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0040 MAGGIE LANE - Health
40 Maggie",Lane W..Barnstable A. 217. W2 a Health Department Drop-Off Hours: 8:00 AM - 4:30 P.M Town of Barnstable Received by Health_ .• oFI"E'O�ti Regulatory Services Department on Richard V.Scali,Director , ,,� Public Health Division D""prs Thomas McKean,Director �f 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE Property Address: LVL- Assessor's Map/Parcel Number: 2` - 140 Applicant(s) Name: &1VA.-VA ' Ooecco— by'" Phone: PLL90 ` MSD E-Mail: Size of Lot: V • ��I'�S 2a. How many bedrooms exist at your property now? 2b. How many bedroom are you planning to add as part of the Accessory Affordable Apartment Program application? _ 2c. How many bedrooms total are proposed at this property(including the Accessory unit)? 2e. Is the proposed Accessory Apartment contained within: . the main house; OR a detached,structure 2f. Submit floor plans for all buildings on the entire property. Show all existing rooms in the dwelling and the proposed accessory apartment. Label each room clearly. Label measured width of all open doorways. Use straight edge for hand drawn plans and be sure all labeling is legible. i n Signed: I Date: Nis- - 1 ` . n y ACCESSORY AFFORDABLE APARTMENT SEPTIC QUESTIONNAIRE FOR STAFF USE ONLY 1. Is the dwelling connected to Town sewer? ❑ Yes �No s 2. Dwelling located ❑ INSIDE P OUTSIDE the Saltwater Estuary Protection Zone 3. Dwelling located ❑ INSIDE [YOUTSIDE public supply well Zone of Contribution 4. Dwelling is connected to ❑ ON-SITE WELL N PUBLIC WATER. 5. Disposal works construction permit on file? 3-'Yes ❑ No 6. If yes, how many bedrooms were allowed by this permit: bedrooms 7. Were building permits obtained for additional bedrooms?. ❑ Yes ❑ No 8. Engineered septic'system plan: a. On file at the Health Division? Ef"YeS. ❑ No b. If"proposed accessory unit is detached from principal dwelling, is that plan on file? ❑ Yes ❑ No 9. Existing septic system capacity is bedrooms For the accessory unit to receive approval from the Health Department the following action must occur: 94iii-s-t�ing system accommodates proposed additional bedroom(s) ❑ Upgrade existing system to.accommodate additional bedroom(s) ❑ Must remove a bedroom from the main house ❑ Must connect detached structure to the existing septic system ❑ Must install septic system for the detached structure. ❑ Other Signed Date i 2 «---------------------------46—�����������������������������j Deck 1 � 3 0' 46' i Bedroom Bath Dining Room Kitchen N Garage ry Bedroom Bedroom living Room 3 0' 46' 30` �- Commonwealth of Massachusetts QCia ; P. ot.tVawry asp . JR �O 40 Maggie In Ptopedy Address Vim +Grossman Omer OwneftNam is W-Bwnslable MA 02668 3-24-14 required for every, page. state zip Code to of hf CWTOW ki%pecWn resufts must be s on NO fi"M:Wspecdon f rrns no not be . any Way. : ee COMPWAne�ss., emsd of tt,e form. 'mph`"" 'W forms A. General Information on the,comprder, I L� use o*tie tag 1. IrWpeCWr (/ keyto won Voiff ausor-do rat. . Mdiael Duo use the retam Nam of ftwspecW key. NEIGHBORHOOD WASTE WATER SERVICES any Name 350 MAIN STREET ComparW Address . W.YARMOUTH MA 02673 stdo Zip Code CWrown 508-7.76-2820 S113522 TdWwm:Nwdm $ , cation 1 that I have psoniy_u�specled ftoft 4 ,rd:below is, d based on my baeuf�,q.._ ie tE a e systems.)am a pEP Tie 5(310 CfiAR 15- tj.The system: passes GIIy>Passes Q Nee&Fug E :bh to Local Ate: 8 to ity T s inspector.shall submit a cat of thts _ he uftd . Bqwd of Ham+or DEP)�.: of •if s etn s ha$.a design of 10000 I or s� �' �t;to.#e.burr, , tie a e o#ase all l �'l ffz T�5 otT�akas ;FomK Sq�s+araee t '�1 of 17. t5ft-W13 1 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assess 40 MaMie In Kim Bamocky Grossman Owner Owner's Name information is W Barnstable MA 02668 3-24-14 required for every paw. City/Town Sti36e Zip Code e of In on B. cerdfiication (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: The system consists of a one 1500 gallon concrete septic tank.An ejector pump from a one bedroom above garage apt a concrete distribution box and 4 500 Gallon dry wells. The system is working properly and the ejector pump is operational and in good working order.] recommend pumping at this time and have advised the home owner. 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 exfiitration 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 N a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): The system consists of a one 1500 gallon concrete septic tank.An ejector pump from a one bedroom above garage apt a concrete distribution box and 4 500 Gallon dry wells.The system is working properly and the ejector pump is operational and in good working order.] recommend pumping at this time and have wised the home owner. TNe 5 official VMpecbm r-am:&bufaoe sewage Disposal system•Pegs 2 of 17 ftw•31t3 I Commonwealth of Massachusetts Title 5. Official Inspection Form Subsurface Sew>a", d System.Form-.Not for Voluntary Assessments 40 Maggie In - PropertyAddress Kim Bamocky Grossman Owner Owner's Name inonnation is Barnstable MA 02668 3.24-14 required for myRown State Zip Code Date of inspection page- B. Certification (cont.) Q Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumpsialarms are repaired. B) System Conditionally Passim(cons): ❑ 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 consists of a one 1500 gallon concrete septic tank.An ejector pump from a one bedroom above garage apt a concrete distribution box and 4 500 Gallon dry wells. The system is working properly and the ejector pump is operational and in good working order:i recommend pumping at this time and have advised the home owner. ❑ The system required pumping more#=,4 times a.year due to..br'okon or o.bstcu0ed.pipe(s)..The system will pass inspection,if(with approval of the Board of Healtii} ❑ 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.evakatim by ft.> .of Health in order to determine if the system is fatting to profit public head,safety or:the environment i. System-will pass.. unless-Board of c ih WOOD".with 3'� . 15.MX.l)(b),*A.tho systm is..notiu ;ina' +; # :@n , ow the ear ❑. Cesspool or privy s Within 50 feet of a surface wales ❑ privy wetland or a salt marsh I or is within 50 feet of a bordering vegetated Toe 5Otti W topecIM Fwm&O Iftm S.0410890 System-Pap 3 of 17 t5ins•313 Commonwealth of Massachusetts Title 5 official Inspection Form Sl bswftce Sewage.D*4x sal System Form-Not for Voluntary Assessmepts Q Maggle In Pmp"Addom Kon Bamoc�y Conan Owner OwnWs.Nam information is MA 02668 3-24-14 required for every BarnshiNe page. cayfrown State Zip Code Date of Inspection B. Certification (cont.) 2.: SyStm"fail unless.the Board of Health(and Pubfic-Wat"L Super,.if any) determines fat the system is funclioning in a numm *9 pWft heakh, safety and�vinonmer ❑ The system has a septic tank and soil absorption system(SAS)and.thwSAS 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.paases.0 ft well srater.analysls,p at a W. 9eMfW Oboratory,for fecal ao m bacteria:. dirates at t and ft presence.of arnrt .ar and r e>n trogen.is,equal to or less.tiian 5 ppm,prrnrided no other faliure Critieria are trigs A copy of the analysis must be attached to this form. i 3. Other The system corwists of a one 1500 go llon.concrete seoctank.An a cue above;garage apt.a concrete. ice€aid 4 500 dry properly and the ejector pump and in atis tote i<have,advised the:home:o r.. D) Failure Cci ft,Ap icat .