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0010 INDIAN POND POINT - Health
10 ,®TDI 11 P D POINT 083-009 MARST®NS MILLS i Al-3i'3 yoly AV 61 8Z'48 !On 3 A3- /0-7 ` 83- Ay- 13�• 13�{'3`� O Front TOWN OF BARNSTABLE LOCATION I XrJ;0,^ P00a 'Poee i SEWAGE# 70ZO - ZSO VILLAGE fn, fn 15 ASSESSOR'S MAP&PARCEL 083- 009 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ZOpo Qa, Isaa1!00 LEACHING FACILITY:(type) 500 go-) LO C ( 3) (size) ►3 x a3 x Z. NO.OF BEDROOMS 3 OWNER PaLu r;4p S PERMIT DATE:_ $- - 20 COMPLIANCE DATE: 2 (� 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 I TOWN OF B ARNSTABLE LOCATION O 1 End"sr. Para 'Po.Ki SEWAGE# 20Z0 . 2�'O VILLAGE dy1_ m:115 ASSESSOR'S MAP&PARCEL og3. 009 INSTALLER'S NAME&PHONE NO. 8 L 8 EX00,03 1,ors • 417- oil S� SEPTIC TANK CAPACITY 2000 adl tml-�dg LEACHING FACILITY.(type) 5004g6 1 WC- 3 (size)' 13 xM x Z NO.OF BEDROOMS 3 OWNER PERMIT DATE: $- 7 • 20 COMPLIANCE DATE: Z // Separation Distance Between the: I 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 I FURNISHED BY i yo'y • Az•,se,' 3z -q8%" A3- /o7 3 �3- /z q 'L Ay- //z eq 3 Ftbni t3 N Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: L� PUBLIC HEALTH DIVISION - T014 N OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for Misposal *pstrm Construction Permit Application for a Permit to Construct Repair(� Upgrade( ) Abandon( ) [Complete System ❑Individual Components Location Address or Lot No. 10 Indio^ Pond PO,n4 Owner's Name,Address,and Tel.No. Pau t ce tt 11co S Assessor's Map/Parcel Q S 3 OOq m4(St0nS it`s 10 1nd',o�n Po nd Po,0 (o l'1' 31 'S 3 So Installer's Name,Address,and Tel.No. b S a Oar taoaAc�oe, tft. Designer's Name,Address,and Tel.No. 34Y Roves• 130 Sanaw*,a, 608'Lt-M- 0WS3 WC Eru►ramen4v-1 Des;pjns Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 130 gpd Design flow provided L4S*-V gpd Plan Date -7 Z S 12.0 Z o Number of sheets I Revision Date Title Size of Septic Tank 150015-00 &I PC.) Type of S.A.S. (3) 500 Gaton L.c sod S Description of Soil Set. pkpnS Nature of Repairs or Alterations(Answer when applicable) `nSkok� nw~ 1500 1 500 +O►f k I Pump (A-Am oer Gon►tk!�., d-box and (30500 Gottan Ltnocvtlxrs Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si ed Date 1 Application Approved by Date Application Disapproved by Date for the following reasons Permit No. , Date Issued 4� 5 L/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in co puter: Ye_ PUBLIC HEALTH DIVISION -3 A;OF BARNSTABLE, MASSACHUSETTS A IpYItat`0"YC for Isposal 6pstem Cole Turtlol� permit Application for a Permit to Construct'V"'. Repair(� Upgrade( ) Abandon( ) Complete System ❑Individual Components Location Address or Lot No. }0 lnd+G %Ck. - po�m Owner's Name,Address,and Tel.No. Qcau t < t ti 1c o S Assessor'sMap/Parcel 0A3 ool9 ` • t�jf"ti �S 10 Indoor` (Donrt pcltaE 611, 312 . SSsv Installer's Name,Address,and Tel.No. 6 a 6 S y r G,,,M ,', IA(- �Designer's Name,Address,and, Tel.No. Lll Gtr 3-4V 1",G'. C 13Q Sa�h<1w.,.h .J0s q• S3 1115c Eoti,rrr?c .1 -,NiicO. fi{;cxn Type of Building: 4 Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) -, Other Fixtures s f L` Design Flow(min.required) '3 10 gpd Design;flow provided '4-T gpd Plan Date -7 t 2 i r 7 o Z o Number of sheets Revision Date Title { Size of Septic Tank 1 OU S Ur) � t �' Type of S.A.S. ( j, "'Description of Soil See vet n n 1 E A Nature of Repairs or Alterations(Answer when applicable) t n c�r,�k f)p,, , t ry � a�n_� '( �.era, V%a m r r r r�rney, r�- 1" o nnrA 17'Cj4r., i.1hn }�r]^_L 4•, r r ,... 1 i 1 i Date last inspected: Agreement: r, { The undersigned agrees to ensure the construction and maintenance of the afore described. n-site sewage disposal system in accordance with•the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of µ ,i Compliance has been issued by this Board of Health. Signed Date Q t < Application Approved by Date _d Application Disapproved by Date " for the following reasons Permit No. �(� ^(� «� Date Issued �'") ,� n =�=== - - -`-- - - -------- ---- ----------- - -- - THE COMMONWEALTH OF MASSACHUSETTS lrr ' f BARNSTABLE, MASSACHUSETTS Certificate of Comp[iallry THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed,(' Repaired(✓) Upgraded( ) Abandoned( )by {> q_,t r n r . at k(l 1 r) has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Nog ( Qated ) . Installer (�'� (� 4 r n ,n l , .,,. l n r Designer's p a r �n„,�n rn n ti C,e f. n #bedrooms Approved design flow 6(5 and The issuance of this permit phall not a construed as a guarantee that the syst will nc on as esigned. ' `s , ,�.----^--- Date � � d� Inspector ._...