HomeMy WebLinkAbout0003 MINTON LANE - Health 3 Minton Lane
W. Barnstable
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 3 Minton Ln.
W.Barnstable,Mass.
Owner's Name:_Patricia Roberts
Owner's Address:
Date of Inspection:_10/10/08
Name of Inspector:(please print)_Eric D.Stevens
Company Name:_E.Stevens Construction,Inc.
Mailing Address: P.O.Boz 71 Marstons Mills Ma.02648
Telephone Number:_(508)776-9054
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of the inspection.The inspection was
performed based on 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:
X Passes
Conditionally Passes c
Needs Further Evaluation by the Local Approving A thority
Fails �-,
Inspector's Signature: Date:
�f7
The system inspector shall submit a copy of this inspection report to the Approving Authority ard of
Health or DEP)within 30 days of completing this inspection.If the system is a shared system or as a
design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report the -r- m
appropriate regional office of the DEP.The original should be sent to the system owner and copis sent to
the buyer,if applicable,and the approving authority.
Notes and Comments;Sysytem is sound and in good working order.Recommend pump tank now and every
two yrs.after.Reccommend risers be installed on d-box and tank to bring within P of grade.
****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.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued) r� i1
Property Address: 3 Minton Ln.
Owner:_Patricia Roberts
Date of Inspection:_10/10/08
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_X I have not found any information which indicates that any of the failure criteria described in 310
CMR 55.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:System is in good working order.Reccommend risers to within 1'of grade on tank and d-
box.
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced
or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,
will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will
pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass
inspection if(with approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:_3 Minton Ln.
Owner:_Patricia Roberts
Date of Inspection:_10/10/08
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 CAM 15.303(1)(b)
that the system is not functioning in a manner which will protect public health,safety and the
environment:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines
that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet
of a surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply
well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more
from a private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to
this form.
3. Other:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 3 Minton Ln.
Owner:_Patricia Roberts
Date of Inspection:_10/10/08
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
x Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool
_x_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged
SAS or cesspool
_x_ Liquid depth in cesspool is less than 6"below invert or available volume is less than day
flow
x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe
(s).Number of times pumped
_x Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ _x_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply.
_ _x_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ x_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _x_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. [This system passes if the well
water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist
as described in 310 CMR 15.303,therefore the system fails.The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
f
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
x the system is within 400 feet of a surface drinking water supply
x the system is within 200 feet of a tributary to a surface drinking water supply
x the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or
a mapped Zone H 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.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 3 Minton Ln.
Owner:_Patricia Roberts
Date of Inspection:_10/10/08
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
x Pumping information was provided by the owner,occupant,or Board of Health
x Were any of the system components pumped out in the previous two weeks?
x Has the system received normal flows in the previous two week period?
x 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)
x _ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
x _ Were all system components,excluding the SAS,located on site?
x_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and
depth of scum?
_ _x_ Was the facility owner(and occupants if different from owner)provided with information on
the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined
based on:
Yes no
x _ Existing information.For example,a plan at the Board of Health.
_x_ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation
of distance is unacceptable)[310 CMR 15.302(3)(b)]
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:_3 Minton Ln.
Owner:_Patricia Roberts
Date of Inspection:_10/10/08
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_3_ Number of bedrooms(actual):_3_
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):_330
Number of current residents:_0
Does residence have a garbage grinder(yes or no):_no_
Is laundry on a separate sewage system(yes or no): no_ [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): no_
Water meter readings,if available(last 2 years usage(gpd)):
Sump pump(yes or no):_
Last date of occupancy:_Spring 08
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sg8,etc.):
Grease trap present(yes or no):_
i
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:_never been pumped
Was system pumped as part of the inspection(yes or no):_
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X_Septic tank,distribution box,soil absorption system
Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to
be obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
System was upgraded to titleV in september of 1997.
Were sewage odors detected when arriving at the site(yes or no):_no_
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Minton Ln.
Owner:_Patricia Roberts
Date of Inspection:_10/10/08
BUILDING SEWER(locate on site plan)
Depth below grade:_2'
Materials of construction:_cast iron _X_40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_X_(locate on site plan)
Depth below grade:_30"
Material of construction: X concrete metal_fiberglass_polyethylene_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a
copy of certificate)
Dimensions: 1500 gal.1110
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 29"
Scum thickness:_t"
Distance from top of scum to top of outlet tee or baffle:_6"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How were dimensions determined: measured-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.):_Tank needs to be pumped.Riser should be
installed to within 1'of grade.
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction: concrete metal fiberglass_polyethylene_other(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Minton Ln.