$0 Ag. : YOU n, ,.kKftde"Yes" "; or O et* . .lam" Yes No to Backup of sewer tnto UPillty or"St'ern cP t' toor �: DW*mp or l Vie: ref t se tcaan8ttr Sty ainv ,an o 0 orckgoad. in 0 s°: : Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form.Not for Voluntary Assessments 40 Maggie In Property Address Kim Bamocky Grossman Owner Owners Name require fb � W Bam�ble AAA 02668 3-24-14 required for every Pa". CityrroMn state Zip Code Date of Iron 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 wafter 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 faa�i.with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.i have determined that one or more of the above failure criteria exist as described in 310 CHAR 15.303,thefefore.the system fails. The system owner should contact the Board of Heafth to determine what will be necessary to correct the failure. E). Large Systems: To be considered a 16i6 system the system roust save a facilftsr with,.a design flag of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of.#*following,in addition to the questions in Section D. Yes No ❑ ❑ the system iswithin 4QQ feet of a surFac:e drinking water supply i .... ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ El Area system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA).or a mapped Zone 11 of a public water supply well If you have answered"yes°to any question in Section.E the system-is considered,a significant threat, yes 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 water Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should, contact the appropriate t5ins•3113 Title s o�t Fo m: sa, W system•Page 5 a 17 Commonwealth of Massachusetts Witte 5 Official inspection Farm SWIS ruse W i3isP©sai m Form:-Not for Voluntary Assessments 40 Maggie In Property Address Kim Bamocky Grossman Owner ownees Name information is AAA 02668 1.24-14 required for every W Sam stable ��� Zip Code re Of i page- 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 partof ❑ ® this Win? ® Were as built plans of the system obtained acrid examined?(if ttty were not available note as N/A) ® ❑ Was the facility or dwelling inspected for sWA of sewage beck up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, locaW QAAW ® ❑ Were the septic tank mw t les.uncovered,opered,..aro the inteft ofthel tarn irk for the condi Of the bates or tees, of uctlon, djrper=mj del4h,$jh of n Was�.fa l ovary(aI�lf_ '). :with, ❑ inibmutcm on the proper main ante Of subsurface disposal systems? The size :Of Ste:A )tut the sib has been based on: ® ❑ EAsftinformation.For exampi%a pla o#WSWO..of Hea0_ Determined in the feW(if any.of the failure cx tena odd to Port C.is at issue ❑ ❑ approximation of distance is unacceptable).13.10 CUR 15.342($)j D. System infOffnadon PASW*rvW Flow cow: 4 Number of bedrooms(design): 4 Nutter of b (awl) 440 DESIGN flow based on 310 CMR 15.203{far example;.110 gpd`x tk of ms); t5ft•3H3. Commonwealth of Massachusetts Tip 5 Official Inspection .Form subsurface.SewW Mposal ftsbm Foy-Not for Voluntary Assessments 40 Mie In I. AddreeS Kim Bammky Grossman Owner Owners Name inkrmati0n is W AAA 02668 3-24-14 required for every Barnstable pne. CityRown state Zap code Efate of Inspection D. system Information Description: The system consists of a one 1.500 gallon concrete septic tank.An ejector pump from a one bedroom above garage apt a concrete distribution box and 4 500 Gallon dry weds.The.system is working properly and the ejector pump is operational and in good working order.t recommend pumping at this time and have advised the home owner. 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No is laundry on a separate sewage system?(include laundry system irtspt ctian ❑ Yes No information in this report.) ��y system ? Yes ❑ No Seasonal use? ❑ Yes ❑ No 1Y1r Water meter readings, if available.(last 2.yeais usage(gpd)): Detail: Well is 120 it from SAS Sump:pump? ❑ .Yea N No . last:date of ►: Fivar Type of.Establishment Design:flaw(based on 310 CHAR 1&203): ca per. it of.desk tbet(seatsipe sq t.Vic): Grime trap Pwarit? -:Ye : :. Industrial waste holding: rtk pit? :. ❑ Yes ❑ No ? Q Yes. Non san"wd ��e:Tme 5 aim: HOW t5ins•3113 Ttlls. SO�de6:ttaQel�iBt1€4� S9w�a f�0�k ►'Rage i:d l7 Commonwealth of Massachusetts Tide 5 Official Inspection Form Subswhme Sewage Dial System Form.-Not for voluntary Assessments 40 Made In Property Addrew Kim Bamocky Grossman Owner Owners Name information is MA 02668 3-2414 required for every W Barnstablecc4fro n State Zip Code Date of iupec Lion D. System Information (cunt.) Last date of occupancy/use: o�' Date Other(describe below): The system consists of a one ISW gallon concrete septic tank.An ejector pump from a one bedroom above garage apt.a concrete distribution box and 4 SW Gallon dry wells.The system is working properly and the ejector pump is operational and in good working order.) reccomend pumping at this time and have advised the home owner. General lnformatbon Pumping Records: Source of information: Not provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: .9auons How was quantity pumped defined? Reason for pumping: Hof : ® Septic tank,distribution box,soil absorptionsystern 0 Single o18111111pool . ❑ Overflow cesspool 0 Privy ❑ . Shared system(yes or no)(if yes,attach previous Inspection records, if any) ❑ Innovative/A{ternative tec;hnology.Attach a copy of the.wmentoperation and maintenance contract(to be obtained from system owner)and a copy of West inspection of the VA system by system operaftr under ❑ Tight tank.Attach a copy of the DER approval. ❑ Other O' .:. r •3l13 Tft5 OW4W WMpecEiW:Pam:& g S-A e Dkp)W System Page 8 of 17 Commonwealth of Massachusetts MUM Tithe 5 Official inspection Form Subsurface wage Disposal System Form-Not-for Voluntary Assessments 40 Maggie In Property Address Klan Bamocky Grossman owner owners Nw e infer is MA 02668 3 2414 required for every W Barnstable state Zip Code fie of Irwpet�on Page. City/Town D. System infolrmation (cono Approximate age of all components, date installed(if known)and source of information: 12 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 32,1 Depth below grade: feet Material of construction; ❑cast iron 40 PVC ❑other(explain); 120 Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage.,etc.):. The system consists of a one 1500 gallon concrete septic tank.An ejector pump from a one bedroom above garage apt a concrete distribution box and 4 500 Gallon dry web., The system is working. properly and the ejector pump is operational and in good working order t rernd pumping at this time and have advised the harm owner. Septic Tank(loco on site plan): 26" Depth below grade: feet Material of construction: concrete ❑metal ❑fibers ❑polyethylene ❑Ww(ems) The system consists of a one 1500 gallon concrete septic tank An ejector purrk:fr+om.a one bedroom above garage apt a concrete distribution box and 4 SW Gallon dry web.The system.+k working. Properly and the ejector pump is operational and in good working order.1 reoommebu Rum:at this tkm and have advised the home owner. If tank is metal, list age: YOM is age cant by a Cie of Corr?( a cx?py of cent ) 0 Yes Q No Dimensions: Sludge depth: •3na nee s M"a ►FO �s SWMP P & •Pages or 17 Commonwealth of Massachusetts Title 5 Official. Inspection Farm &*Surem SewW Mspas-d SrAM ftm-Not for Voluntary Assessments 40 Mamie In Kn Bamocky Grossman owner ownees Name Wdoffnadon is W gamble AAA 02668 3-24-14 required for every g Zip Code Date of Inspection page. CWTown D. System Information (cunt.) Septic Tank(cont) Distance from top of sludge to bottom of outlet flee or baffle 24 Scum thickness Distance from flop of scum to top of outlet tee or baffle 42" Distance from boom of scum to bottom of outlet tee or baffle 20 Hoar were dimensions detern*wd?. T am Comments(on pumping and outlet baftle.;condition,.structual integrity, liquid.Wvels as. kr outlet invert,a of leakage,etc.): The system vas of a one 1500 gallon concrete.septic tank.An ejector pump from.a one bedroom above garage apt a concrete distribution box and.4 500.Gallon dry :The system is working piny and the ejector pump is operational and in good working order l:reco uaend pumping at#his time..and have advised the home owner. Grease,Trap(locate on site plan): Depth.below grade: Mqftrial.of qp r on dons: SMM Diotance.fr Of,WJM ib#*Of r D e,frc >b cd s$ to bot �t :# Dal o.jast V: , , ,gTWO s � V Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface. i sysurn ftm-root for Vduntary Assessments 401VIlawleln. IGm Samocky Grossman owmer owners Name information is MA 02668 3-24-14 required for every WBamstabk St3te Zp.Code . Date of kapeefion Pap. ckyfrmn D. System Information (cxsno Comments(on pumping recommendations, inlet and outlet tee or baffle condition, stfuclural integrity, liquid levels as related to outlet invert,evince of leakage,etc.): The system consists of a one 1500 gallon concrete septic tank.An ejector pump frvm a one bedroom above garage apt.a concrete distribution box and 4 500 Gallon dry well.The system is working property and the ejector pump is operational and in.good working order.F recommend pumping at this time and have advised the home owner. Tight or Holding Tank.