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Home My WebLink About0046 NEW HAVEN AVENUE - Health 46 NEW HAVEN AVE.,MARST.MILLS A=103.070 I I i Commonwealth of Massachusetts 10 r 0�0 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 46 New Haven.Avenuer Property Address Rose Danner Owner Owner's Name -j information is -0 Mton Mills (Barnstable) MA 02648 March 3, 2017 ars s required for every � page. City/Town State Zip Code Date of Inspection p { 5J1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. r f Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Flaherty Jr. RS REHS use the return Name of Inspector key. Flaherty Environmental Services �y Company Name P.O. Box 81 Company Address I Yarmouth Port MA 02675 City/Town 1( State Zip Code 774-994-1166 f SI#4713 Telephone Number { License Number i B. Certification f 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority March 4, 2017 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 completingthis inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report:to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. i t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 VS Commonwealth of Massachusetts Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is required for every Marston's Mills(Barnstable) MA 02648 March 3, 2017 page. Cityrrown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owners Name information is required for every Marston's Mills(Barnstable) MA 02648 March 3, 2017 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps./alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is required for every Marston's Mills Barnstable MA 02648 March 3, 2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 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 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 El ® 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 Y2 day flow t5ins.doc•rev.6/16 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is required for every Marston's Mills(Barnstable) MA 02648 March 3, 2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 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. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �^M 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is Marston's Mills (Barnstable) MA 02648 March 3, 2017 required for every page. Cityrrown State Zip Code Date ofinspection 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 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: ® ❑ Existing information. For example, a plan at the Board of Health. ® El Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 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 t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M ,•'w 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is required for every Marston's Mills (Barnstable) MA . 02648 March 3,.2017 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No 5: 93 gpd; '16:1 Water meter readings, if available (last 2 years usage (gpd)): ' gpd Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: -- � -- Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is bl t B arson s Mills(Barnstable) MA 02648 March 3, 2017 required for every M ( ) page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: owner, pumped last when leaching installed (2014) 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 El 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): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is required for every Marston s Mills (Barnstable) MA 02648 March 3, 2017 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed 6/26/2014 per BBOH permit#2014-213 Were sewage odors detected when arriving at the site? ❑ Yes Z No Building Sewer(locate on site plan): Depth below grade: 2.5feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): >50 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight venting through dwelling adequate, no evidence of leakage Septic Tank(locate on site plan): 1 Depth below grade: 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: 1500 gallon 4" Sludge depth: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is )(required for every Marston s Mills Barnstable MA 02648 March 3, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness <1" Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? dip stick, tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): maintenance pumping should be performed every two to three years, inlet&outlet tees in good working order, tank seems structurally sound, liquid level is appropriate, no evidence of leakage 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is Marston's Mills ( arnstable) MA 02648 March 3, 2017 required for every page. City/Town State Zip Code Date of.lnspection 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.): 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): 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 t5ins.doc.rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is Marston s Mills Barnstable MA. 02648 March 3, 2017 required for every (Barnstable) page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0„ Depth of