Owner:_Patricia Roberts
Date of Inspection:_10/10/08
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:_X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.): D-box is sound and functioning correctly.Reccommend
riser be installed to bring within P of grade.minimal to no sign of solid carryover.
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Minton Ln.
Owner:_Patricia Roberts
Date of Inspection:_10/10/08
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
_X_leaching chambers,number:_5 infiltrators_
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.):_No sign of hydraulic failure.Field was dry at time of inspection.Stone was probed and
no moisture noted.
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Minton Ln.
Owner:_Patricia Roberts
Date of Inspection:_10/10/08
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks
or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 3 Minton Ln.
Owner:_Patricia Roberts
Date of Inspection:_10/10/08
SITE EXAM
Slope X
Surface water X
Check cellar X
Shallow wells X
Estimated depth to ground water 47 feet
Please indicate(check)all methods used to determine the high ground water elevation:
X_Obtained from system design plans on record-If checked,date of design plan reviewed:_9/97
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
X_Accessed USGS database-explain:_Internet
You must describe how you established the high ground water elevation: Perc test dated 1/16/97
shows no water at 132".Usgs maps and charts shows water table approx.47'.
Date: / d
TOWN OF BARNSTABLE
HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: ��I, ` Ti►,
BUSINESS LOCATION: INVENTORY
MAILING ADDRESS: TOTAL AMOUNT-
TELEPHONE NUMBER:
CONTACT PERSON: ku 7�1N`r'
EMERGENCY CONTACT TELEPHONE NUMBER: MSDS ON SITE?
TYPE OF BUSINESS:
INFORMATION/RECOMM DATIONS: Fire istrict:
Waste Transportation: Last shipment of hazardous.waste: —
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) Misc. Corrosive
NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways & garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint &varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor &furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil & stain removers 4b CeAA _ Z 'KA-Wcr Qt
(including bleach) _
Spot removers &cleaning fluids °
(dry cleaners) S.
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
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COMMONWEALTH OF MASSACHUSETTS
r ExECUTIVE OFFICE OF ENVIRONMENTAL AFF2001
DEPARTMENT OF ENVIRONMENTAL PROTSTABLE
C EPT.
V
TITLE 5
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Name:' e r
Owner's Address: "-; T `
Date of Inspection:
Name of Inspector: (please print)) • (/0.401owl
Company Name "14'
Mailing Address:,-?U-I X ` 0V
98,
Telephone Number: � 7-7/-
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true, accurate and complete as of the time of the inspection.The inspection was performed based on 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
Nye, Fu r Evaluation by the Local Approving Authority
,.Paj
Inspector's Signature: f'' 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
DER The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at-that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
Page_2 of;l l
OFFICIAL INSPECTION FORM NO .T FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:..
T./�.Pi12r,Pf7'
Owner:
Date of Inspection:
Inspection Summary: Check AAC,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: 03 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are,indicated below.
Comments:
B. System Conditionally Passes:.
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair, as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain,
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the.
existing tank is replaced with a..complying septic tank as'approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with.
approval of Board of Health):
broken pipe(§)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system.required.pumping more than'4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):.
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
I
Page 3 of l l
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: A A r
Owner:�/�
Date of Inspection: .15/2g/O
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of'Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100,feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A-copy of the analysis must be attached to this form.
3. Other:
3
Pace 4 of 11
OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFAC
E SEWAGE DISPOSAL-SYSTEM INS
PECTION FORM
PART A
CERTIFICATION(continued)
b '
Property Address ` ,
Owner
Date of Inspection: .j
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 efi9uent 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 clooQ ed SAS or
cesspool no
Liquid depth in cesspool is less than 6"below invert or available volume is.less than '/2 day flow
fRequired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
V� An portion of t
— y p he SAS, cesspool or privy is below high grou
nd water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
/ water supply.
7
Any portion of a cesspool or privy is within a Zone l of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water.supply 1 well.
P PP Y
it Any portion of a cesspool or.privy is less than 100 feet but greater than 50 feet from a private water
supply well-with no acceptable water quality analysis. [This.system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is.free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form:]
wL' (Yes/No)The system fails:I have determined that one or more of the above failure criteria exist as
described in 3.10 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large:system:the system.must serve a facility with a design flow of 10.,000 gpd to 15,000
gPd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
— _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 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.
4
Page 5 of 1.1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
`PART B
CIIECKLIST
Property Address:c 4,t L. s7 i
Owner �a
Date of Inspection: Sj��IjUl.
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes o
Pumping.information was provided by the.owner,occupant,or.Board of Health
i "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)
t/_ Was the facility or dwelling inspected for signs of sewage back up
�✓_ Was the site inspected for signs of breakout?