(tank must•bp:"_.ped;at time,of)nspection)(locate on site plan): Wth"below grade Material of construction: Q concrete metal ❑fiberglass ❑polyethylene other(explain): Dimensions: Capacity: gaRm Design Flow. s? ReC Athrm present Yes N Alarm level: Alarm.in waft oar: 0 Yes 0'.fO Date of last pumping: Oda Comments(condition of alarm and float_,etc.):.. •Attach copy of current pumping contrail(required). Is copy: d?'. 0 Yes . Q No. t5im 3M3 nw s avow,spec%ort Fomc Subadao9.Savage 0ispoael&,*w•PSge 11 of 17 Commonwealth of Massachusetts Title 5 Official lns.pectlon Form Subswbw Sewage Dlsposai System Form-Not for Voluntary Assessments 40 Maggle In Property Address rim Bamocky Grossman Owner Owner's Name information is MA 02668 3-24-14 required for every W Barnstable �Code page. CWTOW tie of trffipecion D. System Information (cunt.) Distributor Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Level and working property 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.): The system consists of a one 1500 gallon concrete septic tank.An ejector pump from a one bedroom above garage apt a concrete distribution box and 4 500 Gallon dry wells.The system is working properly and the ejector pump is operational and in good working order.l recommend pumping at this time and have advised the home owner. Pump.Chamber(kxate on site plan): Pturps workir>g o 0 Yes ❑ No* Alarms in working order: ❑ Yes ❑ Na* Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): The system consists of a one 1500 gallon concrete septic tank..An ejector pump from a one.bedroom above garage apt a concrete distribution box and 4 560 Gallon dry wed.The System is working properly and the ejector pump.is. �and in good wRorkrnQ oer! -t.recoqmend'.Fut at this time.and have advised the hcxrte owrter� *If pumps or alarms are not in working order,system is a conditional pass. Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: f •3PI3 Tile 5 O k"pW*M Farm:Subs wWop,Sewage Deposal Sysmm•Page 12 of 17 Commonwealth of Massachusetts Title. 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Maggie In Prouty redress Kn r Grossman Owner. owner's.Name inkimadon is W Barnstable MA 02668 3-24-14 required for every Ckyrrown State Zip Code Dane of Iran Pa". D. System Information (cons.) Type: ❑ wing pits number. ® leaching chambers number. 4 ❑ leaching galleries number: ❑ leaching trenches. number, length: leaching. nj mb dimensions: Q overw f '❑ inmwatiWalleff0the sum Type/name of technology: Comments'(note condition of soil,signs of hydraulic failure, level of pond ft damp.soil,condition of vegetation,etc.): The system consists of a.one 150 gallon a septic tank M.a �r a:bne above apt a concrete demon box anti d GaNmn dry The ► : properly.and.the ejector.pu+f*isopgratiortal:and in good. t es g at th . titre w4 tow advised the:horne owtrer. cesspools( must. purred as part .orb.Fes): Number and configuration 7.7 Depth top of timid to inlet invert Ell of sus layer Depth of scum layer, Dirrs of cesspool . 13d17 t5eis•3113. Tl94SOSx+ekQl eotlO�E61Ak QSSifM99BBi6F�eee1 ',p e Commonwealth of Massachusetts Title 5 :Official Inspection Form subsurface Sw~Disposal 4.940M Form Not for voluntary Assessments '0 Maggie In Kam Samodcy Grossman Owner oaa Ws Name inforrnatan is W Barnstable AAA 026M 3-24-14 required for every page. Chyrrown state Zip Code Date of hupecfion D. Sysi infORnatiOn (Corn.) Comments(note condition of soil, signs of hydraulic failure, level.of ponding,condition of vegetation, etc.): The system consists of a one 1500 gallon concrete septic tank.An for pump from a one bedroom above garage apt a concrete distribution box and 4 500 Gallon dry wells.The system is working, properly and the ejector pump is operational and in good wonting order.1 recommend pumping at this time and have advised the home owner. Privy plan): Materials of construction: : Dimensions Depth of solids Comments(note condition of.soil, signs of hydraulic failure,, levei of ponding,condition of vegetation, etc.) : t5kis•sn9 TW$OWW* MpeWon F_s O-fte epeggp -.Pop14 a 17 h TOWN OF:BARNSTABLE LOCATION. SEWAGE# ._2 VILLAGE -S ASSESSOR'S MAP&LOT�ZQ. 2 INSTALLER'S NAME.&PHONE NO;.— ' �� SEPTIC TANK CAPACITY. U j LEACHING FA.CU-=,: (type) NO:OF BEDROOMS Cl ri . BUILDER OR OWNER. fi C®— PERMITDATE: a COMPLIANCE DATE: 2 Separation Distance.Between:the: Maximum Adjusted Groundwater Table to the.Bottom-of Leaching Facility Feet Private Water Supply Well and.Leaching.Facility (If any wells exist on site or within 2000 feet of leaching facility) Feet Edge of Wetland and Leaching Facility.(If any wetlands exist within.300 feet of leaching facility.) Feet Furnished by - 3 =ss ' kp it Q .! Z i' , cK I t Commonwealth of Massachusetts Title 5 Official Ins ction .Form Sum Sewage Disposal System Form-Not for Voluntary Assessments 40 Maggie In PmpertyAd*m Kim Ba modcy Grossman owner Owner's Nwne wdomution is MA 02MB 3 24-14 mquhw for every She Zip Code 009 of rrgwdon pa". CftYfr"n D. System Information (eortit.) Skew Of She Disposal System: Provide a view of the sewage.dispc"system,including ties to at least two putt reference landmarks or benchmarks.Locate all web within 100 feet: locate where public water supply enters the building.Chedcone of the boxes below. ❑ hand-sketch in the area below drawing attached separately _ _ .i .. .. •. C! ... ^a� .. ...,. _.�.i: .a is. ,<. !';}:. C,-:..... .. :llr�. l�lAl?iSf�1(�. l.f: ...v:n:'it�i`�. ... .._ry.�.. �t;, .a•a 16tr��3113 TftB0-m"hSpedlus.Fogrc a r 16of17 Conmionw of No-a Phu low Tine 5 Official Inspection Form . .away.o�.t �-rat tiorvdunl�y� Offew �o make l� - in 1��1t4 PW D. ftM nt i111ml iatian (coat.) Skdch OF Seweps Dbpwd System:Provide a view of the sewepe d q=d sya®em,In*Wft Iles to d 19M two pwvrAMnt reference bn&m ks or bwwhn Acs.I=Me d web whhrn 4vo feet.L ocate v lie pMc water supply areers the bulking.Check one of the bootee below.. 6 hand*mwh lathe area bdow ❑ drawing aftch d separately A cko� D&,K ► o oa � p 0 . 5 tr 60 T � 6 3 3fj f� 33 ab.-s+e nraa��a.o�sa�a�.w.aw.o.ow.���i+w�saa Commonwealth of Massachusetts Title 5- Official Inspection Forfn Subswlwe Sewaga DOPoeal Form Not for voluntary Assessments 40 Maggie In Properhr Address iCm Bemocky{man Owner OMaters tam infO""at'on is AAA 02668. 3-24-14 required for every WWy�ns`table State zip trod® . t o �f lc�rt p�- D. System ift a#ion (coat.) Ske Exam: ® check slope surface water Check cellar ® Shallow wells 16+ft Estimated depth to high ground water. beet Please indicate all methods.used to determine the high ground water elevation: . . Obtained ftm system din;ph=on recordYMAM Ififiedoed,date of design plan reviewed: oDdee ❑ Observed site(abutting propertylobsQrvation 11 t164 within 150 feet.df SAS) ❑ Checked.with bcal.Boar of Health- : ❑ Checked with local excavator%it m-(after dome ) ❑ Accessed USGS.database-woain: You must describe how youestabbehed the him grc und.w : No ground water encountered at 16ft according to engineered plan dated 317/2002 Daniel,Elraman Civil Engineer . ,+. 15ft-3n9 . 