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HomeMy WebLinkAbout0070 BURSLEY PATH - Health � IBURSLEY PATH, Lot 33 West Barnstable A = 110-025-004 LIL- y t { A k T' 1� No 4214 1/3 BLU FDcP) C� ESSELTE 10 JO, o m TOWN OF BARNSTABLE (,.LOCATION SIAXE## -,S P VILLAGE t Dt �j(,Q ASSESSOR'S MAP&PARCEL IN=T=W S NAME&PHONE NO. SEPTIC TANK CAPACITY Q LEACHING FACILITY.(type) `T(-ZeX�VeS _ (size) LICE NO.OF BEDROOMS L OWNER PERMIT DATE: 03NWIJM14#15 DATET,,--� 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 lands exist within 300 feet of leaching facility) Feet FURNISHED BY i Two 40'trenches. 49 67 21 ♦ \ ♦ \ \ ♦ k ♦ Y ♦ ♦ Y k \ Y \ Yl\ 4 k Y \ v. ♦ v, k Y v Y v \ Y Y Y Y+Yr♦ Y \ \ Y+Y \ \ Y . ♦ ♦ \ Y Y \ ♦ Y ♦ ♦ Y ♦ Y Y \ k k 4 \ Y Y \ Y Y \ k Y 'v \ Y Y k Y k Y \ Y \ ♦ Y \ ' v ♦ \ ♦ Y k Y \ k k 4 \ k k \ \ 4 l 4 ♦ 4 \ Y ' v Y \ k k \ Y Y \ \ 'v Y \ k ♦ Y 4 k + f f I Commonwealth of Massachusetts �n Title 5 Official Inspection Form . I. Subsurface Sewage Disposal System Form Not for Voluntary Assessments Aj 70 Bursley Path .„ i Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable ✓ MA 02668. page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this forma Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:outfWhen hen filling out f A. Inspector Information f on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road ICI Company Address Teaticket Ma. 02536 City/Town State Zip Code �n 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal-system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 03-26-2019 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 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 form should be sent to the system owner and copies sent to. the buyer, if applicable, and the approving authority. Please note: 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.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - I, Subsurface Sewage Disposal System Form- Not for Voluntary Assessments u— 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA 02668 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: This 3 bedroom home has a 4 bedroom septic system. There is a H-10 1500 gallon septic tank and a H-10 D-Box feeding two leaching trenches. At the time of the inspection there were no visible signs of. mast hydraulic failure. 2) 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): t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of,Massachusetts �n Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .u 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA. 02668 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp:doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts �v =. Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 70 Bursley Path Property Address - Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA 02668 page. City/Town State - Zip Code. Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. 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 aseptic 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. c. Other: F. t . 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments !% 70 Bursley Path V� Property Address Shaun Kennedy Owner Owner's Name information is West Barnstable MA 02668 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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. ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. 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. 5) 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 CA. 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 Elthe system is located in a nitrogen sensitive area (Interim Wellhead Protection El Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 cam, Commonwealth of Massachusetts �n Title 5 Official Inspection Form Ii; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u� 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is West Barnstable MA 02668 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes" to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no".for each of the following for all inspections: 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: N ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is required for every, West Barnstable MA 02668 page. Citylrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): GPD lus Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes .® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to 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 Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA 02668 page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface,Sewage Disposal System Form Not for Voluntary Assessments 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is West Barnstable MA 02668 required for every page. City/Town State. Zip Code. Date of Inspection D. System Information (cont.) 4. 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: 1996 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No 5.. Building Sewer(locate on site plan): 42" Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form =Not for Voluntary Assessments 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is required for every west Barnstable MA 02668 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _ 6. Septic Tank(locate on site plan): Depth below grade: 34"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: H-10 1500 gallon Sludge depth: 4, Distance from top of sludge to bottom of outlet tee or baffle 44" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 4 Distance from bottom of scum to bottom of outlet tee or baffle 13" -How were dimensions determined? sludge judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend the new owner put the tank on a maint. plan based on the age and the future use of the home. t5insp:doc•rev.7/26/2018". Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bursley Path V Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA 02668 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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.): 8. 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ............. !% 70 Bursley Path u- Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA 02668 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): 011 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.): At the time of the inspection there were no visible signs of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments h !