_ 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:
Yes no
_ 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(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION-FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART`C
SYSTEM INFORMATION
Property Address:
Owner:bpk-&r?p 11VC 422U-4/1:
Date of Inspection: 5,Zp-3 k5I
/ FLOW CONDITIONS
RESIDENTIAL V
Number of bedrooms.(.design): j . Number of bedrooms(actual):
DESIGN flow based on 310,CvIR 15.203 (for example: 11:0 gpd x#of bedrooms):
Number of current residents:
Does residence.have a garbage grinder(yes or no): q -
Is laundry on a separate sewage system (yes or no) .[if yes separate inspection required)
Laundry system inspected(yes or no):
Seasonal use:(yes or no); eu .
Water meter readings; if a ilable(last 2 years usage(gpd)): _
Sump pump(yes or no)•.�Lt3
Last date of occupancy:\ �A, xa—d
COMMERCIAL/INDUSTRIAL
Type of establishment:.
Design flow(based on 310 CMR.15.203): gpd
Basis of design flow(seats%persons/sgft,etc.): „
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the.Title 5 system(yes or no):`_
Water meter readings, if available:.
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped asp t of the inspection(yes or_no): �
If yes,volume pumped: gallons--How was quan rty pumped determined?
Reason for pumping;
TYP + OF SYSTEM
eptic tank,distribution box,soil absorption system
� Y
_Single cesspool
_Overflow cesspool
Privy
_Shared system.(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank _Attach a copy'of the DEP.approval
_Other(describe):
Approximate age of all components, date installed(if known)and source of information:
Were sewage odors detected when arriving.at the site(yes or no): 7-
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Addressi ?',
dt-/r
Owner: �
Date of Inspection: q/0/
BUILDING SEWER(locate on site plane
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):-
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_ILI"(Iocate on site plan)
Depth below grade: 04aw
Material of construction:�oncrete_metal_fiberglass_polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: /0.5'X t`i X 5'
Sludge depth: 3 °' ell-
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from t p ofeto top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: _
How were dimensions determined:
Comments(on pumping recommen7ations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as.related to outlet invert,evidence of leakage, ):
o 600 Qozw 1
" ?
Cy
GREASE TRAP:,&hoocate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
Property Address: ?AP �
Owner. - - Z,C. /Wte fix',
Date of Inspection:
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(expla.in):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of fast pumping:
Comments(condition of alarm and float switches, etc.):,
DISTRIBUTION BOX:_jZ(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: �toComments(note if box is level and distribs equal,any evidence of solids carryover,any evidence of
akage into or out of box,etc.):
(a
PUMP CHAMBE�(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):.
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 1 1
L
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: v ' �f.
Owner;
Date of Inspection: _ 5/�2 g/d
SOIL ABSORPTION SYSTEM (SAS):v-- (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching.pits,number:_
eaching chambers,number:
leaching galleries;number:
leaching trenches,number, length:
leaching fields,number, dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil; condition of vegetation,
CESSPOOLS:J&�(cesspool must be pumped as part of inspect ion)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids laver:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY(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.):
9
Page 10 of l l
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r
Property Address.
pA
Owner u- --2'Ltec,
Date of Inspection: spq Zoj
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building.
0 q
10
Page I I of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: Ne// t,
ILIA
Owner: ()a.F
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water q 7 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board :)f Health-explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you estEblished the high groundwater elevation:
5 h r &%1140 f
11
TOWN OF BARNSTABLE
LOCATION. C c /3 114r L L^ SEWAGE #
VILLAGE l d r_ca ,Bar tl ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. &L 1 o/D f/i COAS4 1-2T-S 9
SEPTIC TANK CAPACITY 4 OO
LEACHING FACILITY: (type) n"14nJorS (size) 4 X .SO f
NO.OF BEDROOMS
BUILDER OR OWNE 10.r Es Q C I ro Cr4i5
PERMITDATE: COMPLIANCE DATE:—�/ZMJ
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 leachi fa 'lity Feet
Furnishedby
I
i
At - a`
All 3z
•
A3 a 33 +
B3 a 30
A 4 ` '?y '
s y
o
�19 OF BARNSTABL �? g " ` �
Re�ra� 74
LOCATION I.o T 7 f SEWAGE# �H
%TLLA iE &' �l i'�?vf� � ASSESSOR'S MAP &LOT 17!V' 7 7
INSTALLER'S NAME&PHONE NO. BOPI''12Cfr� L®AQ5/:
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BL1II.D OR OWNER
PERMITDATE: 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 9f leachin f 'lili 'J Feet
Furnished byrG�/1
�f f iy '& 17
7,,, '
3 =
36 ,
Apt = 7q Z -
J
i TOWN OF BARNSTABLE
b 3
LOCATION S i' �. C.e a� /l 1*n,,Jv,m , SEWAGE#
�1 �
VILLAGE Wcsa ,morn ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO. -e rlO/G H (!0^S4 y,28'-S 9.2G
SEPTIC TANK CAPACITY 4SOO god gin
LEACHING FACILITY: (type) ?s►4-, Ora ars (size) 9 X s6
NO.OF BEDROOMS 3
BUILDER OR OWNS S O r- i S'
PERMTTDATE: 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 leachi fa 'lity Feet
Furnished by
�4
Al = a1-
Al" 3z
A3 ° 33
B:3 = 30 '
Ay '- '7y d
3 .