0 s ONkiel gftpooef, y ':Fowl$of 17 S CommonweaNh of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage ,I,Sys ffe a :t ..W.Vomit Assessmwis 40 Maggie In ICm Bamocky Grossman Owner Owners Name information isMA 02668 3-24-14. required for every She Tjp code Ode d per- E. Report Com. pleteness Cteckiist ® Inspection Summary.A, B,C, D,or E checked 0 Inspection Summary D(System Failure Crikeria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater 0 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file tLlxs-srra: . re:aade� are z or.w r . Commonwealth of Massachusetts u u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Maggie In Property Address Kim Barnocky Grossman Owner Owner's Name information is required for every W Barnstable Ma 02688 3/24/14 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your rV' YJ 'cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 8 Johns path Company Address S Yarmouth MA 02664 Cityrrown State Zip Code 508-364-9587 S 113522 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 Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1::::::4�—V12/1/2014 _ 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. r� t5ins•3/13 Title 5 Official Inspection Form: u u ace Sewage Disposal Syst m•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Maggie In Property Address Kim Barnocky Grossman Owner Owner's Name information is required for every W Barnstable Ma 02688 3/24/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 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: The system contains a 1,500 gallon concrete septic tank. An ejector u p from a one bedroom apt. As well as a concrete Distribution box. All tees and baffles are In p ace. The Distribution box is level and at normal level. The leaching is made up of 4 500 gallon chambers and at time of inspection levels appeared to never have been at abnormal levels. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4_0 Maggie In Property Address Kim Barnocky Grossman Owner Owner's Name information is required for every W Barnstable Ma 02688 3/24/14 page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑' Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if-(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑. Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a.year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions.exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Maggie In Property Address Kim 'Barnocky Grossman Owner Owners Name information is required for every W Barnstable Ma 02688 3/24/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Maggie In Property Address Kim Barnocky Grossman Owner Owners Name information is W Barnstable required for every Ma 02688 3/24/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone li 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-3/13 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 40 Maggie In Property Address Kim Barnocky Grossman Owner Owners Name information is required for every W Barnstable Ma 02688 3/24/14 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): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17 7 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Maggie In Property Address Kim Barnocky Grossman Owner Owner's Name information is required for every W Barnstable Ma 02688 3/24/14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system contains a 1,500 gallon concrete septic tank. An ejector pump from a one bedroom apt. As well as a concrete Distribution box. All tees and baffles are in place. The Distribution box is level and at normal level. The leaching is made up of 4 500,gallon,chambers and at time of inspection levels appeared to never have been at abnormal levels Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): well Detail: Well is 120 ft from leaching in wich a variance was granted on behalf of the Town of Barnstable Sump pump? ® Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): _ Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 40 Maggie In Property Address Kim Barnocky Grossman Owner Owners Name required for is every W Barnstable required for eve Ma 02688 3/24/14 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Occupied Date Other(describe below): General Information Pumping Records: Source of information: Tank needed pumping at time of inspection home owner was advised. Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping:. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the l/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Maggie In M Property Address Kim Barnocky Grossman Owner Owners Name information is W Barnstable required for every Ma 02688 3/24/14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 12 years. Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 18 "s feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 120feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented throught the roof. Septic Tank (locate on site plan): Depth below grade: 26"s feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain) 1,500 gallon If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gallon Sludge depth: 3"s t5ins-3/13 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 M 40 Maggie In Property Address Kim Barnocky Grossman Owner Owners Name information is required for every W Barnstable Ma 02688 3/24/14 page. CityfTown 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 24"s Scum thickness 3"s Distance from top of scum to top of outlet tee or baffle 42"s Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Recommended pumping at the time of inspection Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM •°'v 40 Maggie In Property Address Kim Barnocky Grossman Owner Owners Name information is W Barnstable required for every Ma 02688 3/24/14 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.): no evidence of leaking tees are in place. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 Maggie In Property Address Kim Barnocky Grossman Owner Owne,'s Name information is required for every W Barnstable Ma 02688 3/24/14 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At Normal Level 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.,): Distrinution Box is level and at normal level with no signs of carry over or decay. 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.): There ius a small ejector pump for one bedroom apt and was operational at time of inspection. *-If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form : Not for Voluntary Assessments 40 Maggie In Property Address Kim Barnocky Grossman Owner Owners Name information is required for every W Barnstable Ma 02688 3/24/14 page. City/Town State Zip Code Date of Inspection D: System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type%name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No signs of carry over. no signs of hydrualic failure 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•3/13 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 13 of 17 F Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 40 Maggie In Property Address _ — Kim Barnocky Grossman Owner Owner's Name information is required for every W Barnstable Ma 02688 3/24/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No signs of ponding or hydrualic failure. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 40 Maggie In Property Address Kim Barnocky Grossman Owner information is Owner s Name required for every W Barnstable Ma 02688 3/24/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) , Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the oxen below: ❑ hand-sketch in the area below ® drawing attached separately t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 r TOWN OF:BARNSTABLE G, LOCATION SEWAGE 2 C)o VILLAGE— -s ASSESSOR'S MAP &LOT Q 2` a � INSTAULLE:R'S NAME.do PHONE NO:. SEPTIC TANK CAPACITY: j: LEACHING FACII;ITY: (type) C^ L�i• �$<� (size} . 1 _.5L� lj✓� NO.OF BEDROOMS C rf BUILDER OR OWNER. PERMTTDATE: 0 a COMPLIANCE-tDATE: :20z Separation Distance.Between:the: , Maximum Adjusted Groundwater Table to the.Bottomtif Leaching.Facility': . Feet Private.Water Supply Weil-and.Leaching,Facility (If any wells,e='t on.site or within 200 feet of leaching facility) _.: Feet Edge of Wetland and.Leaching Facility.