% 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA 02668 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: . El leaching pits number: ❑ leaching chambers number: ' ❑ leaching galleries number: ® leaching trenches number, length: two apx:40 ' ❑ leaching fields number, dimensions: El overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA 02668 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were no visible signs of past hydraulic failure. 12.. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA 02668 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form tI Subsurface Sewage.Disposal System Form Not for Voluntary Assessments !% 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA 02668 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 j- ��./t ( �" Fri v� �',� S��,//e� o.✓ �-�-�-' /'�-5-�-� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 TOWN OF BARNSTABLE LOCATION �rtiA SEWAGE# �g VII,LAGE ASSESSOR'S MAP&LOT INSTALLER'S NAME&PH NE NO.J 'I^+?G 5 Se�A i t SEPTIC TANK CAPACITY I SO G LEACHING FACILITY:(type) .Q,PC.kCA, ' t'IKJ.(siZe) LIO NO.OF BEDROOMS` BUM61ER OR OWNER � (3c'°3r! 9lfQ`6 PERMITDATE: AO fO 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) Feet Edge of Wedand and Leaching Facility(If any wetlands exist within 300 feet of leaching aciGty) Feet Furnished by /g 1 t t Commonwealth of Massachusetts �- Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA 02668 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ❑ Check cellar ® Shallow wells Estimated depth to high ground water: 12 plus feet 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: 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: I augered a hole at a lower elevation and I shot it with a transit to show 4 plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts �- Title 5 Official Inspection Form . <I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bursley Path Property Address Shaun Kennedy Owner Owner's Name information is required for every West Barnstable MA 02668 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater.included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is �steble (/v es r V I S�a�) Ma 02668 7/16/2009 required for 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. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms // on the computer, 11Q�5 use only the tab 1. Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. S.M.Jones Title V Septic Inspection �y Company Name 74 Beldan Ln. Company Address r� Centerville Ma 02632 City/Town State Zip Code' 774-248-4850 S14522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 16.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/16/2009 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This Inspection does not address how the system will perform In the future under the same or different conditions of use. L-� 9/ O� t5ins•09/08 Title 5 Official Inspection Form:Subsurface 5ewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J°e 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 page. Cityrrown state Zip Code Date of Inspection B. Certification (cunt.) 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is Barnstable Ma 02668 7/16/2009 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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•09/08 Title 5 Official Inspection Forth: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 °t 70 Bursley Path Property Address Charles and Karen Paradis Owner owners Name information is Barnstable Ma 02668 7/16/2009 required for every page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) 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 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 f ❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow t5ins•09108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) 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 beloww high ground water elevation. ❑ Z 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 falls. 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) barge 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. t5ins-0901 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 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 page. Cityrrown 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 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. ® ❑ 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): 4 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 496 gpd provided t5ins-09/08 Title 5 Official Inspection form:Subsurtece Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts lugTitle 5 official Inspection Form . Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 page. City/Town State Zip Code. Date of Inspection D. System Information Description: Number of current residents: 2 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current 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 09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 page. Cityrrown 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: 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/Altemative 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of.17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 page. City/rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: original system 1996 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'5' feet Material of construction: ❑cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints ok, no leakage, vented through roof Septic Tank(locate on site plan): 1.5 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 gallons Sludge depth: 411 t5ins-09108 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 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 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 3.5' Scum thickness Distance from top of scum to top of outlet tee or baffle 61* Distance from bottom of scum to bottom of outlet tee or baffle 10" \ How were dimensions determined? Opened covers and tookmeasurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Outlet tee intact.Water level was at bottom of outlet invert. Tank does not need to be cleaned now but should be done every 2-3 years as maintenance. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: El 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-09108 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 ° 70 Bursley Path Property Address Charles and Karen Paradis Owner Owners Name information is required for every Barnstable Ma 02668 7/16/2009 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.): 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•09108 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 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert oil 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 was level and in good condition. Flow was equal to 2 oulets. No sign of past hydraulic overloading. 