A
No. /' /7 v Fee
THE COMMONWEAL OF MASSACHUSETTG--' Entered in computer:
-`" Yes
PUBLIC HEALTH DIVISION - TOWN O BARNSTABLE., MASSACHUSETTS
Zipplication for 30igogal *p5tem (tonotructton Permit
Application for a Permit to Construct Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. a e Sew%ee Rd Owner's Name,AddreN�§and Tel.No.
Assessor's Map/Parcel j.7 y 7 7 ✓��CC// s9 J9 y
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
6011U" COkSt. 404,,_ C,�/r> 6-11
yz f - t `d z -4/sqi
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size `/3, 70 1 sq.ft. Garbage Grinder(AJ)
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 336 gallons per day. Calculated daily flow 4 C U gallons.
Plan Date 7-7 Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil P s P e
Nature of Repairs or Alterations(Answer when applicable)
inspected: DESIGNING
ENGINEER MUST SUPERVISE
Date last ins
P INSTALLATION AND CERTIFY IN WRITING
{" THE SYSTEM WAS INSTALLED IN STRICT
Agreement: ACCORDANCE 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 issuo-a�y t ' B ard�Heaq�g ,
Signed p1,wt 1 1�'( Date
Application Approved Date r' _ _ -2`7
Application Disapproved for the following reasons
Permit No. Y 7e 73 9 V Date Issued
— ————————————---——— - - - ------ -a
THE COMMONWEALTH OF MASSAC
URG ENGINEER MUST SUPERVISE
BARNSTABLE MA LATION AND
SSACHUS CERTIFY IN WRITING
THE SYSTEM WAS INSTALLED IN STRICT
(Certificate of �otnpYta9!
1 � RDANCE TO PLAN.
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( Repaired ( )Upgraded( )
Abandoned( )by jgoY Eo/6 a: ('�xS'Eyvc 6,a-,L
at a 67' -7 e it ,) has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit N � dated
-, '►
Installer ,0Ifo to 9 C 0-)-f-6 We It as Designer a�� C J ,
The issuance of this p t s 1 no construed as a guarantee that the s e 1 fun tionAjesi
Date Inspector
r S
No. �./ a .# ,'"`. Fee
Entered in computer:
4. THE COMMONWEAL OF MASSACH&E, Yes _
PUBLIC HEALTH DIVISION - TOWN F BARNSTABLES MASS AC_.SETTS
Z1ppYication.4ors;Digpogar 6pgtem Conztruction Fermi
Application for a Permit to"Construct(/)Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. p i 7��/ S��v%C e R/d Owner's Name,Add and and Tel.No.
W� r�__ may'-� • r!sl.S!' / r�/1Ci � .'r1
Assessor's Map/Parcel /T�y I '? — -7 I ! ((
-7,7/— 6 o0 3
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
1
y7 Y - V 9d I//
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size z, °y sq. ft. Garbage Grinder(N)
• Other Type of Building_ No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 33 b gallons per day. Calculated daily flow 0 gallons. t
Plan Date /9-7 Number of sheets f Revision Date f
Title
Size of Septic Tank /,OL Type of S.A.S. jA,41 fA?
v Description of Soil
Nature of Repairs or Alterations(Answer when applicable) r
Date last inspected:
1� Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board�He�lh.
Signed 1.'� _ �� Date r7 47
Application Approved b Date � re
—7"
Application Disapproved for the following reasons
Permit No. Date Issued '�7
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS -
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( Repaired`, ) Upgraded(I )
Abandoned( )by g oY fo/e l{- C`6�s F,,.C 6,Un
at r 6r c // 4'aa has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit N . .-v dated j?— 4/ 47-7
Installer $� f�I c K ( off- s 6 vv r 1 vz DesignerP,
The issuance of this permit shall!not be construed as a guarantee that the s 'stem-will fun�crytion a desigi'dGiMm/60,
Cy
Date 0110 l f f Inspector / !t t G� r� v
-----i�--+�--------------------------------
No. /' �+' i Fee • ar
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
'Wigpogal *pgtem'Congtruction Permit
Permission is hereby granted to Construct( P/)Repair( )Upgrade( )Abandon( )
System located at a % 7 Sp v 'r e _a w 6 Ta s 6-p t
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
i
comply with Title 5 and the following local provisions or special conditions.
f
Provided:Construction must be completed within three years of the date of this permit.