(If any wetlands exist within:300 feet of leaching.facility] Feet Furnished by i S • 3 JA e� ss� I. 01 - - e , • `L r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 40 Maggie In Property Address Kim Barnocky Grossman Owner Owner's.Name information is required for every W Barnstable Ma 02688 3/24/14 page. Citylrown 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: 16+ ft 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: 3/7/2002 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: No ground water encountered at 16 ft according to plan on file dated 3/7/2002 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 40 Maggie In Property Address Kim Barnocky Grossman Owner Owner's Name information is required for every W Barnstable Ma 02688 3/24/14 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 11 O ' n I O c� 40 MAGGIE LANE LOWER LEVEL N • O 46 Ft 3 f2 n $taUn Oil TankfU fin.ished Storage Furnace Family/Rec boom OPEN 24 Ft File Room Home Office staffs Closet 0 N r 0 n 0 40 MAG G 1E LANE LOWER LEVEL .s, N O 46 Ft m D 3 l2B un Oil Tank/Unfinished Storage Furnace Family/Rec Room OPEN 24 Ft File Room Horne Office stans Closet 0 W ti m r OCT. 5, 2006 4:44PM N0. 763 P. 1 �oFz r Town of Barnstable " Growth Management Department. = Eaxrtscaete, +' .367 Main Street, Hyannis, NIA 02601 Tel: 862-4678 Fax: 862-4782 EO MA'S FAX COVER SHEET To: jgv1 Date: Time: Attn: Number of Pages (incl: cover sheet): From: ' Comments: 40 MAGGIE LANE LOWER LEVEL --- 46 Ft /213 Oil Tank/Unfinished Storage Furnace fi jFaFamily/Rec Room a4 J� 24 Ft File Room Home Office stairs Closet E a r` m m m m N 1 19 I f- U 0 SEP-18-2006 03 :22 PM P. 02 30' x 7 1 16 x 3 1/2 closet 8' x 6' Kitchen Bathroom 0 V�, 14' x 25 1/2' Living Room 28 14' x 25 1 2' Bedroom Town of Barnstable Health Inspector �FTNE 1p� Office Hours Regulatory Services 8:30—9:30 * * Thomas F.Geiler,Director 1:00—2:00 * B"NSMBLE, MASS. 9. Public Health Division ArfD nwa� Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 AMNESTY PROGRAM APPLICANT - SEPTIC QUESTIONNAIRE I. General Information: Size of Property::7,`. t/7U Address: 0 Map 217 Parceio 3 2— Name: L-Al Phone #: 1—— S Zz 2a. How many bedrooms exist at your property now? 2b. Are you planning to add any bedrooms?_. If yes, how many? 2c. How many bedrooms total are proposed at this property (including the amnesty unit)? 2d. Please include a copy of the floor plans for the entire property - showing the existing rooms in the home plus the proposed amnesty apartment and/or addition. Please label each room clearly on the plans. 3. Is the dwelling connected to public sewer? YES or If the dwelling is connected to public sewer,skip questions#4 through#9 below. 4. .Location of dwelling is INSIDE r TSIDE a Zone of Contribution to public supply wells? 5. Is the dwelling connected to an, ON�SITE WEL or to PUBLIC WATER? 6. Is a disposal works construction permit on file? YES or NO 6a. If yes,how many bedrooms were approved according to this permit? ? Bedrooms. 7. Were any building permits obtained for construction of additional bedrooms? =YES or NO CD 8. Is there an engineered septic system plan on file at the Health Division? YES or NO µ 1 9. Has the septic system been inspected by a DEP certified inspector within the last two years? YES or NO FOR OFFICE USE ONLY C) The Public Health Division has no objection to bedrooms at this property. Z —24 1 L-- pecial Conditions: =T,moval or cLaiy _4,D ba ,en "' 4 lg.< Qovdm ` Signed: Date: Q;/health/wpfiles/amnestyapp Flynn,.Judith From: Taylor, Madeline Sent: Wednesday, October 04, 2006 11:54 AM To: McKean, Thomas Cc: Flynn, Judith Subject: RE: Septic System Questionnaires Received/Reviewed Tom - 9 Linden Street is on town sewer. It may be under 9A or 913 Linden St. Would you mind rechecking your files? 40 Maggie Lane has only four bedrroms total.What you thought were bedrooms in the lower level are actually Kim and Eric's desks in their office. 1025 Service Rd -There should be something on file stating that a 5 foot opening was put in one of the upstairs bedrooms. The owner was required to do this when she applied for a family apartment, reducing the total number of bedrooms to three-2 upstairs and one in the lower level apartment. The only rooms that are not labeled are the second upstairs bedroom and the room that was opened up to five feet. Thanks Madeline -----Original.Message----- From: McKean,Thomas. Sent: Thursday,September 28,.2006 10:02 AM To: Taylor,Madeline Subject: Septic System Questionnaires Received/Reviewed 9 Linden Street The Health Division files were searched and we cannot find any records of the septic system. Please ask the applicant to hire a DEP certified septic system inspector to conduct a full inspection of the septic system. 40 Maggie Lane The floor plans are difficult to read. The basement contains an "office"room and two bedrooms for"Eric"and "Kim"? Where are the walls and doors located? Is this a six bedroom plan? I count one in the apartment over the garage, two in the basement, and three in the main house= Six total. HISTORY-The Board of Health limited the property to four bedroom (per the variance decision letter dated May 30, 2002. Also a permit issued for no more than four bedrooms dated June 7, 2002). We cannot approve the floor plan at this time. The floor plan appears to show a number of bedrooms which exceeds the permitted number of bedrooms allowed. 49 North Precinct Road, Centerville OK-Approved for three bedrooms per permit#91-61 issued in 1991. The submitted floor plan shows three bedrooms total. 1025 Service Road,West Barnstable 1)The floor plans are difficult to read. Lines are faded so walls are difficult to locate. Also not all of the rooms are labeled. Please revise the plans or re-submit new neatly drawn floor plans. 2)The system consists of two"old block cesspools" per the inspection report on file dated 8/16/02,four years ago. I suggest an up-to-date inspection should be conducted to determine whether whether or not the block cesspools are in good condition and are functioning properly . 1 r RECE . �s MAY 8 - 2002 DATE: TOWN Or i3ARN57titiLE HEALTH DEPT. FEE: REC. BY Town of Barnstable, CHED. DATE: Board of Health 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,R.S. FAX: 508-790-6304 Sumner Kaufman,M.S.P.H. Wayne A.Miller,M.D. VARIANCE REQUEST FORM LOCATION Property Address: D Assessor's Map and Parcel Number: �17 ^ ,jZ Size of Lot: 32 15�,;;6 Wetlands Within 300 Ft. Yes Business Name: No Subdivision Name:,V—u t9F5 !J/Q4J s� APPLICANT'S NAME: STC�,t7k 1 Gc4 GG,j (f t� Phone Z— .S/ �� Did the owner of the property authorize you to represent him or her? Yes No PROPERTY OWNER'S NAME CONTACT PERSON Name: Name: Address: 49CK Phone: Phone: VARIANCE FROM REGULATION(List Reg.) REASON FOR VARIANCE(May attach if more space needed) /�T /Z Off o D 7 G e- ,aev,d�asso SA5 u>Jc c , L� /•v ��vJu�cTry ccp — c���'o� aev NATURE OF WORK: House Addition ❑ House Renovation ❑ Repair of-Failed-Septic System UK* -�'!7DGv.