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.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of W Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number. ® leaching trenches number, length: 2--40x4x2 ❑ 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.): Soil was dry and no lush vegetation. Stone was probed in various locations with no sign of saturation. 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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•0901 Title 5 orfidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 -C\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 page. Cityrrown State Zip Code Date of Inspection Da 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 c ,3- J I _ d3 A-3, �� f - - • s V V v. Y V V V V w...- ♦.. t5ins•09/08 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 70 Bursley Path Property Address Charles and Karen Paradis Owner Owners Name information is Barnstable Ma 02668 7/16/2009 required for every page. Cityrrown 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 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: Design plan indicates no groundwater @180". Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °t 70 Bursley Path Property Address Charles and Karen Paradis Owner Owner's Name information is required for every Barnstable Ma 02668 7/16/2009 page. Cityrrown 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 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE 1 LOCATION ? u tev �'4t4A. SEWAGE 0 �g r e ® o® VILLAGE S` ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ' i C{¢ Q� t,. SEPTIC TANK CAPACITY i SO Q LEACHING FACILITY: (type) ���A C11�wc� c P n[A(size) NO.OF BEDROOMS , BLUR OR OWNER � � PERMIT DATE: �GS - 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � 0 i l � �7 ;. No. 1 — I FEE �� THE COMMONWEALTH OF MASSACHUSETTS Q SA2N1STA6L G _t€ MASSACHUSETTS 9 (v 41ppCt`ration for Disposal ,'ligstent Cfoustrur#ton jJerntit Application is hereby made for a Permit to Construct(1G)or Repair( ) an On-site Sewage Disposal System at: Location Address or Lot No. Owner$Nary Agress and Tel.No. L o+ 33 Svrs i cy Pam o rieIeA, 4-i7- s2 3 ,q �,IIS �� �d. 1 ores AA#.. Installer's Name,Address,and Tel.No. De ignep's!"i dress and Tel No. Z rh �•Y1- 477-Z347 Pbre t =Lk Type of Building: Dwelling No. of Bedrooms '¢' Garbage Grinder( ) Other Type of Building No. per Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow +4- d gallons per day. Calculated daily flow gallons. Plan Date to -Z6' 6 Number of sheets 7 Re ision Date Title $arK 11 lC,&A Di s oo s�I Pla ti �a Description f foil O� I Zr T©D so 4, .5D j�• M-w JUKA S Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code a ce he sy �n operation until a Certificate of Compliance has been iss by this Board of Health.'. Signed ate Application Approved by Date Application Disapproved for the following reasons Permit No. 1 JS f Date Issued ( � THE COMMONWEALTH OF MASSACHUSETTS $A R-clST'ASL 6: MASSACHUSETTS Cgertifirate of ( ampliattce THIS IS TO CERTIFY, that the On-site Sewage Disposal System installed( ) or repaired/replaced ( ) on by for at C11 4.1-r,4 Aq-TAJC has been heen rnnstpwrled in accordance with the provisions 5—Pritle 5 and the for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the p ovisions set forth below: 163^ The issuance of this certificate shall not be construed as a guarantee that the system will functi as designed. This Certificate expires on DATE �� ` 6 � Inspect `�iyt'(i..,ry ,•;yFtiyti�,r,�rr, �4 T }�)r s r-' „G, _ �, , : oe .. l - . No. �'C� FEE in ?dr' THE COMMONWEALTH OF MASSACHUSETTS - t3A�'_1US7AG4. iCMASSACHUSETTS 'P 'yfir ction for "mait Application�is hereby made for a Permit to Construct(YC) or Repair( ) atf On-site Sewage Disposal System at: Location Address or Lot No. Owner' Na /�j� A�dress and Tel.No. (� c� t'I�UCS ca U('S � �•y :X�'• ;" , Installer's Name,Address,and Tel.No. Designer's Name, ddress and Te.No. A.55isc.I►�c. ' G� (_U2Q �ires�"cFa�lr M� , 4 77-Z347 Type of Building: 4 '� DwellingNo. of Bedrooms `` ",-.,)Garbage Grinder Other Type of Building �No. erPerson`s 1 Showers( ) Cafeteria( ) Other Fixtures Design Flow 44 U gallons per day. Xcalcul ted daily flow 4 9 gallons. Plan ' Date "Z(a' `�! Number of sheets ,{ Z Revision Date Title 13aCw -o.-hie Ma" p1SnoSai R641- E . �ocirr4Ues Sa�Gt'wJc A.f� Description f$oil O/�" 12 Td 50 i � -15 a o /Z - /D g i X Za Ea.-,d /O,3 - 1.8o MCJ J v►^ S uv.ti Nature of Repairs or Alterations(Answer when applicable)' r Date last inspected: Agreement: .., The undersigned agrees to ensure the construction and maintenance of the aforedescribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code a ov ce the s M n operation until a Certificate of Compliance has'been•iss dy%<t`hi9;Board of Health. Signed ate > z.. Application Approved by i `Date ZD Application Disapproved for the following reasons' Permit No. - Date Issued ( a L:� , 9 i THE COMMONWEALTH OF MASSACHUSETTS YA2/VS'7-ASL'L MASSACHUSETTS . �- ke>rtifirate of 09oznylianve THIS IS TO CEkTIFY, that the On-site Sewage Disposal System installed ( ) or repaired/replaced( ) on y by_ for at ' f s bee cons cted in accordance with the provisions o itle 5 and the for Disposal System Construction Permit No. " dated �•, Use of this system is conditioned on compliance with the p ovisions set orth below: The issuance of this certificate shall not be construed as a guarantee that the system will functi n as designed. This Certificate expires on DATE Inspector q THE COMMONWEALTH OF MASSACHUSETTS No. FA21V S7'�8LE , MASSACHUSETTS FEE � pisposal 'System Gn'otrudion FEzmit Permission is hereby granted to to construct( ) or repair( ) an On-site Sewage System located at C/+ s and as described in the above Application for Disposal System Construction Permit. The applicant recogni es his/her duty to comply wifh Title 5 and the following local provisions or,special conditions. All construction musf,be o 1 to wit in three years of the date below. I c I 7- DATE ._ Approved by FORMi255 Rev.3/95 A.M.SULKk CO.