--� -----------=--------------------------------------------------------------------------------------------------------------------------- No. -w --� Fee `y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION--BARNSTABLE,MASSACHUSETTS Misposat *pstem Construction Permit Permission is hereby granted to Construct(�) Repair( ) Upgrade( ) Abandon( ) System located at k0 '0 ;n r, po n<I po,n k and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. '. Date / �J / Approved by Tawn, of B-arnstable Regulatory Services ti c� Thomas F. Geiler, Director BaRNSkj,AB . Public Health Division MASS. 9�pr i639' a`'� Thomas McKean, Director Ep MA't 200 Main Street, Hyannis,MA 02601 Office: 508 62,-464' Fax: 508-79G=6304 Date: / 7 ZrJSeWage Permit# �v Assessor's Map/Parcel Installer &Designer Certification Form Sx t. Designer: Installers GyZ Address: '�� C'i� ���/ Address.:, On A ' AIi `� ��' �O�C� ��C-xG�.v w'as issued a permit to install A. (date) (installer) L septic system at �n A`�(.� n CO qa �41 t1T based on a design drawn by (address) I� dated .... (designer) I certify that the septic system referenced above was installed substantially according to the design; which.may include minor approved'changes sucli as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were-found satisfactory. I, certify That the. septic system referenced above was installed with major changes (i.e. greater.than.10 lateral relocation of the SAS or any vertical relocation of any component of the septic system).but in accordance with State &Local R '^tions. Plan revision or certified as-built by designer to follow. Stripout (if rP. cted and the soils were found satisfactory. P%\OF�444,�',, DAVID Qkzvt B. (Insta ler's Signatu ) MASON �i� tST P /gyp esi er s Signature) \ PLEASE RETURN TO BARNSTABLE PUBi,� �rifE OF COMPLIANCE WILL NOT BE ISSUED UIN i IL isv i ri i tii� r OWVI AND AS- BUILT CARD ARE:RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK:YOU. q:\ottice,ron1lMesignerceniriicption form Am 1 24e t13 P3 104 �'W51243 TOWN OF BARNSTABLE 11119 SEP -4 P11 NOTICE: The Town of Barnstable recommends that the applicant seek legal advice to prepare a properly worded deed DIVISION restriction document. DEED RESTRICTION q WHEREAS, 1 'C d e �� t c� of ner's name) -T Nv �V1 I �� MA (address) is the owner of T*l&Vy L, Q,wjJ located -- Cad ress) at— MA MA (hereinafter referred to as d be' g shown on a p1 n entitled "Subdivisi n of Land in �, -1711 � ►���1t1,1� MA, Property of �ebabfe F' i d l� , V\ et al, duly recorded in Barnstable County Registry C� of Deeds in Plan Book 193 , Page Or on Land Court Plan Number y WHEREAS, 'qta),m e 9Nio as the owner of said lot has. (owner's name) agreed with the Town of Barnstable Board of Health to a restriction as to the number of bedrooms which can be included in any home built on said lot as a pre-condition to obtaining a disposal works construction permit in compliance with 310 CMR 15.000 State Environmental Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to granting a disposal works construction permit for a septic system in compiance with 310 CMR 15.200, State Environmental*Code, Title V, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage, and authorizing the issuance of a building permit for the construction of a single family home on this property, is requiring•that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, d=dr does her ' lace the NOW, THEREFORE, 1�ecD�L� ! y p (owners name) following restriction on his above-referenced land in accordance with his agreement with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 5 �may have constructed (address) bedrooms. t�on he lot a h1our ontaining no more es that this shall be permanent deed nR�G �1 t a (owners me) Qa MA, and restriction affecting located on being shown on the plan rec rded in Plan Book , Paged Or on Land Court Plan see the following deed: Book _ , Page For title of , _ Or Land Court Certificate of Title Number . Executed as a sealed instrument 3 day of , , Owner's signature Owner's signature Owner's signature CQMMONWEALTH OF MASSACHUSETTS ss 20_, Then personally appeared the above-named known to me to be the person who executed the foregoing instrument and acknowledged the same to be free act and deed, before me, Notary Public - My commission expires: (date) deedr BARNSTABLE REGISTRY OF DEEDS � � n I Joe �.1"C`1 ��s �.�►.� TAYLOR DESIGN ASSOC., INC. SHEET NO. , OF P.O. 'Box 1313 Forestdale, MA 02644 CALCULATED BY_ DATE " 17 d Tel./Fax: (508) 790-4686 CHECKED BY DATE I® � KfCj,.iSCALE + .............._....... ...... ...... ...... .... ... .. ..... ...... 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OF Forestdale, MA 02644 CALCULATED BY C— � DATE Tel./Fax: (508) 790-4686 CHECKED BY DATE i Amot, cl Ith1%1-fi CALE .......... ..........J............... ................... .. . .... ............... .......... .............. ................... .......... ........... ........................................... ............ .......... ....... ... ........ ......................... ............................................ ...................................... ......... -.1........4 ............ ........................ ........... ........................ ......................... ............. ........... ............. ........... ............. ........... ........... ................. ......................................... ................ ............... ........... .......... ........... .... ...........- ....................... ................................................... .............. ...................... ....................... ..... ........ ..........;e.. .......... ........... .................. ;- ... : .......... .......... ........................ . ....... p..................... ................................. .......... 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JOB TAYLOR DESIGN ASSOC., INC. SHEET NO. 4. OF P.O. Box 1313 Forestdale, MA 02644 CALCULATED BY DATE Tel./Fax: (508) 790-4686 CHECKED BY DATE m cco MA.4Ls zvrvs R iL,_-3 SCALE ............................................................................................................................ ........... ............. ..... ..... - -------- ............. ................................ ........... ................. ....................... ............. ............................ ............I ............................... ............. ............ ......... ............ .......... ..... .............. ......................... . .................................... ............................. .................. ...... -----------........ . .... .. .. ........ kn.rc.t.L Je—v.t........................... ............................................... ............................................................ .............................................. .............. ................ ............ ........................ ...;............ ............... ............. ........ ..................... ........................11...................................................... .......... ......................... ........... .......... ........... . . ........ .......... .................. .......... ................... ................................................. ......... ......... .............. ........... ....................... ......................... .................................. ....................................... ........ ......................... ........................ .............. .......... .........................................- ...................................... ............................................................ .. ...... .... ..... .. .... . ......... ...... .... ........... ........... ................ .............. ................. ...... .............. 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J 0 13 L n N TAYLOR DESIGN ASSOC., INC. SHEET NO. OF P.O. 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I............ ......... .......... ....... f Commonwealth of Massachusetts w - .•. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 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. A. General Information 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification Cn I certify that I have personally inspected the sewage disposal system at this addrAs and tr 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 rifaintenanWof o in site sewage disposal systems. 1 am a DEP approved system inspector pursuant t9jSectionT5.340of Title 5 (310 CMR 15.000).The system: ; ® Passes ❑ Conditionally Passes ❑ Fails ` ❑ Needs Further valuation by the Local Approving Authority 11-23-08 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. i ****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. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts H d Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 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: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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 t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15 Commonwealth of Massachusetts • ' Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 every page. City/Town 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 supply well. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °wM 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 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 ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded ' or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow ® 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. El ® Any portion of cesspool or,privy.is within 100 feet of a surface water supply or tributary to a surface water supply. t5insp•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is Marstons Mills MA 02648 11-22-08 required for i every page. City/Town 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. ❑ ® 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 DEPcertified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered'a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either`yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead,Protection Area— IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 f Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wM 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined? (If they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ❑ . ® Existing information. For example, a plan at the Board of Health. ® El approximation 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)] t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number Hof 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 ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Well water Sump pump? ❑ Yes ® No Last date of occupancy: 11-22-08 Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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): t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) General information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1972 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 72 feet Material of construction: ® cast iron ❑ 40 PVC Orangeberg ® other(explain): Distance from private water supply well or suction line: 40' feet Comments (on condition of joints,venting, evidence of leakage, etc.): Good condition. Septic Tank(locate on site plan): Depth below grade: 66"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: . years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Gal Sludge depth: 20" Distance from top of sludge to bottom of outlet tee or baffle 12 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Tape t5insp-03108 Title 6 Official Inspection Form:Subsurface Sewage Disposal Syst~m-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 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.): Septic tank is in good condition with baffles in place. Recommended pumping for solids. 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): t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 1.1-22-08 every page. City/Town 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): Depth of liquid level above outlet invert N/A Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate'on site plan): " Pumps in working order: ❑ Yes, ❑ No Alarms in working order: ❑ Yes ❑ No t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 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: 1000 Gal ❑ 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.): Leach is in good condition and empty at inspection. Stain line indicates water level had reached 30" below inlet invert. t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 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): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 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. 0 �1 -© G B o p &C--3i' i t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 10 Indian Pond Point Property Address Estate of Theodore Eliott Owner Owner's Name information is required for Marstons Mills MA 02648 11-22-08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record Y 9 If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: ® Checked with local excavators, installers- (attach documentation) ® Accessed USGS database - explain: You must describe how you established the high ground water elevation: USGS maps show groundwater at 20' t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 15 " TOWN OF BARNSTABLE ,:OC<'t joN ID ✓' 1 P &0 SEWAGE ASSESSMS NEAP&LOT NSTALI-ER'S NAME PHONE NO. iEMC TANK CAPA=Y &( 6al ,EACHNG FACILrff: (type) {�, (size) 40.OF'BEDROOMS I MILDER OR OWNER 4.I4 DATE: I iaparation)Distance Between the: .j vlaximu n Adjusted.Groundwater Table to the,Batjom of I.eaching Facility Eeet 'rlvate Water Supply Well and Leaching Facility (If any w411s exist on site or within 200 feet of leaching facility] . .._.t. Age of Wedand and Leaching Facility(If an wetlands exist wl"n 300 feet f l a bei ng facility) -uraishcd by„w, w U O e,LI , A4:- _ loa o p A_c--31' A _D-3S6`, a-E- � k _ / - V A. ' TOWN OF BA STABLE LOCATION QQ , �� I®j IfAegSEWAGE# VILLAGE ff,4P _ ..J /�I��/ ASSESSOR'S MAP&PARCEL 693— o 6 2 INSTALLERS NAME&PHONE NO. Ru 1o.4Sec1,4z✓kfy OJ 60AI SEPTIC TANK CAPACITY g v. Ut"ew a-,, I hW o PAP v ' LEACHING FACILITY:(type) i A7 v,c )fi�d 4iiz�r NO.OF BEDROOMS � by=IiI�` P-�—.