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Home My WebLink About0096 BOULDER ROAD - Health 96 BOULDER RD. BARNSTABLE 4 F A = 316 ,027 _ F y a C Y t r �<7 a i � y C s n • 1 ` k t F' e . y .ne _ .,. �. � r y r _ _ is ` , ^ {T.., n - g�. Fl ,. j• �Y iCi �' r. � - `� ..n i r No. �0 I — ' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppliLatlon for Disposal 6pstrm Construction Vrrmit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System 2Kndividual Components Location Address or Lot No.,�V,6pa,,%e O 's Name,Address,and Tel.No. Ow��—may C✓f' Assessor's Map/Parcel ®j? A&4 4--p0,o Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. jW7 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 4e'oo No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) �® gpd Design flow provided gpd Plan Date �` �"''J Number of sheets I/ Revision Date Title Size of Septic Tank er/,f'f/J'�/�' o" Type of S.A.S. Description of Soil V 6:F�X� Zoe Nature of Repairs or Alterations(Answer when applicable) � � ��,�!✓ Date last inspected: Agreement: . LL The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board o lth. Signed Date Application Approved by Date Application Disapproved Disapproved by Date for the following reasons Permit No. _0 17- P G Date Issued t: No. U I Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ` PUBLIC HEALTH DIVISION --TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Disposal 6pstent Construction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System Individual Components J Location Address or Lot No. y,+ Own ' Name,Address,angel.No. Assessor's Map/Parcel Oe; 404&-TA Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. .7 lop Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building G�'f: No.of Persons Showers( ) Cafeteria( ) Other Fixtures - Design Flow(min.required) 7-3'---IrO gpd Design flow provided . gpd Plan Date �`MoY ��/, Number of sheets I/ Revision Date Title Size of Septic Tank d��.f r7-✓Jy'�+' �'p o 0 Type of S.A.S. C O."'C.r IleTd, Description of Soil Nature of Repairs or Alterations(Answer when applicable) � � �.1,d(/✓ Date last inspected: Agreement: -V The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board 01,11ealth. Signed Date Application Approved by J Date Application Disapproved by Date for the following reasons Permit No. ?-G — Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifirate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by J Z ta�B �( li .l'� 0., at 9��oy��.G�CTl �/� .� Il�' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 0 dated Installer/,ow 4eaa 6� Designers Q ,r #bedrooms J—� Approved design flow gpd The issuance of this permit sh I not be construed as a guarantee that the system wil�tio as ig ed. ---- Date . Inspector k� --------------- ------------- --- --=------------------------ - ----------------- ---- =--------------_ _-----=----------------------- - N0.2017 — �� Fee ti-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Vermit Permission is hereby grant Repair Upgrade to Construct( ) Repai Upgrade( ) Abandon( ) System located at fgr 6te 40-47 4"'-140 , i Ze 4 ��V and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date �� lS Approved by ® TOWN OF BARNSTABLE LrOCATION / ®�� SEWAGE# VILLAGE _ " �/�� `ASSESSOR'S MAP&PARCEL3/cf INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY Ci'X��T�I✓� ,>®80 � LEACHING FACILITY: (type) ®° op (size)f��'a NO.OF BEDROOMS .2" OWNER PERMIT DATE: '�� COMPLIANCE DATE: �! Separation Distance Between the: .ow® Ap�� o 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) J Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY Qj��,407 ��®�� In • 1 44 �' o J From: 05/09/2017 15:49 #737 P.001/001 Town of Barnstable SIN t Regulatory Services ti Thomas F. Geiler, Director BARNSTABLE. � Public Health Division 1639-Dl�p3�A Thomas McKean, Director 200 Main Street, Hyannis,MA 02601 Office: 50 86 4644 Fax: 508-790-6304 Date: Sewage Permit#.�20/;;P—`"26'Assessor's Map/Parcel /p Installer&Designer Certification Form Designer: DOUTAi 2�, �'/� Installer: Address: C;46 Address: a�� l� Lf On was issued a permit to install a (date) (inV septic system at �' am ��-AW based on a design drawn b l y(address) b ,V7 0, ftcD44f7 dated Z� . �� (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stnpout (if required) was inspected and the soils were found satisfactory, I certify that the septic system referenced above was installed with major changes (i.e, greater-than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local p '-tions. Plan revision or certified as-built by designer to follow. Stripout(if r- -cted and the soils were found satisfactory. �P�ZN t)F 9� � DApVID y,c (Installer's Signature) R MASON ;L 9 No.1066 rsr