�T v 2�t•O�' Check4st(to be completed by ofce stgf,J`person receiving variance request application) — Four(4)copies of the completed variance request form — Four(4)copies of engineered plan submitted(e.g.septic system plans) Four(4)copies of labeled dimensional floor plans submitted(e.g.house plans or restaurant kitchen plans) — Signed letter stating that the property owner authorized you to represent him/her for this request — Applicant understands that the abutters must be notified by certified mail at least ten days prior to meeting date at applicant's expense (for Title V and/or local sewage regulation variances only) — Full menu submitted(for grease trap variance requests only) — Variance request application fee collected (no fee for lifeguard modification renewals, grease trap variance renewals [same owner/leasee only],outside dining variance renewals[same owner/leasee only],and variances to repair failed sewage disposal systems [only if no expansion to the building proposed]) Variance request submitted at least 15 days prior to meeting date VARIANCE APPROVED Susan G.Rask,R.S.,Chairman NOT APPROVED Sumner Kaufman,M.S.P.H. REASON FOR DISAPPROVAL Wayne A.Miller,M.D. C:\Documents and Settings\decollik\Local Settings\Temporary Internet Files\OLKFB\VARIREQ.DOC _ TOWN OF BARNSTABLE ILOCATION Q0 SEWAGE #200 2--ZL/ VILLAGE ASSESSOR'S MAP & LOT —0 INSTALLER'S NAME&PHONE.NO. cv����� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ���.,�� gt,5-J (size) NO. OF BEDROOMS Ll C InaMkr1 BUILDER OR OWNER PERMIT DATE: �� COMPLIANCE DATE: av Lo 2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �1rtA,�i e j CA - z - S2 ' C� WT-E f I+Io. UIN IQ & ` � �����02 Fee / THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplication for Mi5pogal *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade(/Abandon( ) ❑Complete System L/Individual Components Location Address or Lot No. Owner's Name,Add ss and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. ` Designer's Name, ddress and Tel.No. 7 7/� 77 - zQ 73SS Type of Building: Dwelling No.of Bedrooms Lot Size 3$�sq.ft. Garbage Grinder(/0 Other Type of Building f No.of Persons Showers( ) Cafeteria( ) Other Fixtures &rA 1 1P/'41oe`���` Design Flow gallons per day. Calculated daily flow ! gallons. Plan Date t� O Z Number of sheets / Revision Date 5_ Title S a1. �i Size of Septic Tank l S—nl� Type of S.A.S. Description of Soil H �2hc �J"tv f Repairs or Alterations Answer when applicable Nature o p ( pp ) DESIGNING EMS NG TION UrCKVISE AND CERTIFY IN WRITING Date last inspected: THE SYSTEM WAS INSTALLED IN STRICT Agreement: ACCORD;.'—E TO PLAN, The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued btA this Board.of Health. / Signed Date f�< Application Approved by �/"'° Date 6 Application Disapproved for the following reasons 11 't Permit No. 0� '� ��� Date Issued Fee ",THE COMMONWEALTH S CHUSETTS Entered in computer: i OF AS V� Yes .�_,, ,,P.UBLIC HEALTH DIVISION -TOWN,OF BARNSTABLE, ASSACHUSETTS • ~ `Rpp.1iiation for Mtopozal bpztem Congtruct on Permit Application for a Permit to Construct(• )Repair( )Upgrade(/Abandon ) ❑Complete System.- VMdividual Components Location Address or Lot No. Q;wner's Name,Add ss and Tel.No. Ae �.71-1 Assessor's Map/Parcel r j-' ////W! eil� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 75'-- eQ 735- Type of Building: r` Dwelling No.of Bedrooms Lot Size R770 sq.ft. Garbage Grinder(1L�� Other Type of Build No.of Persons Showers Cafeteria YP g ( ) ( ) Other Fixtures r/1 e_�T Design Flow Z49 gallons per day. Calculated daily flow ''7 gallons. - Plan Date _ SS O Z Number of sheets / Revision Date- 5 D//J 7_ Title S v< ew e O �L1�Q . �,A� Size of Septic Tank l ADD R. Type of S.A.S. G1`- SOD 94/rO�I C �,wi� JJ .� Description of Soil Nature of Repairs or Alterations(Answer when applicable) �)"" Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not,to place the system in operation until a Certifi- cate of Compliance has been issued b this BoarA of Health. f /� Signed -='�''" Date 6/Z/e-- g / Application Approved by.�" n. �I/"` Date 6 ( Sz Application Disapproved for the following reasons Permit No., Deb "2 ��l '�^ Date Issued ? 0 THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER , that the On-site Sewage'Disposal System Constructed( )Repaired( )Upgraded(44 Abandoned( )by I at y� 5�`D� has been construc ed in accordance with the provisions o Title 5 and the for Disposal System Construction Permit No.JCV9_dqj dated 617Jo A Installer Designer The issuance of t 's permit shall not be construed as a guarantee that the syst'&R will f nction as=&sld: Date Inspector i --------------------------------------- r� U No. G !' 7 Fee THE COMMONWEALTH OF MASSACHUSETTS 'j PUBLIC HEALTH DIVISION - BARNSTABLE., MAS ,�±� gE�jTS TA� ry�EN WEER Musr SUFERVISE 13i5po0ar *pgtetn �tCongtructton �N AND CERTIFY IN WRITING C ORDA��CE Tp WAS INSTALLED IN STRICT Permission is hereby granted to Construct( )Rep ' ( )Upgrade( Abandon C LAN System located at /��9 / liter �!1' and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this pc�4k Date: c) L Approved by �"� i TOWN OF BARNSTABI E LOCATION Af SEWAGE # 2-7 zi VILLAGE ASSESSOR'S MAP& LOT —D INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY v LEACHING FACIL=: (type) �x llae2 4el-' (size) NO.OF BEDROOMS Ll C fi.MAt r-r BUILDER OR OWNER � ;a �4 PERMITDATE: COMPLIANCE DATE: av U2 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by F 1 21 of 10114 Rev ILL, =s� F m . f Weller & Associates Bayberry Square — Suite 4C 1645 Falmouth Rd. — P.O.Box 417 Centerville,MA 02632-0417 Date: August 12, 2002 Barnstable Health Department Barnstable Town Hall 367 Main Street Hyannis, MA 02601 Re: Wallace, 40 Maggie Ln.,West Barnstable—Assessors Map 217 Parcel 32 Dear Health Dept.: Please be advised that we have inspected the soil removal and replacement, along with the installation of the septic system, at the above referenced property, and find that it was done in substantial compliance with the approved plan. If you have any questions, please do not hesitate to contact us. Verytruly r y yours, ,I,a OF 44S O DANfEL E. yG 8RAMAN Daniel E. Bra i, E CIVIL U Noo..3268 C �FSS�0 N A L:::::E�Ga r Fax: (508)775-0754 Phone(508)775-0735 Weller & Associates Bayberry Square — Suite 4C 1645 Falmouth Rd. — P.O.Box 417 Centerville, MA 02632-0417 Date: August 12, 2002 Barnstable Health Department Barnstable Town Hall 367 Main Street Hyannis, MA 02601 Re: Wallace, 40 Maggie Ln., West Barnstable—Assessors Map 217 Parcel 32 Dear Health Dept.: Please be advised that we have inspected the soil removal and replacement, along with the installation of the septic system, at the above referenced property, and find that it was done in substantial compliance with the approved plan. If you have any questions, please do not hesitate to contact us. Very truly yours, " OF Mgsf 9 O� OANIEL E. C'y BRAMAN G Daniel E. Brai, PE CIVIL V Noo..3268 C F�SSiON;AI EN�\� Fax: (508)775-0754 Phone(508)775-0735 TO: Barnstable Health Department FROM: Darren M. Meyer, R.S. Certified Soil Evaluator DATE: March 27, 2002 RE: Comparative Sieve Analysis 40 Maggie's Way, West Barnstable, MA I have reviewed the comparative sieve analysis conducted by American Testing & Engineering for the above referenced property and have determined the soil to be LOAMY SAND with a loading rate of.66 gpd/ft2. This determination was made based on the Massachusetts Department of Environmental Protections "Title 5 Alternative to Percolation Testing Policy-for. System Upgrades", Policy #: BRP/DWM/PeP-P00-4. The soil sample was an un-compacted soil consisting of 15% Silt, 4% Clay, and 81% Sand. Based on the textural triangle this soil is LOAMY SAND, and based on the policy a Class I soil with 70-85% Sand, has a Loading Rate of (.66 gpd/ft). 