liquid level above outlet invert 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.): dbox seems level, no evidence of leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in,working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is required for every Marston's Mills(Barnstable) MA 02648 March 3, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: (2) ❑ 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.): (2) 500 gallon precast leach chambers with 4' stone in a 12.83'W x 25'L x 2'D configuration, soils sandy with some cobbles, no signs of hydraulic failure or breakout, chambers dry with no stain line, vegetation typical 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is )(required for every Marston s Mills Barnstable MA 02648 March 3, 2017. page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is required for every Marston's Mills Barnstable MA 02648 March 3, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I ,► 6� r t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owner's Name information is . (required for every arns Marston's Mills Btable) MA 02648 March 3, 2017 page. Cityrrown State . Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells >12 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 6/26/14 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: as built card indicated no groundwater encountered at 12' Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments 46 New Haven Avenue Property Address Rose Danner Owner Owners Name information-is equir required is Marston s Mills Barnstable MA 02648 March 3, 2017 required for every (Barnstable) page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r. • TOWN OF BARNSTABLE LOCATION SEWAGE#o7 L� D VILLAGE ASSESSOR'S MAP.&PARCEL O INSTALLER'S NAME&PHONE NO. �o�ti/� SEPTIC TANK CAPACITYX��rJ�'''� i'oa a �Ad LEACHING FACILITY:(type) (size) J.r X.1% NO.OF BEDROOMS 73 C,4XM,6e0.P OWNER e PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on` site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �.7�1007 Z �ve`�'/ 6 �7 3G.6 ,� ti No. 0-1 wv Fee QU - - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes L,� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS application for disposal stern Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade:Abandon( ) ❑Complete System Al'ndividual Components Location Address or Lot No.�� /✓� ' �� Ae Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 4,-a �".7 <f_114r<!?1OP4l Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Z cS"�Ge 'C/f'r -;7 7 L'/d.G� ,/�✓fir✓�fP�' D eX7 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(min.required) —:p,d gpd Design flow provided gpd Plan Date �� ..�,0�Number of sheets / Revision Date Title Size of Septic Tank ��%� ype of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �' GS ��il'l✓ `� 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 o alth. � Sig Date O Application Approved by Date Application Disapproved by Date for the following reasons Permit No. ,201 Date Issued h"�� 0,(Y 15 No. ~� Fee p� -✓� x3.0 ',;, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: tYe PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftpYitation for ]Disposal *, pstrm Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade� Abandon( ) ❑Complete System 010nodividual Components Location Address or Lot No.�✓� /yE� vd Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. i Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 4e el r No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) d gpd Design flow provided S/'� gpd Plan Date- Number of sheets / Revision Date ~ Title Size of Septic Tank. X�. h' /1O®4 I"yp of S.A.S. �rDescription of Soil Nature of Repairs or Alterations(Answer when applicable) l�'.::5,.dtr V 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`iri operation until a Certificate of Compliance has been issued by this Board o alth. Si Date c Application Approved by / ,Q Date Application Disapproved by Date' Y.' ~ for the following reasons Permit No. „2 U(V - 2117 Date Issued 1 TH E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded Abandoned( )by at y 6� /j'�!�r /��Q�+'�� A y� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. -2 Cl —213dated 61 1'f Installer V/Ih Gr��'`� Designer 4 y/� A& #bedrooms .3 Approved design Q�w 3�9 gpd The issuance of this permit shall n t be co st, e a$aguarantee that the system will nctioh as esigtled. Date Inspector I ______._________________._____.______._____._____________'_________-__---____----------____-------------------------------`_._____________- No. t/ 2 1' 3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposaf 6pstem Construction 3permit Permission is hereby granted to Construct( ) Repair( ) Upgrade Abandon( ) System located at y X,�� G�� _,f Y and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be co`pleted within three years of the date of this permit. t Date / / /C Approved by /I JUN/27/2014/FRI 11 :03 AM FAX No, P. 001 'down of Barnstable E r b regulatory Serdees ♦q ; Richard V. Scab,Interim Director Q Hil.RNSTABY.