-BOST N MA t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I w 70 Bursley Path — Property Address Charles & Karen Paradis I — Owner Owner's Name information is West Barnstable MA 02668 December 10, 2010 1 — required for State Zip Code Date of Inspection i every page. City/Town I 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. Important: A. General Information When filling out forms on the r computer,use 1. Inspector: I n only the tab key to move your Patrick M. O'Connell — cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. — Company Name f� 189 Cammett Road — Company Address I Marstons Mills MA _ 02648 1 — Zip Code State rennn City/town � 508.428.1779 SI 12855 — Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site! sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of i Title 5 (310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority r' 0 �cl., December 10, 2010 Job# 10-293 Inspector's Signature Date The system P stem inspector shall submit a copy of this inspection report to the Approving Authority (Boa Id of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of brie at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t,. j t i to Title 5 Official Inspection Form:Subsurface Sewage Dis sal System•Va e'I of 17 t5ins•09108 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 70 Bursley Path — Property Address Charles & Karen Paradis — Owner Owner's Name information is MA 02668 December 10, 2010 — required for west Barnstable every page. CitylTown a State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D I I A) System Passes: i ® 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: Tank is not in need of pumping at this time, leaching system shows no signs of saturation. I I i I I B) System Conditionally Passes: ❑ escribed in the"Conditional Pass" section need to be One or more system components as d 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. Systern will pass inspection if the existing tank is replaced with a complying septic tank as approved by th:e 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. I I ❑ Y ❑ N ❑ ND (Explain below): I I I i i i i i Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 l5ins•09/08 I ( Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I I 70 Bursley Path — Property Address Charles& Karen Paradis III — Owner Owner's Name I information is West Barnstable MA 02668 December 10, 2010 i — required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box dine 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): �I ❑ 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): i ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): I _ I i — i I — C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determinelif 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 hei Ith, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water I ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 ISins•09108 I Commonwealth of Massachusetts I 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bursley Path Property Address Charles & Karen Paradis — Owner Owner's Name information is West Barnstable MA 02668 December 10, 2010 — required for State Zip Code Date of Inspection j every page. City/Town B. Certification (cont.) I 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: I ❑ 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. i ❑ 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: h - **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliforrn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less 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: i i I i, I I D) System Failure Criteria Applicable to All Systems: i You must indicate "Yes" or"No" to each of the following for all inspections: i Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or j clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool I ❑ ® 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 lless than_day flow Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page A of 17 t5ins•09/08 i i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bursley Path — Property Address I Charles & Karen Paradis — Owner Owner's Name information is MA 02668 December 10, 2010 required for West Barnstable ; — State Zip Code Date of Inspection every page. City/Town 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 for tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® 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.] El ® 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. i Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply j i ❑ ❑ 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 I If you have answered "yes"to any question in Section E the system is considered a significant thlreat, 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 (Sins•09/08 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bursley Path - Property Address Charles & Karen Paradis Owner Owner's Name information is West Barnstable MA 02668 December 10, 2010 required for — 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 i ❑ ® 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? ! I ® ❑ Was the site inspected for signs of break out? i ® ❑ Were all system components, excluding the SAS, located on site? i ® ❑ 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. ® ElDetermined 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: I Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 i ! t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i 70 Bursley Path I — Property Address j Charles & Karen Paradis i — Owner Owner's Name j information is West Barnstable MA 02668 December 10, 2010 required for every page. City/Town State Zip Code Date of Inspection I D. System Information Description: I - I _ I Unknown Number of current residents: I — Does residence have a garbage grinder? ❑ Yes ®1 No Is laundry on a separate sewage system? [if yes separate inspection required] El Yes ®j No I Laundry system inspected? ❑ Yes ❑l No Seasonal use? ❑ Yes ® No i Water meter readings, if available (last 2 years usage (gpd)): Detail: I _ I i Sump pump? ❑ Yes ® No Currently Last date of occupancy: Occupied. Commercial/Industrial Flow Conditions: I I _ Type of Establishment: I _ 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 ❑i 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page,7 of 17 i i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 70 Bursley Path — Property Address Charles & Karen Paradis Owner Owner's Name information is required for West Barnstable MA 02668 December 10, 2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) I _ Last date of occupancy/use: Date i Other(describe below): I i i i General Information Pumping Records: Source of information: Unknown Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: aeons g i I How was quantity pumped determined? — i Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system