HomeMy WebLinkAbout0002 MOUNTWOOD ROAD - Health 2 MOUNTWOOD ROAD,M. MILLS .
A=150'* t
i
TOWN OF BARNSTABLE
E� ---�
C.,$TION SEWAGE #
.L.AE lM_ ;M f l l s ASSESSOR'S MAP & LOT
AME&PHONE NO.' -� �:fry L"tom ���v�r✓ e�� �I2 �1r1�
SEPTIC TANK CAPACITY (000 c`(
LEACHING FACILITY: (type) 500 �W 6,8, "t— (size)
NO.OF BEDROOMS 3
BUILDER OR
PERMIT DATE: C DATE: U l aZ 1Q,5-
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 existr
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) i Feet
Furnished by
__��
. �aC
{-
. /`GJ-7V� /r �-/�
��—
..
"PA. �40
CIO d
00'm
rs.L --
L
a•
s,
\ rN
_ R
C �
TIIIiIIiIIIII
cf °�' � b�J II n j
in
F
T .
Pa
40 b e
� co ��
par- - mco+ io-kA
BQSe-�mern�
un
ce
yl
;C p o nn p.O -a cr, S
9
re m d'/t..y v�l �— A S
yrq.�f v,\j-kr 6"Idm c04
bin W'�C&j
YOU WISH TO OPEN A BUSINESS?
` For Your Information: Business Certificates cost $30.00 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.) Business Certificates are available at the Town
Clerk's Office, 1' FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) and 200 Main Street Offices at the Licensing counter.
DATE: h (J1
j Fill in please:
y3� _ APPLICANT'S YOUR NAME:
BUSINESS YOUR HOME ADDRESS:Ca Mo:uy)f Jody _1 d %M.M;Ily mA Qa,bllt
7w 87-70 1
TELEPHONE # Home Telephone Number:
NAME OF NEW BUSINESS .rcx � P I u l-,-I f� H rubi2 TYPE OF BUSINESS Pl u^M I l��IS THIS A HOME OCCUPATION? , YES NO
Have you been.given approval from the.buildin��gg division? YES NO
ADDRESS OF BUSINESS /llavn�-co, P� J�'i.M,I15 CIA O'a.QU MAP/PARCEL NUMBER
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 : r
This individual has een inforTedjt� permit requirements that pertain to this type of business.
r�
Ahorized Signatures '
COMMENTS:
f �� ✓ ��
77
3. CONSUMER AFFAIRS (LICENSING AUTHORI ) s
This individual been,' rmed ql jlhe c n ' requirements that pertain to this type of business. rya
Authorized Signature**
COMMENTS:
fat' IRS DEPARTMENT OF THE TREASURY
INTERNAL REVENUE SERVICE
CINCINNATI OH 45999-0023
Date of this notice: 12-13-2008
Employer Identification Number:
26-3865028
Form: SS-4
ALEX B BRAGA Number of this notice: CP 575 G
BRAGA BROS PLUMBING & HEATING
2 MOUNTWOOD RD For assistance you may call us at:
MARSTONS MLS, MA 02648 1-800-829-493,3
IF YOU WRITE, ATTACH THE
STUB AT THE END OF THIS NOTICE.
WE ASSIGNED YOU AN EMPLOYER IDENTIFICATION NUMBER
Thank you for applying for an Employer Identification Number (EIN) . We assigned you
EIN 26-3865028. This EIN will identify you, your business accounts, tax returns, and
documents, even if you have no employees. Please keep this notice in your permanent
records.
When filing tax documents, payments, and related correspondence, it is very imeortant
that you use your BIN and complete name and address exactly as shown above. Any variation
may cause a delay in processing, result in incorrect information in your account, or even
cause you to be assigned more than one EIN. If the information is not correct as shown
above, please make the correction using the attached tear off stub and return it to us.
A limited liability company (LLC) may file Form 8832, Entity Classification Election,
and elect to be classified as an association taxable as a corporation. If the LLC is
eligible to be treated as a corporation that meets certain tests and it will be electing S
corporation status, it must timely file Form 2553,. Election by a Small Business
Corporation. The LLC will be treated as a corporation as of the effective date of the S
corporation election and does not need to file Form 8832.
To obtain tax forms and publications, including those referenced in this notice,
visit our Web site at www.irs.gov. If you do not have access to the Internet, call
-
1-800-829-3676 (TTY/TDD 1-800-829-4059) or visit your local IRS office.