�n x 9$ MAn �g Public Realth Division Thomas Mexw,Director 200 Main Street,11yannis,lVIA 02601 office: 508-862-4644 Fax: 508-790-6304 Installer&Desagner Certification Form Date: 6 / Se�►rage Permit �� Assessor's 1VIaplParcel t �` /Desigaer: ► Installe�r: a'� i{7�� t� Address: e AC5t awMa( Address; was issued a permit to install a (date) . — (installer) ,� septic system at 1 ,p'L'6 VOJ 1 Y based on a design drawn by (address) 6 ►�i'vw`1 dated v � � (designer) Y certify that the septic system referenced above was installed substantially according to the desigzx, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (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 Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed in coin 'ante with the terms of the RA approval letters (if applicable) OF QAVID MASON (Installer's Sigure) Xnt(Designer's Signature) (Affix I7esi p Here) FLEASE RETURN TO 1BARINSTABLE PUBLIC HEALTH DMSION. CERTWICATE OF COINO LIANCL WILL NOT BE ISSUED UNTIL BOTH TMS FORM AND AS BUILT CARD A;R�RECEIVED BY BARi>iSTABLE PUBLIC HEALTH DMSION. THANK YO U. Q:1Septic\De3igner Certification Form Rev 8'-14-13.doc _ - ` 6/r J" Town of Barnstable r# J VIE Department of Regulatory Services 8Al2ttaTABttJI.',. . Public Health Division Date - MAM �p r6;p 200 Main Street,Hyannis MA 02601 AEU AAA'1 A p�� Date Scheduled_ (,/� Ok im _S Fee 1'd. Sot Suitacbility Assessment_fog- S "Is Performed By: Witnessed By:LOCATION& GENERAL INFORMALocation AddressOwner'sName Imo./T✓. Address Assessor's Map/Parcel: Engineer's Named"00;e e,0W'Pro� NEW CONSTRUCTION REPAIR G' Telephone# �?ro7a7 Land Use- Slopes(9b) Surface Stones Distances from: Open Water Body ft Possible Wet Area' ft Drinking Water Well ft Drainage Way ft Property Line ft Other. ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands fn proximity to holes) � �:TM•i P. CO " � .W.. 'ate rw 1 ems, L: Parent material(geologic) Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: In, Depth to soil mattleC Depth to weeping from side of obs.hole: in. Groundwater Adjustment Index Well# Reading Date: Index Well level „ Adj.factor m 4 Adj.Groundwater Level PERCOLATION TEST Date_._ Thne Observation ' Hole# �� Time at 9" Depth of Perc Time at 6" Start Pre-soak Time @ Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Pubic Health Division Observation Hole Data To Be Completed on Back----------- ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SP_PTICWERCFORM.DOC i DEEP-OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stones;Boulders. onsistency,%Gravel) �6. 47 E . "non DEEP OBSERVATION BOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsisten % ra DEEP OBSERVATION BOLE LOG Dole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in_) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Con i to c Gravel) , e .. DEEP OBSERVATION DOLE LOG hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface_(in.) (USDA) (Munsell) Mottling (Structure,Stones',Boulders. Consistency, Flood Insurance Rate Map: / Above 500 year flood boundary No Yes .--_____ Within 500 year boundary No^/Yes Within 100 year flood boundary No. Yes Death of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pery us m rial exist in all areas observed throughout the area proposed for the soil absorption system? 1, If not,what is the depth f aturally occurring pery us material?Vv Cea�tifiication 1 G I certify that on bb \ (date)I have passed the soil evaluator examination approved by the Department of Environ ental Protection and that the above analysis was pe orm d by me consistent with . the required training,ex er's n e perience described in 10 CMK 15.017 Signature Date Q:ISEPTICkPERCPORM.DOC T WN OF B (ISTABLE . Z- LOCATION V SEWAGE # VILLAGE ASSESSOR'S MAP & LOT q INSTALLER'S NAME&PHONE NO. l V F�� l� �x`� S sd$ ��L 4 I SEPTIC TANK CAPACITY WL.- LEACHING FACILITY: (type) _ (Size)2- NO.OF BEDROOMS BUILDER OR O R PERMTTDATE: I6 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility t Feet Private Water Supply Well and Leaching Facility (If any wells exist TG Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist �( A Feet within 300 feet of leaching facility) Furnished by LN ��cAQt01 NNNPNNN I t r t t t I 1 �) Q T WN OF B STABLE , L LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT_1!2 3' o7a INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Lr-. LEACHING FACILITY: (type) br�4C V<.' (size) NO.OF BEDROOMS BUILDER OR O R PERMITDATE: IFS COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) A Feet `',> Furnished by O C i� ID c4 „�5 t _Ca' 381 2-G �z No. _ ._ - .,: Fee — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS application for Mizpoml 6petem Cow6truction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components LpFation Addgess_or Lo o. (� Owner's Name,Addre s and �el. 1�6k !-I►C�JQ_ lA�ltottW,1 1�1W�1� 'W� � Assessor's Map/Par ® v q Installer's Name,Address,and Tel.No. V Designer's Name,Address and Tel.No. WRT Type of u� Dwelling No.of Bedrooms Lot Size sq. t. Garbage Grinder 0 Ot er Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow i .. gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. 