I ❑ Single cesspool ❑ Overflow cesspool i ❑ 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 j ❑ Tight tank. Attach a copy of the DEP approval. I i ❑ Other(describe): i t5ins•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Pagel8 of 17 I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 BursleY Path — Property Address Charles& Karen Paradis — Owner Owner's Name information is West Barnstable MA_ 02668 December 10, 2010 — required for — every page. City/Town State Zip Code Date of Inspection — D. System Information (cont.) I Approximate age of all components, date installed (if known) and source of information: Compliance date: 10/30/96 i Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2' 1 _ Depth below grade: feet I Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): j — i Distance from private water supply well or suction line: feet I Comments (on condition of joints, venting, evidence of leakage, etc.): i I — Septic Tank (locate on site plan): 16" _ Depth below grade: feet 1 Material of construction: i i ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i i - I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 10.5' long x 5.8'wide- 1500 gal_ Dimensions: 3" Sludge depth: i l5ins•09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page19 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bursley Path _ — I Property Address Charles & Karen Paradis — Owner Owner's Name information is required for West Barnstable MA 02668 December 10, 2010 - every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) 29 Distance from top of sludge to bottom of outlet tee or baffle — Trace i Scum thickness — 6" Distance from'top of scum to top of outlet tee or baffle — 14" Distance from bottom of scum to bottom of outlet tee or baffle — Measured How were dimensions determined? — i Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom ofoutlet invert and tees were intact and clear. Tank is not in need',of pumping at this time. — i III - j i i Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(expllalin): Dimensions: j Scum thickness m Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I i i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i w 70 Bursley Path i — Property Address Charles & Karen Paradis Owner Owner's Name information is required for West Barnstable MA 02668 December 10, 2010 I every page. Cityrrown 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.): I I i i Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: — Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): i Dimensions: ! — Capacity: gallons I _ Design Flow: gallons per day Alarm present: ❑ Yes ❑ No I Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date i Comments (condition of alarm and float switches, etc.): j I I i ` *Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No I I i i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 I I • I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments <wM 70 Bursley Path Property Address Charles& Karen Paradis Owner Owner's Name information is required for West Barnstable MA 02668 December 10, 2010 every page. City/Town State Zip Code Date of Inspection i 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.): No solids carryover or high stains. Liquid level was at bottom of both outlet lines. I I - Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No i Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i I i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Bursley Path Property Address I Charles& Karen Paradis Owner Owner's Name information is required for West Barnstable MA 02668 December 10, 2010 - every page. CityFrown State Zip Code Date of Inspection — D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: j ❑ leaching galleries number: ® leaching trenches number, length: Two 40'trenches. ❑ leaching fields number, dimensions: ❑ overflow cesspool number: I ❑ 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.): Leachng system showed no signs of saturation or surcharge, area of SAS was probed with no signs of hydraulic failure found. I I it i 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 i Depth of scum'layer i — i Dimensions of cesspool — Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No j l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1I3 of 17 I l Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i wM 70 Bursley Path Property Address Charles & Karen Paradis Owner Owner's Name i information is required for West Barnstable MA 02668 December 10, 2010 every page. CitylTown 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.): t I Privy (locate on site plan): ! Materials of construction: I Dimensions Depth of solids ! — Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i I I i i i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 114 of 17 ! I ! i Commonwealth of Massachusetts Ti`tIe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments i wM 70 Burstey Path Property Address Charles& Karen P_ aradis Owner Owner's Name information is West Barnstable MA 02668 December 10, 2010 required for — -- ------- every page. City1rown 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 feast two reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: i ❑ hand-sketch in the area below ❑ drawing attached separately I� i Two 40' trenches. i I 49 67 h r 21 Q ♦ ♦ \ \ \ \ \ ♦ \ \ \ \ •.r\ V . I • ih I I II Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I �M 70 Bursley Path Property Address Charles & Karen Paradis Owner Owner's Name information is required for West Barnstable MA 02668 December 10, 2010 i every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: i ® Check Slope ® Surface water r I i ® Check cellar ® Shallow wells 30+ i Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: i ❑ Obtained from system design plans on record i i If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) I I ❑ Checked with local Board of Health -explain: I I ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database -explain: USGS topo map. i You must describe how you established the high ground water elevation: Low point of abutting property with no surface water is considerably lower than SAS. Design plan! shows perc test findings with no water at 180". I i i I I I Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page!16 of 17 i r h<L Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 70 Bursley Path Property Address Charles& Karen Paradis Owner Owner's Name information is required for West Barnstable MA 02668 December 10, 2010 every page. Cityfrown 