Commission water contours
map the maps were showing approximately 25'+/-to Around water at this site.
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This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties I
or guarantees, either exp.-essed,written or implied, relating to the system, the inspection and/or this report.
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P TOWN OF BARNSTABLE
LOCATION 1 3 W^Go� I SEWAGE #
VILLAGE M ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. LD T �y/4
SEPTIC TANK CAPACITY r UM
LEACHING FACILITY: (type) P,r X` (size) 1 uyt)
NO.OF BEDROOMS 3 \ ('
BUILDER OR OWNER �y�^^ b V 1'
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
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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 ariy wetlands exist
within 300 feet of leachi g facility) Feet
Furnished by�/4 S/�e G7o n Foi
a
a A0.4 3-4
3 33 65'
- bo CATION SEWAGE PERMIT NO.
VILLAGE
0
-- o A22 � 2t oat
I NSTALLER'S NA III E i ADDRESS
1101L0Ot OR OWNER
M ►P L rZ 1"t o wl IA
GATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
z .z��
1 "
I La i
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0 C A T ION S WAGE PERMIT NO.
A07 (1�ti06 1eh 9<Z
LLAc R A ILL„r �, 12. 1 0O (
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INSTALLER'S NAME 8 ADDRESS
BUILDER . OR OWNER
DATE PERMIT ISSUED
DATE (0MPLIAHCE ISSUED
Al
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Nol3.-.....i. . FE$...Y�..................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALT
bfi•��L...............OF.......9- . .
Appliratiun for Uhipmal Works Tumitrurtivaa ramit
Application is hereby made for a Permit to 'Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
4.0
o Ad ss os.Lot_N�o`
A&A-wve-------
. ........
__C
Owner Address
ae.C.zL. ._.. . . ------------------------------------------Inst er Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms__ AiaA......................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers Cafeteria
Q' Other fixtures ----------------•----------------------------•--••.......
W Design Flow......... 'v2�...................gallons per person per day. Total daily flow-_-_--7-0.........................gallons.
WSeptic Tank—Liquid capacityA.0!0.gallons Length...9.1.... Width..Y____--___ Diameter................ Depth................
x Disposal Trench—No...../.............. Width.................... Total Length.................... Total leaching area--- ----sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.... ............sq. ft.
Z Other Distribution box ( ) Dosing tank /' f
Percolation Test Results Performed by.... .......... ... ....... �K .` -J"`� .... Date..._..----.-�'4_ e 1
Test Pit No. 1.. " ___minutes per inch Depth of Test Pit.................... Depth to ground water..] �
fi Test Pit No. 2________________ unutes per inch Depth of Test Pit.................... Depth to ground water........................
000
--------------------..•-----••---�---•--... -------------;1-�-------.--•- --- -....
Description of Soil--• = .................." ------. 4- ;-64- -------------per m -•�
x
W
V Nature of Repairs or Alteration — wer when applicable.____...........................................................................................
.................................................. ,, .......................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance-with
the provisions of TITLE: 5 of the State Sanitary Code—The undersigned furtlUpr agrees not to place the system in
operation until a Certificate of Compliance has been i e boar ie
7 leg
ed �:
7at
Application Approve ... .... ....��.... ...:.t -- f1 .- .-te
Application Disapprov the following reasons:__...----•--------------•------•-••----••-------•-----------••••---------•----•---....--------•-----•---.....
...................................•------•-----....------------•----•-----••---------.....----------••---------------------------••--------•-----•-•---•--•-------------•-------••---------••---•••----
Date
PermitNo......................................................... Issued.......................................................
Date
`:No..- .,d.~. FFm...'0..................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
J--- ,•.J OF........ .Gd r --._.-..--•--------------------------
,z ppliratinn for Diipniitti lgorkii Tnnw1rnrtinn Pjanfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
......... , ...&
.cation-Add ss /� or t No. ---
/'�P. ...
r ; .. - -f -•---
/�Owner Address
--.. C. .........................................
------••-•--------- --•-----•-----.--_------------------•--•---
Insta er Address
UType of Building Size Lot............................Sq. feet
a Dwelling—No. of Bedrooms--_7�1' '....................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building 1 JaC?.1 -------- No. of persons............................ Showers ( ) --Cafeteria ( )
dOther fixtures ---------------------------------------•---------------•••------•----••---•••-•--••-•-•-••-••-•---••-----•••••---•-••••-......--------•-••......••••-
W Design Flow.........fY..c5oL. ....................gallons per person peril ay. Total daily flow....... ....................gallons.