14 F®S� �/ AMERICAN ENGINEERING &TESTING INC. 14 ROC SAM PARK ROAD, BRAINTREE, MASS. 02184 781-848-5184 FAX: 781-849-9760 MASS. LICENSE NO. CTL-017 CHRISTOPHER TIER - PRESIDENT LI.SA MONTGOMERY - V. PRESIDENT WILLIAM MONTGOMERY - P.E. March 27, 2002 Report No. 032702-L Weller & Assoc. P.O. Box 417 Centerville,MA 02632 Re: 40 Maggie Lane W. Barnstable, MA Gentlemen: The following are test results of a sample of soil as delivered to this laboratory on 3/15/02 1. Sample Description Sample Number Description Source 75 Gravely Sand some Silt In Situ 2. Sieve Analysis (% passing by weight) Sieve Size Result Sieve Based on -#10 Material 3/4 100 1/2 98.6 3/8 98.2 #4 96.0 10 92.3 100 20 82.2 89.1 40 66.4 72.0 50 57.3 62.1 100 35.6 38.6 200 21.9 23.8 270 17.4 18.8 Hydrometer Results Silt= 15% Clay = 4% �emar, : Sa le taken on 3/8/02. Si �� Christ e . Tier President -t` 4 yy p F d ufz fie, Q-0 r/t sFop e Town OF - b1e, Jam ® i ,l���a ' L' � 3 � !I ' 1�Y\ Town of Barnstable � Bs4RNfiCAB# �$ HAS& Board of Health ` 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Susan G.Rask,RS. FAX: 508-790-6304 Sumner Kaufman,MSPH Wayne Miller,M.D. May 30, 2002 Mr. Stephan Wallace P.O. Box 490 West Barnstable, MA a RE: 40 Maggie Lane West Barnstable, A= 217-32 Dear Mr. Wallace, You are granted.a conditional variance to construct, a soil absorption system at 40 Maggie Lane, West Barnstable. The variance granted is as follows: PART XIV SECT. 2.00: The soil absorption system will be located 120 feet away from the existing onsite well, in lieu of the 150 feet minimum separation distance required. n This variance is granted with the following conditions: (1) The designing engineer shall revise the plans to show the following: (a) a 1,500 gallon septic tank and (b) the correct soils encountered during the soil evaluation (loamy sand) as described in the sieve analysis report. (2) No more than three (4) bedrooms maximum are authorized at this property. Dens, study rooms, offices, finished attics, sleeping lofts, and similar-type rooms are considered "bedrooms" according to the MA Department of Environmental Protection. (3) The applicant shall record a properly worded deed restriction, signed by the owner of the property, at the Barnstable County Registry of Deeds restricting the property to four (4) bedrooms maximum. A copy of the recorded deed restriction shall be submitted to the Health Agent prior to obtaining a disposal works construction permit. Wallace (4) The septic system shall be installed in strict accordance with the revised engineered plans. (5) The designing engineer shall supervise the construction of the onsite sewage disposal system and shall certify in writing to the Board of Health that the system was installed in substantial compliance with the revised plans. These variances are granted because physical constraints at the site severely restrict the location of a soil absorption system due to the location of the existing onsite well. The Board was informed that the property owner possesses insufficient funds to construct a new well at this time. It is the opinion of this Board that the proposed soil absorption system is designed to meet the maximum feasible compliance standards contained within the State Environmental Code, Title V. Sincerely yours, Puan G.tk,�R S. Chairperson Wallace 1-0 10 L'0CATION / SEWAGE PERMIT No w 8,20n VILLAGE Z a1 -GZ3 iv I N S T A LLER'S NAMEf & ADDRESS S-�oa�cIr 0 U I L D E R OR OWNER DATE PERIgIT ISSUED DATE COMPLIANCE ISSUED 3 J e FIZZ �VO THE COMMONWEALTH OF MASSACHUSETTS WpJ BOAR® OF HEALTH '(A 1v1 yt� �..�... ..Q�.7...OF....................................... , pphra#ion for Ui"vii al Marks Tomitrurtion ramit Application is hereby made for a Permit to Construct �{-( ) orr Repair ( ) an Individual Sewage Disposal System at.* �: _�� ................. . . ...... -----•• �'!.•c....... - ----•-•-•------- ' •--r ocation-Addr ss or Lot No .....__ ..... --•-�.. ...........•-••.....•..................... - A •-- .. • ....c ... - •- W Owner dd es �., • _ st le Address ...... .- Pq � � � J Q Type of Building / Size Lot____________________ _____Sq. feet U Dwelling—No. of Bedrooms...............;.........................Expansion Attic ( ) Garbage Grinder ( � aOther—Type of Building ............................ No. of persons.... Showers (1 ) — Cafeteria ( ) Otherfixtures -------••---------------•------------....................................... ------------•----.................................................... Design Flow.....................................a allons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity../........gallons Length................ Width.........------- Diameter---------------- Depth................ 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................ fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q -------- .--••••......••.•-•-• •-•••••-- • .. .................................................;....................................... O Description of Soil.......26 .......=" x x ---------------------------------------------------------••-•-••-•••--------•--•-----............•--•--•... ............................... -- ----- U Nature of Repairs or Alterations—Aaswe�napp.,,.ca ble__.____1...._......_ d..U�........ ................. i-----. -----------------------------------------------------•------------------•--•-----•----•------••------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of rLIT% 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bKissue boar of health. igned.... -•------••-•••.........-• ..........•-••.........-•------- Date Application Approved By---- ----- ..••-•.................... "^-------------•-- ........ Date Application Disapproved for the following reasons:------•-------------••-•-•-•---•-----•--...-----.._..---------•------------------------------•-......••-•..._._ ..............••-•--•----•-•-------------•---------------•-------•--------------..........-•---.................--------......... -------------------------------•-------------------------------........ Date PermitNo......................................................... Issued....................................................... Date t/1 74 N ._... Fmc.....�....__ ........_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF............... Appliratiun for Diupuuttl Works TouBtrurtiun Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sew ge Disposal System at j, " t ' T � .........._ �. 1 ................... ........ cat iot��Addr ss or Lot No. • .... �� -•mac: ......--- Owner ••..•••--••Address .... - -•--•---•--•-------------- .................... cc ................ h ��W' al ess+ d Type g / Sq. feet T e of Building / Size Lot__________________________ U n �., Dwelling—No. of Bedrooms.__.. ..... .........................Expansio Attic ( ) Garbage Grinder Other—Type of Building _________ __________________ No. of persons........1................... Showers ( + ) — Cafeteria ( ) Otherfixtures -----•---------------------------••---•--------------.---•-•------•-••--••-•-•-•--••-----•--•-•-•-------•••--•-•----._.......---•---------•-•---•--•- W Design Flow...........................................gallons per person per day. Total daily flow...........................................gallons. WSeptic Tank—Liquid'ca.pacity_,/Aeallons Length................ Width................ Diameter-_ ------------ Depth................ x Disposal Trench—No. ------:............. Width:...::............. Total Length.................... Total leaching area....___....._...__.sq. ft. Seepage Pit No.___------_-.._-_-- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box,,(,_ )... ,.. . .;-Dosing-tank a Percolation Test Results r Performed by.......................................................................... Date------------------••---•-•---•-•------- Test Pit No. 1................minutes per inch 'Depth of Test Pit.................... Depth to ground water........................ tTq Test Pit No. 2................minutes per inch Depth of Test Pit............:....... Depth to ground water........................ x ------------------------------------------------- ---•••----------- K -J._. D Description of Soil......... eA U - -----------------------------------------------------------.......- .............. ...............1:................................................................... w x . U Nature of Repairs or Alterations—Aulwer whe applicable........ ............ .�'�..U....... ._._............_ .... . .__..... ....................................................... ---•-• ••---••--•...-•---••-••----•----------•••-----------•-••••-----•••--••--•--•-•••.......----•....--•••- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITUj 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been-Issue y h,p boar of health. J Signed:_ --- .............. ...... ::.: -- �•• / Date Application Approved By.....'