IMPORTANT REMINDERS:
* Keep a copy of this notice in your permanent records. This notice is issued only
one time and the IRS will not be able to generate a duplicate copy for you.
* Use this EIN and your name exactly as they appear at the top of this notice on all
your federal tax forms.
* Refer to this EIN on your tax-related correspondence and ,documents.
If you have questions about your EIN, you can call us at. the phone number or write to
us at the address shown at the top of this notice. If you write, please tear off the stub
at the bottom of this notice and send it along with your letter. If you do not need to
write us, do not complete and return the stub. Thank you for your cooperation.
Date:
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: B.>- a Gros � Phu Vi J H ectbcr
BUSINESS LOCAT old JVA, M I I15 PA A INVENTORY
MAILING ADDRESS: Sa-,,(\e ab above TOTAL AMOUNT:
TELEPHONE NUMBER:(-71iq� -I gI- yo5 0
CONTACT PERSON: P l e X br un a
EMERGENCY CONTACT TELEPHONE NUMBER: C174) 47- 7051 MSDS ON SITE?
TYPE OF BUSINESS:
INFORMATION/RECOMMENDATIONS: 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 materials 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) Misc. Corrosive
NEW USED Cess ool cleaners
utomatic transmission fluid Disi ectants
ngine and radiator flushes Roa Salts (Halite)
H draulic fluid (including brake fluid) Refri erants
M or Oils Pesti ides
NEW USED (insecticides, herbicides, rodenticides)
Gas line, Jet fuel, Aviation gas Photo c emicals (Fixers)
Dies I Fuel, kerosene, #2 heating oil EW USED
Misc. petroleum products: grease, Photoch micals (Developer)
lubric nts, gear oil N W USED
Degre sers for engines and metal Printing in
Degrea ers for driveways & garages Wood pres rvatives (creosote)
Caulk/G out Swimming of chlorine
Battery a id (electrolyte)/Batteries Lye or causti soda
Rustproof rs Misc. Combus ible
Car wash etergents Leather dyes
Car waxes nd polishes Fertilizers
Asphalt & ro fing tar PCB's
Paints, varnis es, stains, dyes Other chlorinated ydrocarbons,
Lacquer thinn rs (inc. carbon tetrach oride)
NEW USED Any other products ith "poison" labels
Paint &varnish movers, deglossers (including chloroform, formaldehyde,
Misc. Flammabl hydrochloric acid, oth acids)
Floor & furniture trippers Other products not listed which you feel
Metal polishes may be toxic or hazard lus (please list):
Laundry soil & stai removers
(including bleach)
Spot removers & cle ning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar'removers,.
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
h F
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
, yeJ
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 2 Mountwood Road
Marstons Mills MA 02648 r
Owner's Name:' Karen Campbell -_
Owner's Address: P.O. Box 292 ; •�-�
Marstons Mills MA 02648
sr 3� �� ;1
Date of Inspection: August 22,2005 Job#05-249
�;,,i rQ
Name of Inspector: PATRICK M. O'CONNELL ,1
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
c
Telephone Number: 508-428-1779
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
training and experience in the proper function and maintenance of on site sewage disposal systems. I at��� ' 111111
approved system inspector pursuant to Section 15.340 of Title 5 310 CMR 15.00 • .( 0 . The s ste . • �
y m
_X Passes ,yG
T T Conditionally Passes RI= M.
Needs Further Evaluation by the Local Approving Authority
Fail •� 0 E L
Inspector's Signature:
Date: August 22, 200 ��i�FS INSPE
nti nn
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.
Notes and Comments: Leaching chambers have 34"standing water with no high stains. Tank is not in need
of pumping at this time.
****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 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2 Mountwood Road
Marstons Mills MA 02648
Owner: Karen Campbell
Date of Inspection: August 22,2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX 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:
Titla S lncnantinn Rnrm F/l ci,)nnn 2
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2 Mountwood Road
Marstons Mills MA 02648
Owner: Karen Campbell
Date of Inspection: August 22,2005
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
— Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
— The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"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:
Title C fncnontinn Rnrm�ii�i�nnn 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 2 Mountwood Road
Marstons Mills MA 02648
Owner: Karen Campbell
Date of Inspection: August 22,2005
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
— —X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
— —X—
Liquid depth in cesspool is less than 6"below invert or available volume is less than %2 day flow
— _X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
—X_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
_X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X— Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this forma
_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 Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ — 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 I1 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.