Rya e-s iY er s Signature) J PLEASE RETURN TO BARNSTABLE PUBt,._ _.:CIE OF COMPLIANCE WILL NOT BE ISSUED UN r<rL pu i ri i tfi-i 1,0RNI AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. gAoftice fonns`,iest;nercenitication ronn.doc i Barnstable IKE Town of Barnstable Regulatory Services Department ;e,caC j BAANSTABM 9 : Public Health Division m 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012 1010 0000 2847 8537 March 8, 2017 FREDERICK, JUDITH M TR ' 795 LILY BAY RD #702 BEAVER COVE, ME 04441 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5 The septic system located at 96 Boulder Road, Barnstable,MA was inspected on 03/02/2017 by David Mason, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the'system"Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00).due to-the following: 4 Leaching facility with standing liquid level at or above the invert pipe (per ' Town Code 360-20 h). A You are ordered to repair or replace the septic system within two (2)years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. z , PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., IIfl Agent of the Board of Health Q:\SEPTIC\Letters Septic Inspection Failures or Future Evl\96 Boulder Road Bamstable.doc f of IHE ~. "* Town-of Barnstable wtersrt�r.$, , 31AS& Regulatory Services Department - Public Health Division '200 Main Street,.Hyannis fMA"02601 . Office:.508-862-4644 Richard Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 5111/16 DEADLINES TO.REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15,000) _ An'x"marked in the ❑ is the failure criteria and associated repair,deadline 60 DAY DEADLINE CRITERIA: ❑ Discharge or ponding of effluent to the surface of the ground w ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑9ackup of sewage into the house due to an overloaded or clogged SAS or cesspool ONE (1)YEAR DEADLINE CRITERIA T ❑ Static liquid level.in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of.a private water supply well with no acceptable water,quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2)YEAR DEADLINE CRITERIA ❑ Single Cesspool ❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation of a driveway due to H-10 components, etc) ❑ Leaching pit or cesspool with high liquid level;<12"below inlet(per Town Code §360-9.1) XLeaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:ISEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc 3 i - t Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Boulder Road M Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust -a Owner Owner's Name t—+: information is �7 required for every Barnstable MA 02630 March 2, 2017 : page. City/Town State Zip Code Date of Inspection t-•. 1?a� ra'1 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 filing out forms A. General Information II �A, O on the computer, I , U use only the tab 1. Inspector: key to move your cursor-do not David Mason use the return Name of Inspector key. Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-833-2177 S1287 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 March 3, 2017 Inspectors Signature a Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 page. CityrTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain,below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D System Failure Criteria Applicable to All Systems: Y pp y 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 I ® ❑ or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 j _. Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is Barnstable MA 02630 March 2 2017 required for every , page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 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 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of.bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is Barnstable MA 02630 March 2 2017 required for every , page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: 2016; 31,000 gallons and 2015 26,000 gallons Sump pump? ❑ Yes ❑ No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M4.1 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): i t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c�M 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is Barnstable MA 02630 March 2 2017 required for every page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Compliance issued 5/17/2001 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ®40 PVC ❑,other(explain): Distance from private water supply well or suction line: 10 feet Comments (on condition of joints, venting, evidence of leakage, etc.): Not observable. Septic Tank(locate on site plan): Depth below grade: 14 inches feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) There is an existing concrete tee/baffle which needs to be replaced due to decay. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32 Scum thickness 3 Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Scour Stick Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank oulet tee/baffle is concrete and needs to be replaced with a pvc tee due to corrosion. Septic tank is 14 inches below grade. 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 l5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 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): I Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0.5" 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.): There is evidence that the dbox is H10 and is corroded requiring replacement. There is also evidence of solids carryover into the distribution box. Distribution box is 21 inches below grade with a riser within 7 inches of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No" Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500's ❑ 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.): There is standing effluent up to the invert of the inlet pipe in the chamber observed indicating hysdraulic failure. Chambers are 42 inches below grade with risers within 10 inches of grade. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2, 2017 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Ground water contour map ® Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Based on knowledge of area and Town of Barnstable groundwater contour map. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 96 Boulder Road Property Address Judith Frederick, Trustee and Krystyna Dubois Rvocable Trust Owner Owner's Name information is required for every Barnstable MA 02630 March 2 2017 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 MAR-02-2017 10:56 From:BARNST HEALTH 915OBS624713 To:5087718012 P.1/1 TOWN OF BARNSTABLI~ ,L! LOCATION r (,` .t� _ {ZUJ��. SEWAGE 4 1.. 7- VILLAGE__ ' ��I F '` -: ASSESSOR'S MAp& LOT 314,-0 Z INSTALLER'S NAME&PHONE NO. C'OAXIU 77 ) 'C�C� SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �_- NO.OF BEDROOM'$ �� BUILDER OR OWNER 1 V 67 0.7 PERMIT DATE: !q ~0 j COMPLIANCE DATE: � � / 7 Separation Distance Between the: Maximum Adjusted Giaunciwatcr Table to[hc Bottom of Leaching Facility —Feel 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 ff , 1 qY 13* , �0 l W ! �T 1 Town. of Barnstable �P� �111ti . . E Department of Regulatory Services a Public Health Divisoni eu►artarneun, D MAea . s'sllr 200 Main Street,Hyannis MA 02601• as. y Date Scheduled Tlme Fee l/ Pd. CF Soil Suitability Assessment for S age his o al Performed•By:. r Witnessed By: --y Location Address LOCATION& GENERAL INFORMATION '�� ' � Name e Owners - �� ®� 4-C'tT/� . Address � C Assessor's Map/Parcel: ' Engineer's Name 10'e, *"4 Dr.p NEW CONSTRUCTION REPAIR 4/� Telephone$ 3 p 7 ,ol Land Use• / -ire Slopes(%) Surface Stones . Distances f}nm: Open Water Body R _Possible Wet Area R Drinking Water Well • ft Dralhago Way---__R Property Line . - ---__R Other R SIMITCH:(Street name,dimensions of lot,exact locations of teat holes&pare tests,locate wetlands in proximity to holes) J. j Parent material(geologic) Depth to Sedrock Depth to Groundwater. Standing Water In Hole: Weeping 11'om Pit Fnee Estimated Seasonal High Oroundwnter DETERMINATION FOR SEASONAL"HIG WATER TABI, Method Used: Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: In. Depth to loll mottles.. Index W In. Groundwater Adjustment e ell� Reading Dato: Index Wll IeYal -•-- Act,fketor__ Adj.Groundwutar Level PERCOLATION TEST beta IIr(ttmb- Fole# on ' Time at 9" Pere Time at G" �--- Slert Pre-soak Time @ I I Z� 1 Time Time(911-611) End Pro-soak Rnte Min.nuch , 2 MJg1 ' Site Suitability Assessment: Site Passed 'Site Failed: Add(tlonol Testing Needed(YIN) Original! Pabtle Heauh Division Observe ion Hole Data To Be Completed on Back ***If percolation test is to be conducted within 100' of wetland,you must first notify the. j Barnstable Conservation Division at least one(1) week prior to beginning. Q:1SEP lC\PERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth:from Soil Horizon Soil Texture Sdil Color Soil. Other Surface(in.) (USDA) (Munsell) Mottling (Stnucture,Stonei;Boulders. r sl_istency,%'Orayell to i i _ t .6 �i Ii ti DEEP OBSERVATION HOLE LOG Hole# Depth from Solt Horizon Soil Texture Soil Color Soil Other. Surface(in.) (USDA) (Muresell) Mottling, ,(Structure,Stones,Boulders. Consistency,%(]a ILAn Zoe rk DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (MnHell) Mottling (Structure,Stones,Boulders. Consistency. DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Bull Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Slopes:Boulders, ConsistancV. y flood Insurance Rate Map: Above 560 year Mood boundary No_ es- boundary No if 'es Within 500 year n ry Within 100 year flood boundary No.� Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed thrpughout the area proposed for the soil absorptibn system? If not,what is the depth of aturally occurring pervious matorlal? _. Certification I certify that on �� (date)I have passed the soil evaluator examination approved by the Department of Enviro me tat Protectlon and that the above analysis was performed by me consistent with . the required training, �Iclrso experience described In 10 CMR 15.017 Signatur Date (P1 QAS EPTICIPRRCPORM.DOC TOWN OF BARNSTABLE LOC, TION CI& �R I�Z .i2o)qp SEWAGE # 260f-Zqr lk VIULAGE �?1 f4b� ASSESSOR'S MAP & LOT 316 O'Z� INSTALLER'S NAME&PHONE NO. 'F� Cfi0-Cv - `77 S' 2r'a6 SEPTIC TANK CAPACITY e5-A fS ��', LEACHING FACILITY: (type) 2—_52 C6 I � 'S (size) CS`f� NO. OF BEDROOMS 3 BUILDER OR OWNER a6 PERMITDATE: COMPLIANCE DATE: -s - 17 01 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 feetof leaching,facility) Feet Furnished by c..y o r -74- 6 �c r. I' ate: No. 04pl— f Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 70(ppr%cation for �Digogaf *pgtem Congtruction Verrnit Application for a Permit to Construct( )Repair( <Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. g6 �p(!1 r Owner's Name,.Ad�e ss and Tel.No. lot a3 / �� ?AV l v0 Dol s Assessor's Map/Parcel 3�— Q a7 G/d WCQHeQ��/ %r S. G 433�Oh ///t�t . Installer's Name,Add*&1&4=0 Designer's Name,Address and Tel.No. 350 Main StrSd W.Yarmouth, MA 02673 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1606 o:: .t%ct n Type of S.A.S. 4.P loop cy .& ;Aa Description of Soil Nature of Repairs or terations(Answer when applicable) _1115�,4�/ y' °X � C� 0 .5 � Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B d ealth. o Signed t Date (' Application Approved by Date Application Disapproved for the following reasons Permit No. 42 A 4-1 Date Issued r No. �� Fee % THE;COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for loigpool Opment Con5tructiowPer-a t? s Application for a Permit to Construct( )Repair( 4pgrade( )Abandon( ) EJ Complete System ❑Individual Components FAssessor's ddress or Lot No. �� gOv/ f J" �ner's Name. ss.n Tel.No. lot V Map/Parcel 3 Q a? �PcPy Ci t, „. C 4 s f chi Name,Address,a"Al K CANCO Designer's Name,Address and/Tel.No. 350 Main Street f r W. Yarmouth ( . C' Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calcdlated;daily flow gallons. Plan Date Number of sheets �"Fr Revision Date ✓ Y Title Size of Septic Tank /D UD Type of S.A.S. P 1.006 Description of Soil f `' Nature of Repairs or Alterations 0s(Answer when applicable) // s 14 �/ / f� y' 2 a X To C Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this`B°� d Health. Signed V � Date L Application Approved by Date 2®a,,, Application Disapproved for the following reasons Permit No. Vi3`4.>�_ 2 Date Issued 41 157— 2414r C THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( graded( ) Abaj4oned(� )by K P cr has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N702'3 dated 4w- I:F" 2ov,/ Installer Designer The issuance of this permit hall not be construed as a guarantee that the syste, 1 fu -io desig ed� Date 7 / Inspector i No.4 401 Fee �0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 0igogal 6potem Con!5truction Permit Permission is hereby g anted to Construct( )Repair( Upgrade )Abandon( ) System located at 3 O ,?ec c //A and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of S permit. µr. Date: Approvedpy;.- 3 .r 'l' SOU S �� ,.S/off. ., 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT WITHOUT DESIGNED PLANS I, (, w , hereby certify that the application for disposal works construction permit signed by me dated ` ° 1 , concerning the property located at o a(40�f meets all of the following criteria: , This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. �• There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system �• There is no increase in flow and/or change in use proposed �• There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] /• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen (14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) ��a B) G.W. Elevation +the MAX. High G.W.Adjustment. D T, S DIFFERENCE BETWEEN A and B ��• �' SIGNED : DATE: [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No 'd additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert ?�, �I i� 1 N `�\ o a -� b� �— G t —tea � � cn �.� TOWN OF BARNSTABLE LOCATION l'l [9-+{417) SEWAGE # LZ ? j VILLAGE 51 46 " . ASSESSOR'S MAP & LOT 316—C L INSTALLER'S NAME&PHONE NO. C$41u-"0 SEPTIC TANK CAPACITY ' LEACHING FACILITY: (type) '. !