WSeptic Tank—Liquid*capacity/_0agallons Length----46....... Width................ Diameter................ Depth................
x Disposal Trench—No...../............. Width.................... Total Length.................... Total leaching area....1.1.r- ---sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area.__- ............sq. ft.
Other Distribution box Dosing tank
Z ( ) g (
~' Percolation Test Results Performed by..:. ........::......:........ tk ` Date_..._........_........................
,W1a Test Pit No. 1..k:7.X_._minutes per inch Depth of Test Pit.................... Depth to ground water... '?
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil--------••------ - `� ��'!� o.� P�.. ------.....tl-------- -
x
W
UNature of Repairs or Alterations—An wer when applicable...............................................................................................
--•-----•------------------------------------------ ......----••--•---------------------------------•--------------------••-------------..........................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIZ 5 of the State Sanitary Code— The undersigned furthof agrees not to place the system in
operation until a Certificate of Compliance has been ii e/d b��e boar d e
, S Date
Application Approved Bya..: �. . -1�0k -- ............
ate
Application Disapprove j the following reasons:.................................................................................................................
.............................•-••-••---•-•-•••••.......------._..............----•---•-•-....-----•••....•-•---•---•-••-•-•-•-••-•-•-••--•-•••••••••--•-•-•-------•--••--•--------•-----•---•--...--••--
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF . HEA�LTH
ff �.
....................OF....... 47 15"
.................................
Wnfifiratr of Tumptianrr
TH S T RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by----------- ----- .......... ............................._........---------•---••......_..._..._ ........
*.. aIle
at..........................
...............
has been installed in accordance with the provisions o TI 5 0 The State Sanitary Code s ed in the
application for Disposal Works Construction Permit No...f:"'__ _ :.......... dated. .. ._ ...e .__._.__.__.
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A O ARA EE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
IV
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
4e- ..........................................OF.............................................................................:.......
Nogyn
.. FEE ...........
Tonstra tion rrmit
Permissionis eb granted........ . •-----_---.•------•---------•-'. -------------------------------------•-----.._....._:..:
to Construct ( epair an In ewage ispo s em
atNo... •-•-- .• --- ....-- ----- -- --••••--
Street + ,�
1 'r I�
as shown/he;pfor Disposal Works Construction Permit No..._ ated.._ _...... . ...................
;:4iT.{4•-'ryt. .................................... .----.-_---.......•........................--.........
.aril of Health
DATE ------------••-•-••------------•-•-.._.....
i -.FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
r
SI TE PL A N T YPICAL PROF IL E
SCALE — / " = ¢ v ` FL, rc�. g7,p
NOT TO SCALE
/B"STD. LT WG T. C.I. MH COVER r '
r 4"C.1. PIPE 4"BIT FIBER PIPE TIGHT JOINTS
W OUTLET LEVEL
FLO L/NE 'r _
_ _ TO FIRST JOIN :_ ._,. ,I
DWELLING 53.aa' /o" /4 _ O O -
4 53
C.1. TEE
C./. TEE L
--- STANDARD PRECAST 4
CONCRETE 10DUGALLON
SEPTIC TANK DIS7RIBUT/ON BOX
B TO BE INSTAL L ED ON
LEVEL , STABLE BASE. �. 4
- S SEPTIC TANK
TO BE INSTALLED ON
LEVEL , STABLE BASE
n T 1 4-:, 0„ = 2' — //B TO 1/2 WASHED PEAS TONE LEACHING PIT
p ALL AROUND FREE OF IRONS, FINES BASE TO BE LEVEL
t ` AND DUST IN PLACE
<' t- BRICK B MORTAR COURES
3/4" TO l-1/2" WASHED CRUSHED
$ o o 15, 4 4 " c AS REOUIRED TO BRING \ STONE ALL AROUND FREE OF
COVER TO GRADE 24 C.I. MH COVER IRONS F/N£S AND DUST /.N PLACE.