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 I ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i . . i i t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 117 of 17 610 TOWN OF BARNSTABLE Mr Y?a J ri 3vo,s u►e #� OFFICE OF DAAIflTADL i BOARD OF HEALTH -- � rise. 367 MAIN STREET HYANNIS,MASS.02601 y: March 31, 1995 Nr, dal 1rd. M, ue—s Dear Ml^. ►2o d�r'I 9 u e5 The new 1995 Title V Regulations are in effect today, with the exception of the provisions specified (i.e. 310 CMR 15.100(2)will become effective July 1, 1995). Please see the attached cover page of Title V and 310 CMR 15.005 (2) D-ansition Rules. We are accepting your application for a disposal works construction permit merely as a courtesy. In the unlikely event that it turns out that the effective date is tomorrow, we will have a record of your submission. In the more likely event that your application is not protected, it must comply with the new Title V Regulations. Sincerely, Thomas A. McKean, C.H.O. Health Agent of the TOWN OF BARNSTABLE BOARD OF HEALTH i 1 I, 1 ,r Barnstable C ournt:v Heal. th and Environmental Laboratory Superior Coui-t. House , Route 6A P.O. Box 427 Barnstable , MA 02630 (509) 362-2511 ext . 337 Volatile Organic Analysis Analytical Method : 502.2 Collection Date: 03/16/95 Date Received: 03/16/95 Analysis Date: 03/22/95 Client: EDWARD RODRIGUES Mailing EDWARD RODRIGUES Sample Location: LOT 33 Address : 9 HILLSIDE ROAD BURSLEY PATH FORESTDALE MA 02644 WEST BARNSTABLE Sample TD: 699602 Laboratory Ill: 699602 Sample Description: PRIVATE WELL Compound Amount Detected (ug/L) Detection Limit (ug/I,) Benzene BDL 0.5 Bromobenzene BDL 0. 5" BromochIoromethane BDI 0. 5 Bromodichloromethane BDL 0:5' Bromoform BDL 015 Bromomethane BDL 0. 5 -. n-Butyl.benzene BDL 0.5 sec-Butvlbenzene BDL 0. 5 t:ert-Butylbenzene BDL 0. 5 Carbon tetrachloride BDL 0.5 Chlorobenzene BDL 0.5 Chloroethane BDL 0. 5 Chloroform 2.9 0.5 Chloromethane BDL 0.5 2-Chlorotoluene BDL 0.5 4-Chl.orotoluene BDL 0.5 Dibromochloromethane BDL 0.5 1 , 2-Dibromo-3-chloropropane BDL 0. 5 1 , 2-Dibromoethane BDL 0.5 Dibromomethane BDL 0. 5 1 , 2-Dichlorobenzene BDL 0.5° 1 , 3-Dichlor.obenzene BDL 0. 5 I. , 4-Di:chloro.benzene BDL 0. 5 . _ Dichlor.odifluoromethane BDL, 0. 5 A J-Dichloroethane BDL 0.5 1' 2-Di-chloroethane BDL 0.5 1 ,1- Dichloroethene BDL 0.5 cis=1 ,2-DichloroeY,hene BDL 0. 5 trans--1 27Dichloroetbene BDL 0. 5 -1 ,2-Dichloropropane BDL 0. 5 1 , 3-Dichloropropane BDL 0. 5 2 , 2-Dichloropropane BDL 0. 5 1 , 1-Dichloropropene BDL 0.5 cis-1 , 3-Dichloropropene BDL 0. 5 trans-1 , 3-Dichloropropene BDL 0. 5 Ethylbenzene BDL 0 . 5 Hexachlorobutadiene -~BDL .. 0. 5 Isopropylbenzene BDL 0. 5 4-Isopropyltoluene BDL 0. 5 BDIj: Below Detection Limi t: i fr page 2 Sample ID: 699602 Laboratory ID: 699602 Compound Amount: Detected (ug/L) Detection Limit (ug/L.) Methvlene chloride BDL 0. 5 Naphthalene BDL 0. 5 Propylbenzene BDL `10. 5 Styrene BDL 0.5 1 , 1 , 1 , 2-Tetrachloroethane BDLr''0 `5 1 , 1 , 2 , 2-Tetrachloroethane BDL 0 5. Tetrachloroethene BDI_j ,kk` r 0 5 Toluene BDL0. 5 ' 1 , 2 , 3-Trichlorobenzene BDL _ 1 , 2 , 4-Tr.ichlorobenzene BDL 3 0:5: 1 , I. , 1-T.r. i.chlor.oethane BDL 0. 51 1 , 1 , 2-Trichloroethane BDL 0.5 Trichloroethene BDL 0. 5 '-� r - Tr. i.chlor.ofluoromethane BDL M 1 , 2 , 3-Tr. :ichl.oropropane BDL 0. 5 1 , 2 , 4-Trimethyl.benzene BDL 0.5 1 , 3, 5-Trimethylbenzene BDL 0.5 '• Vinyl chloride BDL 0. 5 Total Xylenes BDL 0.5 y4 o" . ;t BDL: Below Detection Limit q i ' homas F. Bourne, Laboratory Director r' yl.illl-L I,`)`I(,I) ! < r • 4 I +'ri BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT 0 Y SUPERIOR COURT HOUSE ` V BARNSTABLE, MASSACHUSETTS 02630 �aq9 A- Y •7A'S5 PHONE:362.2511 LAB 337 - s,i Rc_,T)RTC T11,f; , EDWARD t c 1.ur: THOMAS BOURNE M:l i l i llc.) 91IT 1,f,;; ID>; .RD Affiliation :► COUNTYL�\T3 At]r]I'r�s�; : FORP,f;T1)AI.,I MA 0;64 1 `Pyre of Supply: W Te.l eI:dlolle : We 11- • Dept:li: 70 ET "�Inllt 1 r, 1,(Wil I i r,ll : I1TIR,;1,FY 1)ATiI Da t_e of C o.l ].sc t: i.uu : 03/16/91; rown : WI.;;T f�,\RNS;'fi\f31,C Da Le of Analysis : 03/16/95 (Lot 33) "Al SAMPLE=== ________________________________--___ . RESULT RECOMMENDED LTMTTS Total. C'o.Li.fot•III 13j.Ir.;t 1,1. ijj/100 mL 0 :T I,11 6 . 2 C,c,llclur. l. i i i I.v (III-i.r.L•omllos/c.Tn) 100 500 1.1 oil (ppill) < 0. 1 0. 3 Nit.r-a1-.e-Nitr.oclell (pV)nl) < 0 .1 .10. 0 `Sodium (pplll) .14 20 .0 I.'r�l�l)?L (l,litll) 1 . 3 P,. "Fr) II'" 1-11G \`;.\T,'�'!;(`; I'!,!:POT?'IT 1), THE FOLT.,OWINC ADVISORIES, ARE GIVEN : ttt<Il.r;t. Inll:it' Inr i t :, 1.{It 1'c`c:uhl"WIILk-d lillliLs for drinkim:1 wall-er t)dl.'i.11nc'Luus P lac+ �£'a# . . • 1lluln<I.=_; F. Bourne_ , LabOratury. D!rector 9 A4 S}? i i • I 30 2'- �8•.E 17 O• o o i to � � � 14DMM�cN�P1r �TG� t (Jo I I 58 AN K- M too, 44 .a 4 B.2ooa+ N Io P2o P. to pp }•� �vea�H. BURS L C Y pAI 93. 3 w P. 1 OLDIIA1:1 ` �NO.232Q SH OFWITAXAM \ 9 c�aQHw AL `� No._..................... Fitz_..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �otHe pooNo ti»- Sd.17 Appliratinn for Disposal Works Tonstrurtinn jrrmi# Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal �* System at: p .....L�'1:.3�_.._.5,air.S..tpe . ---T-4TA-----__--!!CNT.P.MR 'T,, _............... 3��....__ ....._............_.... Lo atl.Address or Lot No. _....�af.,�r.arch_..._.t'I......f�Q�(t..e�r.�c e.�.....-------•--....----_... ... l.�S:ide.....,�aa.�.. own Address a Cli f laltl...__..lZ�t_�K.z� E G��uc�f�ticl................. ............./�:AR.!!�!f_C.t{.. M_!4_......... gN��it�!..../a�NN..RQAD Installer J I Address Type of Building Size Lot...................._......Sq. feet Dwelling—No. of Bedrooms...............y...._........_.............Expansion Attic Garbage Grinder (r) aOther—Type of Building-_(!AA._QAA&9 No, of persons............................ Showers (fit — Cafeteria ( ) a d Other fixtures ................------------------------..---------...----------------.._...------------------..-•--••---....-----__--------.._---.........._.__ W Design Flow................................_...........gallons per person per day. Total,daily flow............................................gallons. Ix Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No..................... Width.................... Total Length Total leaching area..:.............sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.......-._-- _._sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation .Test Results Performed by.......................................................................... Dat 11 --r -•••. a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to water............. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to nd a w to ..... •-••--••••--.................. •--••--------------------•-..... ... . ........._�_,� O Description of Soil 93., I-- M) .— fie .�......_�._..... �✓...... ................. .: �9�6 W ........................!._._.___._-____--__----•-•_--•-_--•___-_----•-•••-_--_-•---_-•_-•-_-•-_--....................................-_............ ___ ____..... ______— FT+1 U Nature of Repairs or Alterations—Answer when applicable............................................. T. ........... 1�- _-___-__-� --•--------••---------------•..................................-................................................................................_........ Yth Agreement: 8The undersigned agrees to install the aforedescribed Individual Sewage Disposal Syste e9 c the provisions of TITLE 5 of the State Environmental Cod —The undersigned further agrees no o p ace the system in operation until a Certificate of ComV' 77 d by t rd of health. Signed ..- 1..... ............................... �° .�, ... b Dam Application Approved B - pP PP Y ..... .......••••-•--�........ Application Disapproved for the following reasons- ...............-....................................................................................................1.................. ................-..................................................-.......................................................................................................................................... ------......----��......-----...... PermitNo- ----- ----------------------.........................----------- Issued .....------....._..----------......-•----..._............---•------- Dam THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ger#ifirate of Qlamplittnre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by-------•----------------------------------------------------•------..........------.....-.------........----------- ..... •---------........----------..........--------•---••------•-•-----•---•--•--•---••...........------..................... Insceller ..........................'.................................................................................................... ..................................... ..-.................... ....... .... ....—has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ................................................ dated .................._............................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......i........--------.............................................................................. Inspector :........................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN'OF BARNSTABLE No..............:........•• .FEE........................ nk Disposal tk kf�aan ri lx '. Permissionis hereby granted....................•-• •---.....:......_.... ......... ..................... ..............................................._.... to Construct ( ) or Repair '( ) an Individual Sewage Disposal System atNo............................................................._...........---.._...... .. as shown on the application for Disposal Works Construction;Permit No .... Dated.......................................... ................. ..:...................... ....------ ......IL----------------- Board of Health DATE. _ > ..s FORM 36506 HOBBS d WARRP-M.INC.cPURUSHERB� .•/l �` 4 •r` YOU WISH TO OPEN A BUSINESS? For Your Information: Business Certificates cost $40.00 for 4 years. A Business Certificate ONLY REGISTERS YOUR NAME in the Town (WHICH YOU MUST DO according to M.G.L. - it does not give you permission to operate). You must first obtain the necessary signatures on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st Fl., 367 Main St., Hyannis, MA 02601(Town Hall) and get the Business Certificate that is required by law. DATE Fill in please: APPLICANT'S YOUR NAME/CORPORATE NAME BUSINESS YOUR HOME ADDRESS: TELEPHONE # Home Telephone Number NAME OF NEW BUSINESS EIN: Have you been given approval from the building division? YES NO ADDRESS OF BUSINESS 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 This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature" COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature COMMENTS: r _ Bottle Number: 699601 Date: 03/28/95 a. O� BA��J� - BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE O ' V BARNSTABLE, MASSACHUSETTS 02630 • • �1A Se' PHONE:362-2511 LAB 337 Client: RODRIGUES , EDWARD Collector: THOMAS BOURNE Mailing 9 HILLSIDE RD Affiliation: COUNTY LAB Address : FORESTDALE MA 02644 Type of Supply: W Telephone: Well Depth: 70 FT Sample Location: BURSLEY PATH Date of Collection: 03/16/95 Town: WEST BARNSTABLE Date of Analysis : 03/16/95 (Lot 33) PARAMETER SAMPLE RESULT RECOMMENDED LIMITS Total Coliform Bacteria/100 mL 0 0 pH 6 . 2 Conductivity (micromhos/cm) 100 500 Iron (ppm) < 0 .1 0 . 3 Nitrate-Nitrogen (ppm) < 0 .1 10 . 0 Sodium (ppm) 14 2-0 . 0 Copper (ppm) < 0 . 1 1 . 3 BASED ON THE ANALYSES PERFORMED, THE FOLLOWING ADVISORIES ARE GIVEN: * Water sample meets the recommended limits for drinking water of all above tested parameters . Thomas F. Bourne, Laboratory Director ell Barnstable County Health and Environmental Laboratory Superior Court House, Route 6A P.U. Box 427 Barnstable, MA 02630 (508) 362-2511 ext. 337 Volatile Organic Analysis Analytical Method: 502.2 Collection Date: 03/16/95 Date Received: 03/16/95 Analysis Date: 03/22/95 Client: EDWARD RODRIGUES Mailing EDWARD RODRIGUES Sample Location: LOT 33 Address: 9 HILLSIDE ROAD BURSLEY PATH FORESTDALE MA 02644 WEST BARNSTABLE Sample ID: 699602 Laboratory ID: 699602 Sample Description: PRIVATE WELL Compound Amount Detected (ug/L) Detection Limit (ug/L) Benzene BDL 0. 5 Bromobenzene BDL 0 . 5 Bromochloromethane BDL 0. 5 Bromodichloromethane BDL 0 . 5 Bromoform BDL 0 . 5 Bromomethane BDL 0. 5 n-Butvlbenzene BDL 0. 5 sec-Butvlbenzene BDL 0 . 5 tert-Butvlbenzene BDL 0. 5 Carbon tetrachloride BDL 0 . 5 Chlorobenzene BDL 0. 5 Chloroethane BDL 0 . 5 Chloroform 2 . 9 0. 5 Chloromethane BDL 0 . 5 2-Chlorotoluene BDL 0. 5 4-Chlorotoluene BDL 0 . 5 Dibromochloromethane BDL 0. 5 1 , 2-Dibromo-3-chloropropane BDL 0 . 5 1 , 2-Dibromoethane BDL 0. 5 Dibromomethane BDL 0 . 5 1 , 2-Dichlorobenzene BDL 0 . 5 1 , 3-Dichlorobenzene BDL 0. 5 1 , 4-Dichlorobenzene BDL 0. 5 Dichlorodifluoromethane BDL 0 . 5 1 , 1-Dichloroethane BDL 0 . 5 1 , 2-Dichloroethane BDL 0 . 5 1 , 1-Dichloroethene BDL 0 . 