T41. S incnantinn Fnrm 411 1;i1n01) 4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 2 Mountwood Road
Marstons Mills MA 02648
Owner: Karen Campbell
Date of Inspection: August 22,2005
Check if the following h
_ ave been done. You must indicate yes or no"as to each of the following:
Yes No
_X_ — Pumping information was provided by the owner,occupant,or Board of Health
— _X_ Were any of the system components pumped out in the previous two weeks?
X Has
the system r_ _ y received normal flow '— s in the previous two week period ?
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
_X_ — Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ — Was the facility or dwelling inspected for signs of sewage back up?
_X_ — Was the site inspected for signs of break out?
_X_ — Were all system components,excluding the SAS, located on site?
_X_ — Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of
scum?
_X_ — Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems`?
The size and location of the Soil Absorption System (SAS)on the site has been determined based on:
Yes no
_X_ — Existing information. For example,a plan at the Board of Health.
_X_ — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Titlo S fncna�tinn pnrm(.ii ci�nnn 5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWA
GE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 2 Mountwood Road
Marstons Mills MA 02648
Owner: Karen Campbell
Date of Inspection: August 22,2005
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: 1
Does residence have a garbage grinder(yes or no): No
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 meter readings, if available(last 2 years usage(gpd)): 2003—114,000 gal.2004—111,000 gal.=308 gpd.
Sump pump(yes or no): No
Last date of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
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: Tank was pumped last year.
Source of information: Homeowner
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
_X_Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Compliance Date of January 20, 1999(repair)
Were sewage odors detected when arriving at the site(yes or no): No
Titles i 6
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 Mountwood Road
Marstons Mills MA 02648
Owner: Karen Campbell
Date of Inspection: August 22,2005
BUILDING SEWER: XX (locate on site plan)
Depth below grade: 1'
Materials of construction:_cast iron _X_40 PVC other(explain):
Distance from private water supply well or suction line: 25'
Comments(on condition of joints, venting, evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 16"
Material of construction:_X_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:8.5 long X 5.2 wide- 1000 gal. tank
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle:30"
Scum thickness: trace
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: 13"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
time. _Tees intact and clear, liquid level at bottom of outlet invert Tank is not tin need of Pumping at this
GREASE TRAP: No (locate on site plan)
Depth below grade:_
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
T410 i IncnAntinn 1'.nrm 411 ciInnn 7
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 Mountwood Road
Marstons Mills MA 02648
Owner: Karen Campbell
Date of Inspection: August 22,2005
TIGHT or HOLDING TANK: No (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: gallons/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.):
DISTRIBUTION BOX: XX (if present must be opened) (locate on site plan)
Depth of liquid level above outlet invert: 0"
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.):
Box level and no evidence of solids carryover or high stains present in distribution box at time of inspection.
PUMP CHAMBER: No (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.):
Titlo i incnontinn Fnrm�n snnnn 8
. Page 9 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 Mountwood Road
Marstons Mills MA 02648
Owner: Karen Campbell
Date of Inspection: August 22,2005
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
_X leaching pits, number: One Pit
_X_leaching chambers, number: Two 500 gal.Chambers
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.): Leaching pit previously failed and still in service Leaching chambers have 3 4"standing water with
no high stains.
CESSPOOLS: No (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 or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (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.):
T41. 9
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 Mountwood Road
Marstons Mills MA 02648
Owner: Karen Campbell
Date of Inspection: August 22,2005
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.
Mountwood Road
Water service
#2
28 37
22
28 50
67
40
57
Titin S Incnartinn pnrm ail si�nnn 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 2 Mountwood Road
Marstons Mills MA 02648
Owner: Karen Campbell
Date of Inspection: August 22,2005
SITE EXAM
Slope None
Surface water None
Check cellar Dry
Shallow wells None
Estimated depth to ground water: More than 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:
Checked with local excavators, installers-(attach documentation)
_X_Accessed USGS database-explain: USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el.40 and topo map shows property above el. 70.