1 Description of Soill Nature of Repairs or Alterations(Answer when applicable) 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' _. and of Health. Signed Date C� Application Approved by Date Application Disapproved for the following reasons Permit No. __!Y— �L(a D Date Issued No. a p" w..�c,, Fee ._7J a� THE COMMONWEALTH OF MASSACHUSETTS i Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Yes 01pprfcation for ;fgpogal *pgtem Congtructfon Vertu Application for a Permit to Construct( )Repair( )Upgrade( )Abandon(---) ❑Complete System ❑Individual Components 119[c�attion Add ss or Lot o. "Owner's Name,Address and el.N _ Assessor's Map/Par 4 ` Installer's Name,Address,and Tel.No. u ,AY Designer's Name,Address and Tel.No. U��T CoNvv iZ�TI U . Type of y to l�7:2 l _ a`C �t� Dwellin No.of Bedrooms Lot Size sq. 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 r� 4o4t Type of S.A.S. L L1V I41 Description of Soil r Nature of Repairs or Alterations(Answer when applicable) 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 ' oard of Health. r i. Signed Date t 0 ll,(F Application Approved by Date — Application Disapproved for the following reasons Permit No. ! 9-- ZF_&O Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(Ioe)Upgraded( ) Abandoned( )by i�Lps.AT, at L /e A/. 4L- ��_ � �n� has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9e;'.-140 ated Installer Designer The issuance of this^pe t shall n t be construed as a guarantee that the system unction as designed. Date J y Inspector No.--i--- k -------------------------Fee -- -7-9 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS llfgpaal *pgtem Con$truction 3dermft Permission is hereby granted to Construct( )Repair(->e)Upgrade( )Abandon( ) System located at� ) �tw� ( OAX 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. F Provided:Construction must be completed within three years of the date of this permit. Date: 5— 162 -?2 Approved by C 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) JO)U;E�ohereby c ify hat the application for disposal works construction permit signed by me dated concerning the property located at tvo �� ' meets all of the following criteria: • The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system ` • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) JIV B) G.W.Elevation Z +the MAX.High G.W. Adjustment. 7 = / D N EBE ENA and B 3 J SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder:cert ., . . . . y� ...� �. -" •- _ �� ASSESSORS MAP : a ! i'A c TEST HOLE LOGS R EL• _ _ _ l) "The installation shall conii,., with Title V and Town A/M ,Board oL �.. FLOOD ZONE: ,IG SOIL EVALUATOR: l✓ I� Ull I leallh Regulations. u 2) The installer shall verily the location of utilities, sewer inverts and septic REFERENCE: _aD � - D '! .�k WITNESS : ( 1�J1 ,`i "► i � components prior to installation and setting base elevations. DATE: ' (�> I -7 PERCOLATION RATE: . , / ! l 3) All gravity septic piping to be 4 inch Sc1� 4U PVC at 1/S" per foot. The first 1�q' Clt9� two legit out of the d-box to the leaching shall be level. ,, 7. � i 4) This plan is not to be utilized for property line determination nor any other TH- 1 ! TH-2 purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over II 10 septic components. t, 1 � 7) The property is bounded by property corners and property lines. '� 8) The property owner shall.review design considerations to approve of total LOCATION MAP design flow and number of bedrooms to be considered for design. Receipt 42 of payment for the plan and installation based on the plan shall be deemed — approval of the design flow by the owner. 9) The existing leaching or cesspools shall be pumped and filled with material '0 r-1 per Title V abandonment procedures. Those within the proposed SAS shall _ _ _ be removed along with contaminated soil and replaced with clean sand per Title V specs. 10)System components to be 10 feet from water line. Sewer lines crossing the Ho Lr► w0, � .__ water line shall be sleeved with 4 inch SCII 40 PVC with ends grouted if _,. applicable. The proposed SAS is being installed below the water service 1 - ----T I line. The line is to be sleeve' as aforementioned and maintained in place. SEPTIC SYSTEM ! DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. FLOW ESTIMATE ! 12)The installer is to take caution in excavation around the gas line if such ' exists. Z, 13)The installer shall verify the location,quantity and elevation of the sewer 1 BEDROOMAS AT 110 !GAL/DAY/BEDROOM -�/�GAL/DAY lines exiting the dwellingprior to the installation. 11t( 14)This plan is representative only that a system can fit on a property meeting SEPTIC TANK Title V requirements. GAL/DAY x 2 DA1�S GAL USE (600 GALLON SEPTIC TANK o '40 to Q SOIL ABSORPTION SYSTEM , /f ff Q 40 1 ; Val : m r� a DAV1 SIDE AREA: X L`J 'j' Z1a:J 7 nip \� r �3�• v , No.10h -, 3C1�>1 Lkl( ' BOTTOM AREA: lZ► �C �� sTe SEPTIC SYSTEM SECTION 14 of q it Li - - 74►`T 7 L �o GAL _41 44 '� SEPT I C TANK - ��.._ KP 5 � SITE AND SEWAGE PLAN LOCATION : t333` PREPARED FOR : .Z ) LE-f�oall�p J O o r' SCALE: DAV I D B . MASON,RS DATE: DBC ENVIRONMENTAL DESIGNS I EAST SANDWICH . MA W t DATE ( HEALTH AGENT Z I ( 508 ) 833- 2I77 - i7i