5 cis-1 , 2-Dichloroethene BDL 0 . 5 trans-1 , 2-Dichloroethene BDL 0. 5 1 , 2-Dichloropropane BDL 0 . 5 1 , 3-Dichloropropane BDL 0. 5 2 , 2-Dichloropropane BDL 0 . 5 1 , 1-Dichloropropene BDL 0. 5 cis-1 , 3-Dichloropropene BDL 0 . 5 trans-1 , 3-Dichloropropene BDL 0. 5 Ethylbenzene BDL 0 . 5 Hexachlorobutadiene BDL 0. 5 Isopropylbenzene BDL 0 . 5 4-Isopropyltoluene BDL 0 . 5 BDL: Below Detection Limit page 2 Sample ID: 699602 Laboratory ID: 699602 Compound Amount Detected (ug/L) Detection Limit (ug/L) Methvlene chloride BDL 0. 5 Naphthalene BDL 0 . 5 Propylbenzene BDL 0 . 5 Stvrene BDL 0 . 5 1 , 1 , 1 , 2-Tetrachloroethane BDL 0 . 5 1 , 1 , 2 , 2-Tetrachloroethane BDL 0 . 5 Tetrachloroethene BDL 0. 5 Toluene BDL 0 . 5 1 , 2 , 3-Trichlorobenzene BDL 0. 5 1 , 2 , 4-Trichlorobenzene BDL 0 . 5 1 , 1 , 1-Trichloroethane BDL 0. 5 1 ,1 , 2-Trichloroethane BDL 0 . 5 Trichloroethene BDL 0. 5 Trichlorofluoromethane BDL 0 . 5 1 , 2 , 3-Trichloropropane BDL 0. 5 1 , 2 , 4-Trimethylbenzene BDL 0 . 5 1 , 3, 5-Trimethylbenzene BDL 0 . 5 Vinyl chloride BDL 0 . 5 Total Xvlenes BDL 0 . 5 BDL: Below Detection Limit Thomas F. Bourne, Laboratory Director i 10 No =-� --- Fee-----�`5------- BOARD OF HEALTH TOWN OF BARNSTABLE ZppCicat ion-for Well Congtruction3permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: jcation Address — Assessors Map and Parcel— -- Owner Address -45 _ ��� t� �'��E _/__----------------- 3. '/3 ,�- .ca�.v Installer — Driller Address Type of Building Dwelling---------------------------------------------------------------- Other - Type of Building--------------,---------------- No. of Persons-------------------------------------------- Type of Well— - ------—- -- ----____ Capacity-------------------- Purpose of Well-------------------------------------------- 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. Signed date Application Approved By �- ---------- ---- — -� -g --- date Application Disapproved for the following reasons:------------------------------------------------------------------- - -- -- --------------------------------- date Permit No. ---— - — —--- Issued--- -- -- - - --- --- — -------------- date BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of (Compliance THIS IS TO CERTIFY, Th the Individual L Well Constructed ( ), Altered ( ), or Repaired by ------------ - - — — — ----- �p flnstaller �i 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 W-1,57:-3----Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WiILL FUNCTION SATISFACTORY. DATE —-- __—_—— —-- ---- Inspector---------------------------------------— - - ----------- �.�.y'r�'�:T-.rl.rri'••"�,{L•�.,.ry.u�.,r`l/-�'+-?CM."�^''}�^'�..•.y-y^'W..i•"tjr•-.ati�..��..�}a�'��'`.C"�"vY�-a"�4+Yi..'7i�'yr4'f+T:1Ci���'�«.,r+�'s',„�•..n +il. d �-0 --,W - I ----_ -_5------_ No.�r-�-�---�1�--- Fee � � BOARD OF HEALTH TOWN OF BARNSTABLEr, Ztpplication Ar Vell Construction Permit Application is hereby made for a permit to Construct ( ), Alter ( ), or Repair ( )an individual Well at: -- ► v1f\ t.* y— 4t —— — --------- — ---—-----------—-- Location Address Assessors Map and Parcel / Owner Address f' f x ___ Installer — Driller Address Type of Building Dwelling------------------------------------------------------------- Other - Type of Building-------------------------------- No. of Persons---------------------------------------------- Type of Well- - ----------- Capacity -------------- - ---- - -—— Purposeof Well--------------------------------------------------------- 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. Signed {`t �.. s��✓+r �r%! __�_------- - ----��-- =-- .. --- --------- date Application Approved By --2- ---- ----- date Application Disapproved for the following reasons:----------------------------------------------------------------—----- ------------- --=- —-- --------- ----------------------------------------------------------- date Permit No. ------- --- Issued--- -- - - - — -- — - ---------- date BOARD OF HEALTH :TOWN. OF ;B,ARNSTABLE. _ Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired Installer at- - r9 -- ---- dr1 ''— "> 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 NoW-25�---_1-3----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 l TOWN OF BARNSTABLE Veil Conoruct ion Permit w °s- _1�' No. -- Fee--2�---- Permission is hereby granted- ----------- to Construct (X Alter ( ), or Repairff''(�� ��) an Individual ell No. — — -- �—" -- ——1 Stre ------------ V/ L_ / �`-%ne as shown on the application for a Well Construction Permit No. ----------1 - Dated---- - r-d-- ----------------------------------- ------------ ------------------------ _.. { C� Board of Health DATE---- - -=-L - L —---— -- 553R 42: 2,8 r a ►sr• -pest Pr-r I � ` L• cry � 1—iZESE4� N 0� roIf ► ' I I i I".s6oGpL.CO/tic. (� I I 5EPTi c TA/tlt N / \ / � �•�PoSED O O - / N Z`• t 4o us F- j s,q 9s•o 44' i a !. `Q ¢��N OF AlgSs�c ,�FN5H OF h.y8u / o= WALTER yN 2 WILL!AM F. °y 'P. m. o MO ANOLAM N 9L N v No.23207 ti o CIVIL y — 9g m w v 9No.i38990 Z; I 'sumj �G,sAeP �Q AL { 1 ECK f• � � �� �,Jl�J�- �j� [f i Iulzn�.J. 2-49o•7J �,L- 58 i S46o e^se, NI I E-y PA ?' t_-Jg.00 R 3i 2.68 BARN5TABLE , MA DISPOSAL PLAN SAt Jew tC- 1-I , M W.P.OLDHAM ASSOC. SANDWICH,, MA. 40 0 40 80 SCALE 1"=4� (-&-1995 1"=40' 12 scale feet 9MET / G P 2 t �S.p /- F�a• GQADC 9 3�0 F..r• a 93x o /.1. C�ftAnE -Z�e sLoPf` 9 3x D 90.5 I H� F,�L �z f�f�r• 2'' %6=y2wtsl+.d 15 o O 2'o i D 13T• W Box (�� SEPTIC f L_ f�pwe r 4 DiwH. pvc. Ppr TA.r►trc 90 ,4 (/� � � • 35 'r'�/QICAL (tiliif�►6�AT�aJ 40 0 (p l PRo;rtLt o� Di bs4.L. S�ST�M Go"�^a - L'cAG44 i-4 CZ -r S-"-j c 11 i 92• o 0 General Notes: 10 ►Z Disposal system designed in accordance with the provisions of Title 5 of the Massachusetts Environmental Code and 5/�►.1D BoTT. 72'I local Board of Health Regulations. 8 6.O F�tzc. All pipe and fittings to be Schedule 40 g3,p l 08 or better. �,{ ED/U" During installation distribution box is to SAN be water tested to insure that it is level. D Six inches of crushed stone is to be placed beneath the septic tank and 4i3� box The first two feet of pipe out of the distribution box are to be level. 77.o I8o THe installation shall be certified by the tJ o C Po ►i D Vi 4t 2 Designer and submited to the local B.O.H. � So1L ST>:.ATA ose - vjo 4ox4 x z: �a ,ny Trc„c Percolation Test. Date Percolation Test Rate G min/inch drop Soil Type Class ]: Factor 0 .74- q- Bedrooms X110 G.P.D.= 440G.P.D. Required 44-OG.P.D. X200 = 1500 Gallon Septic Tank Required No garbage disposal 'to be installed. 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