0 A ND FRA ME '
a 1 4" _ 1 - � - - LEACHING PIT SECTION-
1 B" FLOW L I NE - - - --- --
/J STD. p!z��4,E2T �ouG • INLET - -- --- -
a A'h' PIPE -- I I. CONCRETE TO BE 4000 PSI 28 DAYS
N �� , / 2. REINFORCED WITH 6" x 6" NO. 6 GA. W.W.M.
w I - ( 3. 2' AND 4' SECTIONS ARE AVAILABLE FOR GREATER
rp. � � I I ,�
N �. - Ga,,�Z. ,"000 �•t�.�. . � i ! DEPTH REQUIREMENTS.
�'� .� I.rV C- rx-P OI (}I OPENING WITH 4-//8" 4. NUMBER OF PITS REQUIRED I _
! I OUTER DIAMETER Q o
NOTE: EXCAVATE TO ELEVATION ____OR LOWER AS
I-3/4" INSIDE D/AMETER
�. 79�57 prf ICJ REQUIRED TO REMOVE ALL LOAM AND CLAY BENEATH
I� �! ` '� PIT. REPLACE EXCAVATED MATERIAL WITH! CLEAN
� 7T 4 k
GRAVEL TO DESIGNED GRADE . r
9 541.4. rr,
J 5 s T
54
MIN.,
y EFFECT/VE DIAMETER
(NOT TO EXCEED 3 TIMES EFFECTIVE DEPTH)
WATER TABLE
5 Q hr .
ti, Q �
9 z SOIL AND PERC. DATA GENERAL NOTES
(� � �40 �ulj �
�1 PERC. RATE : 2 MIN. /IN . NO HEAVY EQUIPMENT TO RUN OVER SYSTEM.
S SEPTIC TANK, DISTRIBUTION BOX , LEACHING PITS TO BE STANDARD
TEST BY: '�',L � �c?� � t,U ti' � 1 /.� L a p,) v v�f � �� (r.� .
PRECAST REINFORCED CONCRETE UNITS.
WITNESSED BY: ZrSo�,9AJJ T N .ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN ACCORDANCE
TO REVISED TITLE 5 OF THE STATE ENVIRONMENTAL CODE ,
TEST PIT GR. EL.: j5"4 DATE ' / '' ' ' MINIMUM REQUIREMENTS FOR THE SUBSUFACE DISPOSAL OF
TEST PIT NO. I TEST PIT NO. 2 SANITARY SEWAGE EFFECTIVE I JULY 1977,
0 0 ---1 ANY CHANGES TO THIS PLAN MUST BE APPROVED BY THE
BOARD OF HEALTH.
I AT COMPLETION OF CONSTRUCTION , PRIOR TO BACKFILL►NG, THE
hA 0 BOARD OF HEALTH SHALL BE NOTIFIED FOR INSPECTION.
PITCH ALL SEWER LINES 1/4" / FT. UNLESS INDICATED
OTHERWISE.
'vn 4, eOu0U nTIiiirZ
DESIGN DATA
BEDROOMS DISPOSAL
EST. TOTAL DAILY EFF. —GALS.
LEGEND _ SEPTIC TANK ' GAL
SIDEWALL AREA GAL./SQ. FT,
BOTTOM AREA FT. SEY!'AGE DISPOSAL SYSTEM
EXISTING GRADE
LEACHING REOUIREO_ �'3_.� _�� SOFT
ZONE � � �o. oo� FINISHED GRADE
ACTUAL!LEACHING AREA FOR
r yrG-' +t
+'� ►• .c... �+ •< - � T �>' �- `,.J ; � v- 's--� �^ ` to '-^� `�" 6,
-r y a�_ r�1 /� t 12 D. 0�3 INVERT ELEVATION
DOMESTIC WATER SOURCE: L 4
t
PROPERTY LINEaw,
PLAN REFERENCE: - oa , �_ c �a W� ,._', �.
r
L- v _' .' 4� t.�=� i � rx.� <<....-t..-�.. N �s _„ N �(�
MEAN HIGH WATER
t: . SCALE: AS INDICATED DATE :
BENCH MARK DATUM: A � 11 f5 ` �' `' L r `` �f � '� 4 � MARSH � WM. M. WARWICK Q ASSOCIATES
BOX 801 - NORTH FAL/NOUTH
7 g
1 MASSACHUSETTS 02556