Date: / e / 7 Approved by Y�
SENT 9Y: 80RTOLOTTI CONST; 5084280390; JAN-4-05 12:43; PAGE 1!1
Town of Barnstable
Regulatory Services z
aAnr► Thomas F. Geiler,Director
MABIPublic Health Division
rD"'�`�► Thomas McKean,Director
200 Main Street,Hyannis,MA 0260I
.)Mee: 508-862-4644 }pax: 508-790-6304
i
Installer& Designer Certification Form s
i
Date: ! �z3ld y
r n�Sv�-tZ1r2 '`. .�� •2, ��Lc_�v,�'� �G Installer:
Address: _�1 ��r210E-tL �Zo�,c� Address-
Oil `�'"�``y �^�a��f1 Low j` 'vas issued a per it to install a
(date) (installer}
I
septic system at_ /J7 0061 `l / L'/"Ul� ased on desigl drawn by
Avv An 5$D k sct%. t�6t_u,jc&&(address)
�ll�Svs_S r�GII�GtZ dated -
- (desigvtr)
i
I certify that the septic system referenced above was installed �ubstaitially according to
the design, which may include minor approved changes such is lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes
eater than I0' lateral relocation of the SAS or an vertical relocation r€'r y xo of any component
of the septic systern)but in accordance with State &Local Regalations. Plan revision or
certified as-built by designer to follow.
f p
R
.-.. _ SULL VAS!
CO
�-- NO..2 73�
(Installer's Signature) IL
!o '
t-�SN L t
AO--"
Signature) —:Stii"pere)
PLEASE RETURN TO B ARNSTABLF PU13LTC:HEALTH))M 'ION. CERTFFICAut
OF COMPLIANC7+, V6`ML NOT BE ISSUED T.TNTTL DOTa HIS FORMAND AS-
PT LT CARD MZE RECEIVED I3Y THE BARNSTABLE.PUBLI'C 11E4LTF1 DIVISION.
TffikNK YUL7,
Q: CCi".'ification Fi rin f
i
i
I
tt
" r�ci�MapyParcel` 174007007 �F#r►ds®w er /
F'd e ;' 1 4007007e V Acco nt 003895 nt: 0104023
Qvet� t LOT 7 �' o xe 1 Ac �s
r v'ui MUTTI, LAWRENCE;POWERS,SUZANS/ 101 1
Ngt3tdgs. 1 ea 00000000 '`r
/ 5 CAPES TRAIL ea dctd x 88
W BARNSTABLE MA 02668 s; sewera c' 00 0000 000 �
DeedDafe 020185 Refere ce. 11041 27
J n a 1st, MUTTI, LAWRENCE; POWERS,SU epee 0285
a r r
ec!Re 4405/305 ����
5%atues° rad 000045000 Bw1 � s
.f 9 000104400 x ra Fe lures 0000000000
MIN-1 LANE q d$ 2048 Frr�fg 0000
�
y , - SERVICE ROAD .,c;nex:. 2101 war t 0000
hF
D ---- --------------
dd
No --------------- Fee
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application for Vell Con5tructiodPrrtn'
Application is hereby made for a permit t � ' r , Alter ( ) or Rpair ( )an individ'ua_l Well at:
Ah
Location — Address Assessors Map and Parcel
H C)�in O �� -- —-— �1 b ►�__ =—_—
wner Address-A Nry
1
Installer.— Driller Address
Type of Building
Dwelling I --------------
Other - Type of Building----------------------- No. of Persons--------------------------------------
Type of Well— — �=Y"—�; --- Capacity-- d - -- - —---
Purpose of - '�--- CJL cL ---
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private W- 1 Protec on Regulation — The undersigned further agrees not to
place the well in operation until a C if' a ompli ce has been issued by the Board of Health.