T:t1. C rncr�ortinn Fnrm�ii ci,)nnn 11
j~ TOWN OF BARNSTABLE
LOCATIOI`<' :J Alel ne"OQ A SEWAGE #
VILLr&GE MWP f?d 2.5 f'�i`OC 1 ASSESSOR'S MAP&,LOT IV"0 77
.mil INSTALLER'S NAME&PHONE NO. rjf,�,
SEPTIC TANK CAPACITY _ /D Oa /
LEACHING FACILITY: (type) I 5W Q0 �ryLt//,�� ie) / �� �•
NO.OF BEDROOMS
BUILDER OR OWNER k-4,01-fn An AVb>�!� .,
e
PERMI TDATE: / — / % - f-9 COMPLIANCE DATE:
Separation Distance,Between the:
Maximum Adjusted Groundwater Table and 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) !a.+' ` Feet
Edge of Wetland and Leaching Facility(If any wetlands exist " S
within 300 feet of leaching facility) !•` Feet
Furnished by
x
him
<t
4S .� • 40h
4
No. Fee `
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Mifspaar *pztem COnfStruction Vermit
Application for a Permit to Construct(4-I Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. :9, 1%1v 4-4 TU1cv ,Qar, Owner's Name,Address and Tel.No.
•°vi�rsrt�t?s ryl6tls> k�,�<� ��«/,,6.�//
Assessor's Map/Parcel ,
Installer's Name,Addres�ss,,j and Tel.No. ct/%<j- 01 Designer's Name,Address and Tel.No.
12
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank / Type of S.A.S.
Description of Soil 44cif Srsrr�
Nature of Repairs or Alterations( nswer when applicable) .:�,i a4ll Z-.rao 6141 l�r� 441i;&
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-
ate of Compliance has been issued by this Boaz of Health.
Signed t G 2[ ,�� Date
Lc
pplication Approved by Date01
pplication Disapproved for the following reasons
Permit No. Date Issued
d
0 `
-. No. — 2 t + Fee V�r
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: -
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
Application for Mioogar *pgtent Con,5truction Permit
Application for a Permit to Construct(('Repair( )Upgrade( )Abandon( ❑Complete System ❑Individual Components
Location Address or Lot No. 117p vq TwOdt! /Q® Owner's Name,Address and Tel.No. !/2 g- $a5
Assessor's Map/Parcel 49*"5,ve,5 Nil/1�f k g i^�6! Cf9�►sp�e/�
o
Installer's Name,Address,and Tel.No. y7y p�y!/ Designer's Name,Address and Tel.No.
Jej ep4 D. fqa-^•V S
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building �— No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil �,�_'1js, 6�
Nature of Repairs or Alterations(Answer when applicable) & e/�
c
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Health.
Signed Date
Application Approved by Date
Application Disapproved for the following reasons r `
r
i
Permit No. Date Issued :
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( 4+Repaired ( ) Upgraded( )
Abandoned( )by �� _��? �
at 1 w(",4T"66es /chas been constructed in ac o dance
with the provisions of Title 5 and the for Disposal System Construction Permit No. `)T— 2 7-- datedf,-
Installer Designer ✓���d� &, /�ssyr ,S
The issuance of his permit shall not be construed as a guarantee that the system will function as designed.
Date i d' — 1 Inspector
No._ 9 2 Z. �S D 077 Fee 1 v.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Migpogai *paem Congtruction Permit
Permission is hereby granted to Construct( 61$epair( )Upgrade( )Abandon( )
System located at 9 6L42�«t2cz�
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 p
Date: 1 �"f/ 7 Approved by ,
" .'• 10/9/97
NOTICE: 'Phis Form Is To Be Used For the Repair Of Failed
Styptic Systems Only'-
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
5 , hereby certify that the application for disposal works
construction pem1it signed by me dated _!9 -y9 ,concerning the
property located at 2 M-'V-nTc./vao1 /2� /yl.•rsTOHS 4'J.// meets all of the
following criteria::
—There are no wetlands located within 100 feet of the proposed leaching facility
*—There are no private wells within ISO feet of the proposed septic system
ere is no Increase in flow and/or change in use proposed
VI-1--ere are no variiances requested or needed.
• If the proposed leaching facility will be located within 250 feet of any wetiands,the bottom of the
proposed leaching facility will ma be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete ithe following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map) _
SIGNED: �1K utit,Uy DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch phut of the proposed system. Also if the licensed Installer posesses a certified plot plan,
this plan should be submitted).
q:health folder:art
b�o� �✓,nom1 H�oli/�
0
xOSTi�jg, ��,
6 Aal f'J
LOCATION 4u SEWAGEP-"MIT NO.