-4- OWNER e®Joy res4 • (4r/ hv.,r��uuf 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 r.within 300 feet of leaching facility) Feet FURNISHED 13Y - 9� . Oz all�`� 1 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA 0 No.- -- -------------- FeeO - BOARD OF HEALTH / TOWN OF BARNSTABLE Applicat ion-*rVelf, Congtrurt ion Vrrmit Application is hereby made for a permit onstruct ( ' Alter ( ), or Re air ( )an individual Well at: 19-141,0 -----------/----------------- --------------------- - --------------------------------- -------------- �� J Location - Address d7ivT- Assessors Ma and Parcel H yy, -/ �- — L C U-'�--------------- ---� — /0 7,3 fAfc --�P_V-/V 6 -47!7_/esrall/ A716 s Ow er Address S YY'O h- - lr G(, 10k' LG/rlcr mac. --Sr`�-��r a7�3 O�Cc%�s f --------- - - - - - - Installer - Driller Address Type of Building Dwelling-------- --------------------------------------------------- Other - Type of Building-------------------------------- No. of Persons.-------------------------------------------- Type of Well -�--�5 _4©_-"aUr __ Ca acit - /02--- ?O_M5 Purpose of Well T /�3LC --------- -- ---- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. d Si ne - - - -- - -- ---g -- -- -- .�,r-n-aC_ - ---- - to t--�-- date Application Approved By ----- - --- --- -- -— --- -- -- date Application Disapproved for the following reasons:-----—------------------------------------------------------------------- ------------------------------------------------------------------------- date PermitNo.- ----- --- -------------------- Issued--------------------------------------------------------------------------- —1 date rotection ELL \/ / . . � $ # . i z 7 � . \ � ! � BOARD OF HEALTH TOWN OF BARNSTABLE� (Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ` by-----------------------------------------—------------------------------------- --------------------------------------------------------- Installer at- --- -- -- - ---- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well. Regulation as described in the application for Well Construction Permit No. ------------------_-----Dated---------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------——---— - - ---- -- Inspector-----------------------------------------------------------------,-- N i I !i I y-. No. -- -------------- Feel, ------------- - f r BOARD OF HEALTH / TOWN OF BARNSTABLE ApplicationArVell Congtruction Permit II Application is hereby made for a permit onstruct t Alter ( ), or Repair ( )an individual Well at: Rio ho� ----- -- - 001 --- =----- -- - - Location — Address pIl7NT Assessors Map and Parcel =- E -' C_c c ° ''� --- --- ==- - !0-7� If-466- 641V- _ -l-1qresr�!U- ni/6cs j,0-ner Address f ���-' a 3 -0� -- - -- - - - -- ---------------------------- ----- --------------------------- Installer — Driller Address J Type of Building Dwelling -- -- ------------------------------------------- '! Other - Type of Building ----------- No. of Persons------------------------------------------------- .S� 9U PUG ,eon e-9d Type of Well- --- --- - -- --- - Capacity-- 1O- - G - -�- - - - ---�-— Purpose of Well -/d0 T /'�L -- ----------- Agreement: The undersigned agrees to install the aforedescribed individual well,-in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by ihet Board of Health. I Signed --- ---------------------------------- 0 date — Application Approved By ------ - --- — -----—---------- ---- -- ------------- date' Application Disapproved for the following reasons:----------- ---------------------------------------------------------------- ----------- " _� date Permit No. - -------' - --- .. Issued---------------------------- — date — -- — — ,v BOARD OF HEALTH TQWNI, OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by----------- ---------------------------------------- -------- ------------ Installer at------------ ----------- ---------- - ---------------------------------------------------------------------------------------------- 'has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. -------------------------Dated------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY DATE- --- ------ — - ------ -- Inspector--------------------------------------------- - ------------ BOARD OF HEALTH TOWN OF BARNSTABLE Veil Congtruct ion Permit No. - - -- -- — Fee----- ----------_ Permission is hereby granted--- `� � --` f �...---- l ------------- to Construct ( ), 4e ( ) " r Repair ( )_an I divid I Well at: No. _1r� - -- 5 - - -v -. �-- -- ----------------- 1 j"-.�- ��-- j Street T � 1 as shown o, the ap licatio a Well Construction Permit 7 -z No. - � t ----- Dated------ ------�------ �----------------------------------- ----- - —-C��- - Ward of Health DATE- lo__--- 0----------- I ' . 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