Signecl A A — --
- J
Application Approved By-7 -F
date
Application Disapproved for the following reasons.----- —— - ---- -- --------
""—"---` -- date--
r� �
Permit No. `�`� --- --Issued--_-----�-��� ---- -- ----
date
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Certificate Of Compliance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
y Installer
at— -— -------- -- ___ —_---------
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
Regulation as described in the application for Well Construction Permit No. -----------------Dated-------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE----- --- --- — Inspector—_—_—— - ----- —- ----
--
--- Fee— •-,----- ---
---
BOARD OF HEALTH
TOWN OF:. BARNSTABLE
Zpplicat ion-*rWell Con0ruct ion Permit 0
3
Application is hereby made for a permit t' Cowtrcl
Alter ( ) or.R�air ( )an individual Well at:
`�_ - �--- --- --
- � — AaE —d�''- . Assessors Map and Parcel
_ L
HC
—�—-- — t O
caner Address
--------- ` -- ^�- .
Installer — Driller Address
Type of Building
Dwelling --— -----
-,Type of,Building--------------- No. of Persons=----------------------------
Type of Well ,�— Capacity--2_v—r,P ---- —--—
Purpose of Well--� � �� tv
Agreement:
The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The
Town of Barnstable Board of Health Private W 11 Protection Regulation — The undersigned further agrees. not to
place the well in operation until a Certifi e . f �omplialnce has been issued by the Board of Health.
Signed _-
1
Application Approved By �, , v Gate j
e
V..
Application Disapproved for the following reasons -=---------------__
date
Permit No.— -- Issued'—' -k C /(/ ---- ----
If date, r
4
BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate Of, ComOance
THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( )
y Installer
at
has been installed in-accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection
i, Regulation as described it,,the"application for Well Construction Permit No. --------------Dated----- -----
THE ISSUANCE OFJHIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT,THE WELL
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------`—"r —- -- Inspector-- ----------------------------——-----— --
t
4 BOARD OF HEALTH _
TOWN OF BARNSTABLE
I&ll Contruct ion PermitNo.
� �..! Fee ------ —
Permission is hereby granted ------------
to Con tr ct ( , Alter ( ,,.or Repair ( ) anrIn ividual Wei at: a
I'1 I m (6ANo. — -- ' ' - --- —-------- - — - -
�— I V ! Street
as shown on the a plication for a V, lell,.Construction Permit
No.- 0 , 5 �— -- . Dated �` -------- -- -
2Boa4d
9,//,:v
Health
DATE—�
ii
k
SEPTIC PROFILE TEST HOLE LOGS
T.O.F. AT EL.
l
ACCESS COVER TO WITHIN 5. OF FIN. GRADE (NOT TO SCALE)
f
T AccEss COVER (WATERTIGHT) To ENGINEER:
r- WITHIN 6' OF FIN. GRADE
t - MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM j WITNESS: -' p. f`. I •�M
RUN PIPE LEVEL 2' +,DOUBLE WASHED PEASTONE _ �- DATE:
PERC
FOR FIRST 2' fr
. RATE
PROPOSED _ `3' MAX.)
GALLON sEPnc �'+ � ^ CLASS. SOILS P# ¢--
I •. � yam._..
cl
TANK (H- _lzo�-T j
X SLOPE) CRUSHED STONE OR MECHANICAL '` ` v a ELEV. ELEV. ""y
COMPACTION. (15.221 [2 3 �. + i F .. t. a r' Ep
"
DEPTH OF FLOW ( + LX SLOPE) ( % SLOPE)
TEE SIZES: 3/4" TO 1 1/2" DOUBLE WASHED STONE _
INLET DEPTH 2f
LOCATION ATCATC ION MAP SCALE 1"
OUTLET DEPTH a I
ASSESSORS MAP PARCEL
_ LEACHING tp `� r is i rt 7
' __- ---
FOUNDATION-- ; � SEPTIC TANK D BOX
FACILITY
ZONING DISTRICT: R r
41,
-- - YARD SETBACKS:
FRONT =
SIDE =
A-i ; ' REAR =
v- PLAN REF. /
4f , r Wd AY.
s.
---Q 4 r r I .. w, r c-: FLOOD ZONE: i
___��
o - N 0TES:
-- I € 1. DATUM IS
A
SEPTIC DESIGN: (G SAGE DISPOSER Is � ) --
_ Pa.�ES�i_*�� F' OW ___ k�F i -__ D) - --- GPD MUNICIPAL WATER IS
• � OMS G 2
A
t_'�il4 ri U UC jf i :r `'
r - � —
' � SEPTIC TANK: GPD _ 4. DESIGN LOADING FOR ALL PRECAST UNITS TO 3E AASHO H-
5, PIPE JOINTS -IO BE MADE WATERTIGHT.
USE A GALLON SEPTIC TANK _C-0--
6. CONS t RUCTION DETAILS 0 BE tN n�.`.vt.vtrNCE WITH MASS.
I__IvACHING: ENVIRONMENTAL CODE TITLE V.
d �, � �.` -- _ __ _ ?. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
USED FOR LOT LINE STAKING.
BOTTOM: 8, PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
{ f 7
TOTAL: 4a S,F. GPD COMPONENTS 9.
Tfi NOT TO BE BACKFILLED OR CONCEALED WITHOUT
t ��, . INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
FROM BOARD OF HEALTH.
— 10. CONTRACTOR SHALL BE RESPONSIBLE FOR VERIFYING THE
LOCA71ON OF ALL UNDERGROUND & OVERHEAD UTILITIES PRIOR
._ TO COMMENCEMENT OF WORK.
Ll 0EI
�--�- SITE AND SEWAGE PLAN
100.0 PROPOSED SPOT ELEVATION OF
10OX0 EXISTING SPOT ELEVATION
'I N THE TOWN OF:
100 PROPOSED CONTOUR .
` _-•-�-- � _� -�"'. ,' ���; -- — 100 — — EXISTING CONTOUR PREPARED FOR: .'
I
,
0
•----- BOARD OF HEALTH
i D
MA
SCALE DATE
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APPROVED DATE
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down cape engineering inc.
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CIVIL ENGINEERS Na 3fvq
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LAND SURVEYORS `f5TE '�
939 main st. yarmouth, ma 02675
ARNE QJALA, F.E., .L;S,� DATE
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-
SEPTIC PROFILE TEST HOLE LOGS - --- — '
— ----., ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALES M1 ACCESS COVER (WATERTIGHT) TO ENGINEER: A �
1 WITHIN 6" OF FIN. GRADE ti t
trIWIMUAI .75' OF COVER OVER PRECAST �q 2% SLOPE REQUIRED OVER SYSTEM WITNESS: "�i_ E," ��` 1_�
------
DATE:
' RUN PIPE LEVEL / 2" DOUBLE WASHED PEASTONE �
FOR FIRST 2' r »r
a 3'�MAX PERC. RATE Z Ms j
r - PROPOSED {
GALLON SEPTIC q-1 5 `�' /� CLASS _ y__� SOILS P
- _ —
— r TANK (H- ✓_) GAS _
L-------- ----- —-- BAFFLE -7.�5
(_ _X SLOPE) _5 CRUSHED STONE OR MECHANICAL
COMPACTION. (I5.221 [2]) 2' 4 e- `1✓" ELEV.
) 1/2"
4 ..
DEPTH OF FLOW A- o�
I x SLOPE � •
TEE SIZES: (--- 3/4" TO 1 1/2" DOUBLE WASH-__D STONE
� _
INLET DEPTH
LOCATION MAP SCALE 1" = >
OUTLET DEPTH
LEj�CHING PARCEL
FOUNDATION— 10 -- SEPTIC TANK -- - — ZZ D' BOX -- - - -- --�-- -- - I ? ASSESSORS MAP
FAC I LITaY +
'(7) ZONING DISTRICT: r
cee 'I °I Cra YARD SETBACKS:
FRONT =
��� ( I ✓ SIDE = S
� •� / I..-E r~ REAR - 1�
PLAN REF. 4-
'� '--►y FLOOD ZONE:
f i
`?-
C� VA
NOTES:
SEPTIC DESIGN: (cARE:aGE u!�,PosER !s_..N �w�'�.�. ... ) 1. DATUM IS
,-y � ��
y // _vr u �. rnl '4 k,lrry� rrry« � { a�JCJIhr��E`L.UVV' !��; C�G}v'fiL�U'N�.J h_-L,`_.._hl'U) =-./' 1
USE A , GPD PESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8" PER F00f.
j _ _ (16 6 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H
:\t SEPTIC TANK: GPv
5. PIPE JOINTS TO BE MADE WATERTIGHT.
�\ USE A—.1500 GALLON SEPTIC TANK W!IH MASS.
-- 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE
LEACHING: ENVIRONMENTAL CODE TITLE V.
y{: .�- y � ,, .4 �,$ THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
SIDES: USED FOR LOT LINE STAKING.
!307 OM: �'`�%`--.- - � - 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC.
9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAIINED
.,
"�., �•\ � ^ � �, `, _____.�� -_.__._,4r_ __ "�°`-}?�" �-_��._ _ '���%�"�y��`.�-L�:""�._.. ____ FROM BOARD OF HEALTH.
,
l j7GEN�
SITE AND SEWAGE PLAN
C 100.a PROPOSED SPOT ELEV,>TION OF
10OX0 EXISTING SPOT ELEVATION
I TH OF. �. v
_ N E TO
00� PROr OSED CONTOUR
t 00 — — LXIS'ING CONTOUR PREPARED FOR:
Ile ,
j F\ ►'�iE 6. •s� V iG' Q c'c 'ice
HOARD OF HEALTH
- MA SCALE: DATE: �-jAPPROVED D;TE
- aff 506-3624b4 t
fox 50a mt�-ow
down cape engineering, ine. ARNt
\ ..
r , AOjALA
� � -,
CIVIL, ENGINEERS Imo}
.��N D ST-JRVEYORS
armouth ma 4ti67� ��.�
9�39 main St. ,
y
JOB# ARNE H. 0JALA, S. DA TE
-- --
bmwigam hill
1 l `I 1 i r i v ,
S�P 7_I�_ P R I L .� E 1 H O L F LOGS
T.O.F. AT Ei_. �--� --
----j o o ACCESS COVER TO WITHIN 6' OF FIN. GRADE (NOT TO SG&4
= a
�~ ACCESS COVER (WATERTIGHT) TO
/I WITHIN 6' OF FIN. GRADE
f' * WITNESS:.75' OF COVER OVER PRECAST - 2% SLOPE REQUIRED OVER SYSTEM .�
_ �►....� �'�: !
DATE: _ ..
�. RUN PIPE LEVE1 Z" DOUBLE WASHED PEASTONE; 9�a f
FOR FIRST 2' 4 F _ 2'-
�. , ERA:, RAT _ f
PROPOSED -u
Ic , 1
3 MAX ?
I
GALLON SEPTIC �'(.-'T 5 (��xc� ,LASS ___ SGILS P#
TANK (H— !O GAS
SLOPE) 6' CRUSHED STONE OR MECHANICAL
ELEV
COMPACTION. (15.221 [2]) _ - -
1
$ — — — - , o 0
DEPTH OF FLOW __-- _—____ (�' `
(_�__X SLOPE} 3 '4" TO 1 1 i 2 DOUBLE WASHED STONE
TEE SIZES: y
INLET DEPTH = �L�_ � -A- "
OUTLET DEPTH LOCATION MAP --=-- SCALE 1 =
can 7 a K 4 j v
--- LEASHING PARCEL 7 -
FOUNDATION-- � -- SEPTIC TANK -- ? ---- D' BOX ------ ` ' --" --— FACiLIT✓ ='` ASSESSORS MAP
ZONING DISTRICT:
YARD SETBACKS:
FRONT
SIDE
REAR - 1
W " .,,,.
�. F" , PLAN REF. - ' '
FLOOD ZONE. ( ,
cN /
SEPTIC DESIGN -� {GAF2E;AUE o+sPosER 1 , DATUM ,S ,�.�—_�---- °T`�' -
91 ( ( torr, nr cif h.l c"t �itAf. --%e r r"prlrg4c, ( 1�� r.t.�(31 - /-�Dn WATP-R IS
USE G!' a Al,
\ '^ Al,SIGN FLOW ry 1.t -. _.
A � 3. MINIMUM PIPE PITCH TO BE "1 j8" PER FOOT.
' 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO
SEPTIC "TANK: .�' GFD ( ��) = t _
\ 5. PIPE JOINTS TO BE MADE WATERTIGHT.
USE A 1,5On CALLON SEPTIC TANK
g�' - -- 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
LEACHING ENVIRONMENTAL CODE TITLE V.
§,� ' .. o,,g 7. THIS PLAN IS, FOR PROPOSED WORK ONLY AND NOT TO BE
SIDES. USED FOR LOT LINE STAKING.
tIe< x. �- r .'j 'lit~( _-
i 6 070M, __— _____ _._._ "�r__ >.._..IL 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC.
9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
TOtA." F' ;_�..UPD INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
FROM BOARD OF HEALTH.
o
` EN
c� E AND SEWAGE L
�- --- SITE N SEWG PAN- --- -- - — --- - _
PROPOSED SPOT ELEVATION OF �
100x0 EXISTING SPOT ELEVATION
IN THE TOWN OF:
PRO, OaED CONTOUR ( 1 ,� G•-�' r
lk-
' '" 100 -- — EXIS'kNG CONTOUR PREPARED FOR:
-lK `tIJ6�wNta� ,
0 �- ---- -_—iw
BOARD OF 19,A.TH
,l MA D SCALE: �`� ATE:
i. f A.�'PROVED Di TE f
ru, soe 363-
;, <
t �, 'r•1-1• ` �� I
�
fit, . '�`
4 down cape ey gin eering, Inc. �Nrl ` , > � A �,* H.
4Jr_A
�` ✓ , a. -° CIVIL ENGINEERS �.I
939 main st yarmauth, ma 02675 w - —
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