== , ; �' �, ........ 1 I --_-------- Dat Application Disapproved for the following reasons:.... "=.11 ---------------•--•---------------------------•------------------------ , Date PermitNo......................................................... . Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS•' BOARD OF HEALTH ..........................................OF..................................................................................... (Irrtifiratr of Tompliaurr THIS IS TO CERTIFY, Thq the, dividual Sew e D* ?Ossk$"ystem constructed ( ) or Repaired ( ) by - •---••----------- - I-- • ---•--•__�- !r ------- atj _--L.� -- tin .' 1�,+ (;1 � •---Instal ;�f,b`--� --------NCI -• s�---=--- f" , <:✓ L�,� has been install accordance with the provisions of TITLE 5 of.The State Sanitary 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 ILL FUNCTION SATISFACTORY. DATE.. _ _---_--- z- . ' ................................... Inspector............. ----__------•----•-----------------------------•---•--•---- THE COMMONWEALTH,OF MASSACHUSETTS BOARD OF HEALTH .......... ... . .. ...... .......OF..................................................................................... ! uU No......................... FEE..._._ .... Disposal Iforkii Tunstriun "prutif Permissionis hereby granted................................................................----•-.......-•-....-••-•----•-•--•••......----•----...................._._.. to Construct ( ) or;Repair ( ) an Individual Sewage Disposal System atNo........................................................._........ ...............................Str.e- Street as shown on the application for DisposaI7 4of ks construction Permit No..!' 4.__ ..../.. Dated.........................................' ....................................... .....----...------------...A-e,/--.------ 7- Board of Health DATE................................................................................ :. FORM 1255 A. M. SULKIN, INC., BOSTON ~`•try i . u YK •M 6 � � N �• yla: l� �. • ® Oy,m wy y . �:. .✓-k:. t ag�� �V. 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I W - - , op i --------- - - - - - j�6F9 fl I i t ' 7 TEST HOLE LOG L nATF: 7 b �, � ac u.S ,rL1•92 , Z0 Z P SOIL EVA1XlkTOR::,/_2, vl45 /ZS, Csdc G A I lw-.s s:.//6,4G�.41' PERC RATE . �pV /9 loye 3 w SG 3'2j S, o S�' f ZNy �oyrr s/8 c,.o ExrsT: zsys/ yy 55 0 (s <f2 4 r O � P,SY /5� 1 i qz 51,o i i 1 E / DE*91(i DA�'A DAILY F!,,' l7i BDRmS. x 110 GF'D ='y'� GPD . i.NK: GPD x 200% =,980 GPD USE:/sop GALLON PRECAST SEPTIC TAWK LEACHIN FACILITY: USE: �..$X 8._SX.Z ti Sp o ty .D.Fj/4J><GG.S C �1"��1►J 2�� o� RE��.9cE CAPACITY: EX/3Tiy � Q N`c� SIDEWALL: _f/_d..X Z�aC D,e,- YSZ J \ � / 1 GUG LG �U q / o a BOTTOM:- TOTAL: ._._. SO$. 57 fi--� Ac 5 %Ao U V' NJ cl 10 ,s NOTES: .. 1. ALL PIPE TO BE 4" DIA. SCI? 40 PVC. �� + e 2. PIPS TO 't1F; i,A1J LEVEL FOR 2' OUT OF DISTRIBUTION BOX. 3. RAISE ALL PPPLICABLE FLAITHOLF, COVERS TO WITHIN 6" OF FINIFf' ORAPE. 4. SEPTIC SY—l'T IS NOT DESIGNED FOR THE USE OF A GARrAGE D 15: . :',L. 5. SEPTIC TA.NIk ('+ DISTRIBUTION BOX TO BE INSTALLED ON A 6" LAYFi* +—:F.' STONE, 6 INSTALL 'SAS F:-: ,'1 E 111 OUTLET TEL. 2" LAYER OF 6EASTONE OVER 7"-1�" DOUBL' :1TED S?-011F. ALL r?;cta:u TOP OF FOUND. �.�3 F,LEV. '7Z,00 t nsa r7g'7 G •58.0� 5� SEP " ' SYSTEM PROFILE R. 'a9 "r SITE SEWAGE PLQ4 FOR GENERAL NOTES Z 0 lt:PW C7( ;;� el/./ Gr/. &AXA - 1S-7',q,8G,a 1. 0ONTM0,02 76) At fflfff§� t&f, 1NN. L6&_'r6j9` Z12 OF ALL UTILITIES, ABOVE JUID UNDERGROUND, 2RIOR TO Al1Y EXCAVATION OR CONSTRUCTION. PREPARED FOR 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH 310 GTII2 15. 00: TITL1: V. 3. THIS PLAN TS NOT TO BE USED FOR PROPERTY LINE DATE : 0 ZOO Z c DETERMINATION, ..CAGE : 1.'� = 3v 36 Z o aZ 4. ALL DISTURBED AR^aS TO L01114ED AND SEEDED. i 5. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY REQTTIREP i113I1ECTIONS. WELLER & ASSOCIATES 4, E,1ctspx Cr5s�.5 -To Be �k1�n t�l 1645 FALMOUTH RD. SUITE 4C P.O. BOX 417 CENTERVILLE , MA 02632 �� Pil I wq( c�&) 5N,%c> TEL: (508) 775-0735 FAX: (508) 775-0754 APPROVED BY: a Z TEST HOLE LOG b Loc us DATE:�j�J2. 7, Zao Z P A SOII, EVALUATOR:.,(Q �`'1�7�E„Q lZS� G,SE ( G A 111 THE s S: -1�424-,—,41' IQO GW PERC RATE:" �OV O N SG. w7.O �oy� 3 ExI z.Sys/ !sue C2 G.S. i d z Sy, 1 D - �9z�, / ���1� :1SNo GcJA�E,R EiS/c0 u.J7�er4a. I)FSIGi4 DATA :iAILY FL, ";: (7i BDR►Z5. x 110 GPD =7 7 a G;?D J P`., O STsPrIC_ a>NdC: y�D GPD x 200% =BBo GPD d 1 .000l -�.-�' USL:/sop GALLON PRECAST SEPTIC TANK LEACHING FACILITY: 46 00 ' l E• . S X 8. y Sc7U ��?y4>LrGG.S / h1l�Hi►J 2o•e� o �rc�GAc 4!F CAPACITY: s% /o oo�S SIDEWALL: .I/d Z�-e O,GG= y�Z BOTTOM: TOTAL:-- Sp s S q v ,�� REMaIE �M��t� M4�eetPlt. FC>R- At lie • VUJJJ � D' a �'� "+i7 �:•, a.DANtii 0 !o y zZ' NOTES. 1. ALL PIPE TO BE 4" DIA. Sri? 4U PVC. 2. PIP13 TO itE LAID LEVEL FOR 2' OUT OF DISTRIBUTIO14 BOX. 3. RAISE ALL RPPLICAELE lfAi1HOI•F, COVERS TO 4?ITilIN �6" iN OF FINISH GRADE. l 4. SEPTIC SYSTEM IS NOT DESIGNED FOR THE USE OF A GAREAGE DISPOSAL. 1U� 5. SEPTIC TANK AND DISTRiBuTION BOX TO BE INSTALLED \ ON A 6" LhYER OF ST011E:. 6 I IISTALL GAS BAFFLE IN OUTLET THE. 2" LAYER OF 3/8" PEASTONE OVER i"-1�" DOUBLE MSHED STONE ALL ASOL?'U TOP OF FOUND. @ F,LEV. rIZ OD etsa lcxa 5g f � _ G2.00t G�.9•o 56.aa 5� SEPTIC SYSTEM PROFILE 't"a I T�*-g e 04. 5(.o SITE SEWAGE PLAN 1710 f FOR GENERAL NOTES T 0 /y��j7�� L/�� Div. �!" v S7/g�G 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION OF ALI. UTILITIES, ABOVE. AND UNDERGROUND, PRIOR Z TO ANY EXCAVATION OR CONSTRUCTION. . PREPARED FOR 2. SEPTIC SYSTEif TO BE INSTALLED III COMPLIANCE WITH / 310 CMR 15. 00: TITLR V. �'`�- � ' '`3i`f �� `� 3. THIS PLAN IS NOT TO EE USED FOR PROPERTY LINE _ PETER.*fINAT T Oli- DATE : /-;1,49 � Z8 Zvo Z SCI LE : 1.' = 30 MAY 3 a Zo aZ 4. ALL DISTLRBED AREAS TO LOP14ED AND SEEDED. i S. CONTRACTOR TO PROVIDE 24 HOUR NOTICE FOR ANY WELLER & ASSOCIATES REWIRED INSPECTIONS. 1645 FALMOUTH RD. N SUITE 4C P.O. BOX 417 CENTERVILLE , MA 02632 HMO '�LlEb wq� ccx J 5Ad-No TEL: (508) 775-0735 FAX: (508) 775-0754 APPROVED BY: F lJ a Z y R TEST HOLE LOG p Gacu s DATE:;ti192, 7, Zdo z P- 1p - SOII, EVALUATOR:.,(, /-lC)e6,e 2S, c:lr4w_ GA wiINEss: ./y�.¢c�� T PERC RATE'- �OV o s` 3'2) 8 2o S,�' f ZN" s/B r,5.o. Ext lyy� z.sys/ 55 0 (� CZ SL i o z,sy 4/v .00 �CISn��- 1 / llFSIGII DATA DAILY F.Il::".': (y; -BDrJdS. x 110 GPD EP'PIC T?;ldK: y�D GPD x 2CO8 ;�D GPD USE: �pvo GALLON PRECAST SEPTIC TJLNK \�\ LEACHIN.3 FACILITY: USE: _ wtl,p1►3 Zos1 o� \ XIsT. , 1000 CAPACITY: SIDEWALL: / D.ac=Z:. sC O,GG= ��/�Z 1 GlJGLG� q VI \ BOTTOM:- FC>P-' A f-Lev, 55.o o /U 'ram �'.�aq�R t1OFA► -- - 4 ,`:i- �• ter-'-' ►t � - ��:s. .: At C) Tom,. NOTES: G8 I 1. ALL PIPE TO BE 4" DIA. SCI' 40 PVC. 2. PIPE TO BE LAID LEVEL FOR 2' OUT OF DISTRIBUTION BOY. 3. RAISE ALL APPLICiNBLE FANHOLF. COVERS TO WITHIN 6" OF FINISH GRADE. 4. SEPT.IC SYSTEM IS NOT DESIGNED FOR THE USE OF A GAREAGE DISPOSAL. 5. SEPTIC: TANK AND DISTRIBUTION BOX TO BE INSTALLED !JN A 6" LW ER OR' STOVE. 6 INSTALL 3�S EP.FFLE I OUILe;T TEE. 2" LAYER OF 3/8" FEASTONE OVER till-1v^" DOUBLE WASHED STONE ... .,_ 2 ALL ALROUVU TOP OF FOUND. @ F LEv. 77Z.00 58.7 .� CEX�sr►�,) 58,� 5{ SEPTIC SYSTEM PROFILE 61 SITE . 'y SEWAGE PLAN GENERAL NOTES FOR 3A-V�- /57;q.6G a: 1. CONTRACTOR TO BE RESPONSIBLE FOR THE LOCATION / OF ALL UTILITIES, ABOVE AND UNDERGROUND, PRIOR TO ANY EXCAVATION OR CONSTRUCTION. PREPARED FOR 2. SEPTIC SYSTEM TO BE INSTALLED IN COMPLIANCE WITH 310 CMR 15. 00: TITLE V. 3. THIS PLAN IS NOT TO ES USED FOR PROPERTY LINE DETER!4INAT1011. DATE : M14.4, 28, Zoa Z SCALE : 1." = 30 4. ALL DISTURBED AREAS TO LOA14ED AND SEEDED. f 5. CONTRACTOR TO PROVIDE. 24 HOUR NOTICE FOR ANY REQITIRZD INSPECTION:. WELLER & ASSOCIATES G, - SX45rltye Cossr=us Ta ve ��pao lev/ 1645 FALMOUTH RD. - SUITE 4C P.O. BOX 417 �1.1�p ��� �� GC.�►� Sf10-�O CENTERVILLE , MA 02632 TEL: (508) 775-0735 FAX: (508) 775-0754 APPROVED BY: