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Home My WebLink About0012 WILLOW STREET - Health 12 Willow Street_ - West Barnstable'r a A= 156-032 , Q a 1 ' I i t n I Ii i J 1 TOWN OF BARNSTABLE LOCATION / Z SEWAGE#ZZIIJ 07. VILLAGFff,/, ASSESSOR'S MAP&PARCEL/1e- 05 Z- INSTALLER'S NAME&PHONE NO. (210W>M146 SEPTIC TANK CAPACITY &!UV LEACHING FACILITY:(type)`j Ig4LL5®pg?c_�,; (size) NO.OF BEDROOMS OWNER —Toou C-4. 6°' iwa PERMIT DATE:'a�� I V COMPLIANCE DATE: �� Jzo dI 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 �s TOWN OF BARNSTABLE LOCATION 11Z ,�l�l SEWAGE # VILLAGE W a r n ASSESSOR'S MAP 6i LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS RIVATE WE FOR PUBLIC WATER BUILDER OR OWNER C { ariQ `P DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No - �r2 ��Si�1G t�"i9M£fi W�►�'f2:._. Y To I. easi IanLi,�cs C' 1` O x a. mvo�l y� Pasv��►d 'T�-'od a u _, _ No. �� = Fee BOARD OF HEALTH TOWN OF BARNSTABLE ;a ZlppYtcattou -for Yell Cougtructtou Vermtt Application is hereby made for a permit to Construct( ), Alter( ), or Repair( ) an individual well at: } Locatio -Address Assessors Vap and Parcel /p- A. V wd4&Z Owner A ddC �� 3� Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well Capacity Purpose of Well Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. Signed D e Application Approved By Date Application Disapproved for the following reasons: Date' Permit No. Issued Date -------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certiftcate of Comphauce THIS IS TO CERTIFY,that the individual well Constructed(k45-/Altered( ), or Repaired( ) by �L Installer .has been stalled in accordance with the provisions of the Town of Barnstable Board of Health Private Well,,Proteftion .Regulation as described in the application for Well Construction Permit No.�9l1 —M-t Dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. 1 ' -- Fee S� BOARD OF HEALTH TOWN OF BARNSTABLE M 2pplicatiou jFor lVerr Construction Permit Application is hereby made for a permit to Construct( ), Alter( ), or Repair( ) an individual well at: c� 01 b)aAn') Location-Address Assessors Map and Parcel Owner `1 V Address /Installer-'Driller ` Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well ,�?_I� Y °1 ," -r" Capacity Purpose of Well �J}ti1� 't� Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. JJ Signed Date Application Approved By ------ A=' Date ,.Application Disapproved for the following reasons: a z Date Permit No. Issued Date .�4------------.o.--------------- -------------------------------------... ---ova, -----------..------..e-toa�»dee..... BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of (Compliance THIS IS TO CERTIFY,that the individual well Constructed(L);/ Altered( ), or Repaired( ) by f(/ Installer at has been4nstalled 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 Noi ,QI 63—pG 9' Dated /. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector --------.-------------..,»--- ------------ - -----------.-----..d..----^--------------------------- --,.-- BOARD OF HEALTH TOWN OF BARNSTABLE Yell Construction Permit No. `0 Fee 5 Permission is hereby granted to (f.ej (ref( !� Installer to Construct(c),-/ Alter( ), or Repair( an individual well at: No. 1,11.�r��1�rr i1 Street 1� as shown on the application for a Well.Construction Permit No. 1ps)Q "? "b y Dated AF jlq Date J .Jl Approved B(.,, �, J ./ _ _`�' I Commonwealth of Massachusetts Title 5 Official Inspection Form 6, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. CityfTown state Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections Company Name PO Box 896 Company Address East Dennis MA 02641 Cityfrown State Zip Code 508-385-7608 S13742 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 10/10/13 ins'pect6r 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. V, 5 r3 t5ins•11/10' Trtle 5 Oftial Inspection dace Sewage Disposal System-Page 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. Cityrrown state Zip Code Date of Inspection B. Certification (cunt.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17. Commonwealth of Massachusetts Ville 5 Official l Inspection Form s Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. Citylrown state Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface wafter ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh tams•11/10 Title 6 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 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. Citylrown State Zip Code Date of Inspection B. Certification (cunt.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment ❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 10.0 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 day flow t5ins-11/10 Title 5Official lnspedion Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts mom Title 5 official Inspection Fora s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is West Barnstable MA 02668 10/08/13 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is 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 ebst 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 El El Area 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 Departirtent. t5ins•11/10 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 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. City/rown 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 (f any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information_ Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑=Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® , No Water meter readings,if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15203): 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 11/10 Title 5 Official Inspection Form:Subsurface Sewage Deposal System•Page 7 of 17 f Commonweafth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 12 Willow Street Property Address John Mika Owner Owner's Name requir afo is West Barnstable MA 02668 10/08/13 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes,attach previous inspection records,if any) ❑ Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the WA system by system operator under contract. ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5in:•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form s, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is West Barnstable MA 02668 10/08/13 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (f known)and source of information: 03/31/11 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): 1.4 Depth below grade: feet Material of construction: ® concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1,000 gal Sludge depth: 2" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 I Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 12 Willow Street Property Address John Mika Owner Owner's Name requiraaion is uired for every West Barnstable MA 02668 10/08/13 req page. Citylrown state Zip Code Date of Inspection D. System Information (cunt.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" Scum thickness 2" 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 16" How were dimensions determined? measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5irs•11110 Title 5 Ofticlal Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on.pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 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 r 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-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form K Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(f present must be opened)(locate on site plan): Depth of liquid level above outlet invert even 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 box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) pocate on site plan,excavation not required): If SAS not located,explain why: t5:ns•11110 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 18 ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/attemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has three rows of six diffussors in a 31'x9'field of stone.There was no sign of ponding or failure in the stones. 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•11/10 Trite 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �t 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. Cityrrown state Zip Code Bate of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. CityRo✓n state Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately rear SR 49 81 61 66 76 mrs•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West BamstaUe MA 02668 10/08/13 page. Cityfrown state Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 20.0 Estimated depth to high ground water: feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 0 iciatl Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 12 Willow Street Property Address John Mika Owner Owner's Name information is required for every West Barnstable MA 02668 10/08/13 page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A,B,C,D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ir,s•11/10 Title 5 Official Inspection Form:Subsurface SoMe Disposal System•Page 17 of 17 1 , Town of Barnstable P# 13 2ol- Department of Regulatory Services ' Public Health. • SARNF1G+s!'i, • Division Date .3• / / 200 Main Street,Hyandis•MA W601 fp N1Itt� _ Date Scheduled_ I Time—I Fee Pd. Soil Suitability Disposal Assessment or Sewage Dis 1 f g P Performed By. 'T'"�� V'V�"r`(i(J Witnessed By: v W, lnn7t)i�l S LOCATION& GENERAL INFORMATION Location Address /,-Z Owner's Name LbeS T�AQN S 7,q f3 le. Address 1,2 GU 14 g, 5 T Assessor's Map/Parcel: 5k— v3; Engineer's Name DI 'gYiO /S14$6N NEW CONSTRUCTION REPAIR t'� Telephone#SU�'� 83 3 —Z 7 7 Land Use Slopes(S'o) Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) Parent material(geologic) Depth to Bedrock__ Vv Depth to Groundwater. Standing Water in Hole: A Weeping from Pit Face Estimated Seasonal High Groundwater d\b77 DETERMINATION FOR SEASONALHIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: Depth to weeping from side of obs.hole: in, Groundwater Adjustment fr. _ Index Well#t Reading Date: Index Well level� a Adj.fhetor— Adj.Groundwater Level PERCOLATION TEST Date_.. ._, Time Observation Hole# Time at 9" Depth of Pero Time at 6" Start Pre-soak Time @ 2 ` Time(9"-6") End Pre-soak SPAI Rate Min,%cht Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back----=----- ***If percolation test is to be conducted within 100'of wetland,you must first notify the, Barnstable Conservation Division at least one(1) week prior to beginning. Q:\SEPTICIPERCFORKDOC 1 DEEP-OBSERVATION HOLE LOG Hole # Depth from Soil Horizon Soil Texture Soil Color Soil. Surface(in.) (USDA) Other (Munsell) Mottling (;i;tnucture,Stones,Boulders. C;onsistency %OrayeO _)q_ ------- Y�X?� C �-1 y DEEP 013SERVATION HOLE LOG Hole# - Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders. on i engy %Gravel) II DEEP OBSERVATION HOLE LOG Hole Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) (USDA) (Munsell Other ) Mottling (Structure,Stones,Boulders. it DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell). Mottling (Structure,Stones;Boulders. Consistency, Flood Insurance Rate May: Above 500 year flood boundary No— Yes T - = Within 500 year boundary No Yes - Within 100 year flood boundary Na v Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious ma 'al exist in all areas observed throughout the area proposed for the soil absorption system? teri If not,what is the depth of naturally occurring perviqjm material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environ 2tal Protection and that the above analysis was performed by me consistent with . the required training,ex rd and x erience described in 310 CMR 15.017. Signature Date o l Q-%SBPn0PERCFORM.DOC Town of Baruf able °FEE r� Regulatory Services Thomas F.Geiler,Director + BARN.$Tik$EE, a Public Health Division rFa, Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644_ -Fax: 508-790-6304 Installer &Designer Certification Form Date: 7IIIAD Designer. 11:2 12, DIIJ Installer: W � Address: . >. 0",-v NV a Address: CVPLA On 3 - l - CJ' 1WV{� WW 4i� was issued a permi to install a (d te) (installer) �� septic system at W tujVk3 "It� based on a desi gn drawn by (address) � dated �clesigner) I�-:C -ify that the septic system referenced above was installed substantially according tee Elie design, which may include minor approved changes such as lateral relocation of the i,ztribution box and/or septic tank, . I certify that the septic system referenced above was instal -d v�nth'. a�or,changes greater then Y O' lateral relocation of the SAS or.-any vertical reLooafi6n of any compondat of the.septil systern)but in accordance with State&L•oca1;IZegilat ons. Plan revision oT certi : d as-b t�*desil;ner to follow. fi : n . r., -�cr+a�Mgs Z fikiD 13 ( sta ignature) C 'IASON `rn •n sgNl TAA�P� (I3 er s Signature) (Affix e. gner'.'s Stamp Here) PLEASE RETURN TO 7BAMSTA&LE PUBLIC.-DEALTH.DIY:ISION. CERTIFIC TE OF.: CQRPLIANCE W LL `Ni�T IRE': SSUED :I3PITII BOTR :T$l[S FORM t` AS_ BUILT fARD ARE RECEIVE_ I? BY Ta. ARf�XBLE PtIBLI.0)EIEAL�DIVI$IE}I�i TF€ANK YOU , Q:HealdVSep lc/Desiper Certification Fore, ` No. �Ol/ V r J � s Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye application for bisposaf *pstrm Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.�� W o//pit) 8'T Owner's Name,Address,and Tel.No.J6//A) Assessor's Map/Parcel`S4 le 4.4 G(l//0A) �'f Installer' Name,Address,and Tel.NoSGGw'' 4MV� Designer's Name,Address,and Tel.No�B C- E,VY/ 11A& �L 3ZWi'O7JGr RP, 45�7/0' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3�j L gpd Plan Date 3,A Y Number of sheets ! Revision Date Title � pp`` Size of Septic Tank � Uh.J Type of S.A.S,j J&tvS D 6 A46 4,e& 3 Description of Soil Nature of Repairs or Alterations(Answer when applicable) &CIAI �.�• 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 nvironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Bo f alth. Si Date ,r 4, Application Approved by Date u Application Disapproved by Date for the following reasons Permit No. eW l t —dam c-D— Date Issued 3 J No. �/ ::,�,. f Fe THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer: Awor ayes PUBLIC HEALTH DIVISION,-.TOWN OF BARNSTABLE, MASSACHUSETTS ZWOration for Ni posal *pstem Construrtion Vermit , Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No./1�1 601,1106V E 77 Owner's Name,Address,and Tel.No._]644.) /tV"K Assessor's Map/Parcel � R� 3�Z, Installer' Name,Address,and Tel.No;SGo71r"�gM� 1/ Designer's Name,Address,and Tel.No.�B iOr�e�G� ees-/C -A F4,97— bvic V /`?'f 5 b6-833— Z/77 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided 3 L gpd Plan Date 3 A Number of sheets Revision Date Title Size of Septic Tank 1X0 (. 4(6hA_) Type of S.A.S.`:j �&M)S- D f (7 LIDS 41ec 34 Description of Soil Nature of Repairs or Alterations(Answer when applicable) &�/,t) 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 nvironmental Code and not to place the system in operation until a Certificate of ! Compliance has been issued by this Bo f alth. Sig Date Z' S py Application Approved by Date Application Disapproved by Date for the following reasons Permit No. � �/ CG`7° Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliante THIS IS TO CERTIFY,that the Ong-site Sewage Dig osal system Constructed( ) Repaired( ) Upgraded( ) Abandoned( )by yLJ! G' LAI$ of has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No.-'ll G7'�?aated Installer Designer #bedrooms 3 Approved design\flog 3 3 J gpd The issuance of is permit shall not be construed as a guarantee that the system will funn tiilJJL as designed. /f Date > a b' i Inspector 0 ----------------------------------------------- ---- No. � / /� ( � F Fee ee /Q THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS disposal 6pstem Construrtion permit Permission is hereby granted to Construct( ) Repair(b/j Upgrade( Abandon( ) System located at S5 - / )e�°�- Sly e t)S14 41 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must complete within three years of the date of thists permit. Date / Approved by i 1 b ASSESSORS MAP: T LOGS NOTES: �� -- --��------ PARCEL : EST - HOLE L E L G FLOOD ZONE: 1�bT ATVbiC ,�L& SOIL EVALUATOR: � w YI �/� M"'a6 v_. _.._..- 1) The installation shall comply with Title V and Town of Yarmouth Board of o _ _ _._ . ._ _ _ . __.....__-._ WITNESS : �� p Y REFERENCE: gi,l�,,.l OC �(J h.l �� C DATE: I•, �I HealticRegulations. 1 �� >��I ��L, PERGOLA ION RATE: ..� -,2 INt1 � I . 2) The installer shall verify the location of utilities, sewer inverts and septic 1 . components prior to installation and setting base elevations. V )6b' 9, 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first --R) TH- I TH-2 two feet out of the d-box to the leaching shall be level. �p Syy� 4) This plan is not to be utilized for property line determination nor any other 1�� /(7y2�3 Z �r �✓ Z. purpose other than the proposed system installation. -- '1 tV 5) All septic components must meet Title V specifications. may, 6) Parking shall not be constructed over H10 septic components. _ 7) The property is bounded by property corners and property lines. LOCAT I O�P-----� - 8) The property owner shall review design considerations to a '� bK pProve of total ,�-•'' design flow and number of bedrooms to be considered for design. Receipt of payment for the plan and installation based on the plan shall be deemed . / approval of the design flow by the owner. 9f 9) The existing leaching or cesspools shall be and filled with material per Title V abandonment procedures. pumped o �� Those within the proposed SAS shall �g O � �' � be removed along with contaminated soil and replaced with clean sand per 4z � Title V specs. 2z- � � � Z ______.. 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if 1 r SEPTIC SYSTEM DES I G N applicable. The proposed SAS is being installed below the water service J 1 \ line. The line is to be sleeved as aforementioned and maintained in place. ,,-:Xl j 11) If a garbage grinder exists it is to be removed and is the responsibility of the FLOW ESTIMATE owner to ensure such. 12)The installer is to take caution in excavation around the as line� g e if such 1j 7j BEDROOMS AT IO GAL/DAY/BEDROOM GAL/DAY exists. 13)The installer shall verify the location, quantity and elevation of the sewer SEPTIC( TANK------ lines exiting the dwelling prior to the installation. / � � � i � �X►�j�l \ _ g g p COAL/DAY x 2 DAYS - 60 GAL � . I � USE I,�Op GALLON SEPTIC TANK E1U511��¢,Q i . � � " CpD Nam_ ' , 1 S I L ;[3SORP ION SYSTEM - 1 I ► �-i rt,�►v I�17 �l�j l l h1`1 k_� I- --,0 (" I)uJ / �►u �: o(c) _✓.__ . _._ _ _. —�— -�--_ h-11� .�i D1� i '�/'I� T�wet t' I�� W �1 11O 6'CUiASUN _ ►fig`► IT o �,F ,S ,F,hr. _ 2, 43 i 1(o 00 I EPT LIC SYSTEM SECTION �P VA 4JA0 I N 6B0X_ GAL SEPTIC 'TANK5`1 I 31TE AND SEWAGE PLAN i� ►��,'1' .: iv _�-�_.. V' U.. f zif,Q t 2�_ -_ LOCATION : -4 I Z W l ww Z`�Zf�n PREPARED F 0 R : N1171 L�' �Pw'�fm;Q I ----- --�"'� SCALE: I ' DAV I D B . MASON ie-) DATE: 3 Z o DBC ENVIRONMENTAL DESIGNS EAST SANDWICH . MA l DATE HEALTH AGENT ( 508 ) 833- 2 1 77 Z