YlLLAGE
rry�sv�.f/s wiz �
INSTA LLER'S NAME i ADDRESS
6 U I'L D E R OR OWNER
DATE PERMIT ISSUED 12 _i� ^ 7 �
DAT E COMPLIANCE ISSUED
. - �� 73
r
No.......-••--•l--•---•- t +�................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA IT I A
T
---
.-------� '4...OF..... ............. ....................
Appliration for DiopooFal Works Tonotrurtion frrutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
Sys...._..a ..... ..........
L on-Address or Lod No.
............ ................ '..:..- -- ............. ...........:...____... _...-----•------------•-•-T -•-•-- ---._................................................
•-
W �nstallier
we .Address
Address -
T of Building Size Lot..d,A!;!�9-.......Sq. feet
Dwelling—No. of Bedrooms-__-_--2................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons_-_-___-___-__•--__•_______ Showers ( ) — Cafeteria ( )
a' Other fixtures ___ ______ _____ ______
W Design Flow..........57-0........................gallons per person per day. Total daily flow.....____.rat®o......................gallons.
WSeptic Tank—Liquid'capacity/ ons Length---------------- Width................ Diameter................ Depth................
x Disposal Trench—No. .................... th............. Total Length___..... ._._.. otal leaching area.................. ft.
Seepage Pit No----
1 ------ bet -.---•--. ......_.. Total leaching area-..,:1. a...sq. ft.
Z Other Distribution box ( ) Dosing tank ( 4
'-' Percolation Test Results Performed b •--__-_---_____.� ._ ��. Date....�_�_-_l.S-__=?�.__..
a y-- C C t
Test Pit No. 1._ .__.__-minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
..
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O �. .. 3 .
Descri tion f Soil -••---. ..............
U
W -- --•-----•----•----------------------------------•--•--•••----------------------------.._---.....----••-----•----•-•----••••-•------•..__.........------••------••---•••--•---•---•-••--------•-•-•...
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boar of health.
Signe /a2 �.... 7 T
_______ ____________4.__.... ........_...............
Date
ApplicationApproved By---•--••-------•••--------••••---•----••---...-•-•--•._....-----•--•--•----•-•------------•-•--•• ...............................
Date
Application Disapproved for the following reasons:-----•--------------------------------------------------------•---------------------------------------....•-•-•-
-•-•-•------•-••--•----•---•••-•-....--•--•--•--•--••-------•--------------------•---........----------••-•-•-•--------------•••-••--••--•--•-----•-•-•••••-••---•--••------•--------••-•••--------..---
Date
Permit No.......................................................... Issued-.......................................................
A Date
J
No!�&L..... FEx..........%J
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA T
Appliration for Dispaa i al Waarks Tomitrnrtiaan Famit
Application is hereby made for a Permit to Construct (k or Repair ( ) an Individual Sewage Disposal
Syst a - G�x .�
4. - Lo ,n Address / r o Lo Now
•--- — •= � -------------... -•----•---------------.._.!_....:G ..................... -----•---..............._
�G �" .__ Ow r � � Address
a .... ......... ..�'°��••__ ....._...-------- - ... .. ..........�--------------�---------.....
nstaller Address
¢� Type of Building *� Size Lot_! q _ ._Sq. feet
Dwelling—No. of Bedrooms______ ________________________________Expansion Attic ( ) Garbage Grinder ( )
'04 4 Other—T e of Building ____________ No. of persons____________________________ Showers — Cafeteria
Q' Other fixtures __.!' ?"'- '_"�____ _______________________ _ -------- --- -- ----------------------------------
,^�.C D
WDesign Flow...........�`Q______________________--gallons'per ,person per day. Total daily flow..__._.____._.__________:__.__-_.____._._.__gallons.
WSeptic Tank—Liquid capacity/_- .___ allons Length................ Width----------------.Diameter................ Depth................
x Disposal Trench No _________ th ._.. Total Length otal leaching area..................._sq- ft.
Seepage Pit No `�_ ""D. - �' be _..._. _•_---::. Total leaching area•_-_4' '..sq. ft.
Z Other Distribution box ( ) Dosing tank ( d - ,� ! Xr. 77
14 Percolation Test Results Performed by- ............r __._. :r. ___ _ 1, ''" ___..
aDate -�• -
14 Test Pit No. 1_. '."....minutes per inch ,Deptfi of Test Pit____________________ Depth to ground water.........................
(4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil _---------- /.......
W
UNature of Repairs or Alterations—Answer when applicable-----------------
- - ...............................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT LEI 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been
_ issued by th boar of health.
_ __Signeda
Date
ApplicationApproved BY -------------=...........................................................-------
Date
Application Disapproved for the following reasons:--
------------0----------*.......*--------------------------------------------------------------------------
--------------------------------•-------------•-------_------•--•--••--------------------•-•--•-•----------....------------------------------------•--------------------•-------_...--------------------
I Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL H
.e,•t. -..OF...... ..........................
......... ..............................................
Grfifirtt a off�aam tli�anrr
THI S TO CERTIFY hat Individual ewage Disposal System constructed (40 or Repaired ( )
by...._...._ --- ...
- ---- - ---- --•- --- •--- ---------- -••-
nstal w
has been installed in accordance with the provisions of T TIZ 5 of The State Sanitary Code as described in the
application for Disposat Works Construction Permit NC(__ `�_________________ da.ted__../^� "_ k``
THE ISSUANCE O6`'T7115 CERTIFICATE SHALL NOT BE CO1$S3RIlF,1lJ AGUARA TEE THAT THE
SYSTEM W FUNCTION SATISFACTORY.
DATE......... .............................................................. Inspector........_�__�. ---
TH"E. COMMONWEALTH OF MASSACHUSETTS
{ BOARD RF HEAL
No......... .......1. FEE........................
Disposal Works Tomitrurbian Vrr t#
Permission is hh by granted.......... ...._............. _.._.
to ConsAru or Repair ) n In dual Sew e isal Syst at No. -----JAA_ �t'� •-•----•-•-
Streetas showe application for Disposal Works Construction Permit _______ :-_________ Dated__-1 ..`I,G._:__�_�__._._....
Board of th
DATE.:7 ` ........................................................... "1
FORM 1255 HOSES & WARREN, INC.. PUBLISHERS .t
T� t tGt-.1 V�,TA
S1t..1GL& �=nM1L4 - 3 T3tEDZO0AA
FLow = Ito v- S = SSo G•F .D.
1E"P i-I C 0 t G-9 P?6.P.D.
U Ste- l oOp S,4L
G
.SPoCAI PIT - L)SE.
irU�wALL
CE�D p Sd G.PD. i
ToTAL '1:7)ESIGIJ = 4,ZS G.P.D. , PIN
n
PEfdGDLQTIC)LJ t?- ,T e : tt.l ZM I Q 0lz Ix--SS•
I-IN
DO
2c2 t I�
t; v HII..-IARE) r,
5
ice/1 Gi
LoT n Ti) ljAlv!;r
Tooq YJATez_
Tor 1-►40 n ioo.o
0-.
,�.,... 4''
!'y Iuv• 97 v
LoAM Poe I ooc> lwv- '.A
/ + Iw. 64L. 4G 7
T�USO1t. -sox 9G / Sepnc '
4)z VENSG loop 95$ �Nv 1w. .�
ratT wN�rc GAL. tie, 9G.z ;
�jAcJ� L.sAr-N ,A
PST ,
\fl1 °
WASHED
�AQa• STONE NL� ,�
CGtZTtFt�t� pl..o"i" Pt_ !>t�i
L b CA T t o" M,(.r2ncwi M}u"
SG.AL N: `70l2r�loi''1"7
t•-1c.i,(�t5t�1 Gc�lf�L.�IS W►Tt-i Tt-(i_ S1 Df�.t_.I►-.lam LD„i,
A1.Ib >E`Ct?yACiG S:'CQ�I�CMcuTS OP TNC
G�TL 12 IS 4 icy
F B,4XTCtZ- e.,-'.. WIC
REGIS't'�tzED
Tl-�l5 C7{_AI-1 l �-1UT L'A�>CQ vt A�.J 0STE2VILLG c� I�CASy,
1t.1;(t?J.'✓lt=1Ji lJi:�ll'c�' TtaC: CFc-i ('�i SIdGWLD A.PPI_IGA.!-_VT_ J �
f.:'�C- E::F"� U->L►� 1<� i�r j'C_t=itr(ttiJC; l.,c>-'C" Lttil��..; _ r �
A�J tN►D'l�. ��:.:� �.n