��f �' i ;�-ia � (size) ��'C r (X NO. OF BEDROOMS 3 BUILDER OR OWNER PERMIT DATE: LI J�/ G l COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells'exist on site or within 200 feet of leaching facility). Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet . Furnished by Z5 47' pt0. P'T 1 COMPLETE • ■ Complete items 1,2,and 3.Also complete A. Received by(Please Print Clearly) B. Date of Delivery item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse C. Sign so that we can return the card to you. ❑A ■ Attach this card to the back of the mailpiece, X or on the front if space permits. U14ddressee r D. Is delivery address different from item 1? ❑Yes i Article Addressed to: If YES,enter delivery address below: ❑ No / i 4�� a �zz 3. Service Type Certified Mail ❑Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes WPS Form 3811,July 1999 Domestic Return Receipt 102595.00=M-0952 _ I UNITED STATES POSTAL SERVICE First-Class Mail I Postage&Fees Paid USP Permit No.G-10 I • Sender: Please print your name, address, and ZIP+4 in this box • I Public,Nloslltb Division d+� I t c� of Bamstable PA Box 534 lqy=k MMSOUS9tts 02601 111 i 11, I II I Ill it i 11111 11111 it it'll II ,:11 ?='::;:<<::: Rh { Z 203 498 927 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail(See reverse StT'Qt& umbpf i Post State IP C Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee u') Return Receipt Showing to Whom&Date Delivered n Retum Receipt Showing to whom, Q Date,&Addressee's Address TOTAL Postage&FeesGo 1$ Postmark or Date Stick postage stamps to article to cover First-Class postage,certified mail fee,and charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the Q) return address of the article,date,detach,and retain the receipt,and mail the article. L - 3. If you want a return receipt,write the certified mail number and your name and address - rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. 00 M 5. Enter fees for the services requested in the appropriate spaces on the front of this E I receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. ti 6. Save this receipt and present it if you make an inquiry. 102595-97-B-0145 a Y Town of Barnstable Regulatory Services FT"E rgy� Thomas F. Geiler, Director Public Health Division + BARNSTABLF. 9cb "�: � Thomas McKean, Director �fD►rw+A 367 Main Street,-Hyannis, MA 02601 Office: 508-862-4644 Fax: 509-790-6304 August 31, 2000 Paul E. &Krystyn Dubois 42 Kennedy Circle So. Easton, MA 02375 NOTICE TO ABATE VIOLATIONS OF 310 CMR: 15.00 THE STATE ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE SUBSURFACE DISPOSAL OF SANITARY SEWAGE, AND 105 CMR 410.00 STATE SANITARY CODE H- MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION. The property owned by you located at 96 Boulder Road, Barnstable, listed as Parcel 027 on Assessor's Map 316 was inspected on August 29, 2000 by Donna Miorandi, Health Inspector for the Town of Barnstable, because of a complaint. The following violation of 310 CMR 15.00, the State Environmental Code, Minimum Requirements for the Subsurface Disposal of Sanitary Sewage and 105 CMR 410.00 State Sanitary Code H- Minimum Standards of Fitness for Human Habitation was observed: REGULATION 310 CMR 15.02 (207) AND 105 CMR 410.300: Overflowing sewage onto the ground. This violation is a serious public health hazard. 1) You are directed to hire a licensed septage hauler to pump the overflowing cesspool within twenty-four (24) hours of receipt of this letter. 2) You are also directed to keep the on-site sewage disposal system pumped as many times as necessary to keep from overflowing onto the ground. 3) You are further directed to contact and hire a licensed Disposal Works Installer within seven (7) days of receipt of this letter in order to repair this system or connect to town sewer. You may request a hearing before the Board of Health if written petition requesting same is received within seven (7) days after the date the order is served. Non-compliance could result in a fine of up to $500.00. Each day's failure to comply with an order shall constitute a separate violation. aa RDE O THE BOARD OF HEALTH A. McKean Director of Public Health dubois/wp/q/]s S E W A.GE PERMIT NO. dlil�AGE INSTA LIER'S A NME a ADDRESS ^ BUILDER OR OWN ER , DATE PERMIT ISSUED � , � _.� DATE COMPLIANCE I.SSUEDy �. ` .. Q� -- � � -� ,, � � � .;�-. C�,�� `,� L -� 4 # ;� f S n R-�;. °J t THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH ---.".......TQTZ................OF_.......BA.US.TABLE......---.------------....----------.................. Appliration for Diipntial lVorkii Towitrurtion ramit Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal System at: Boulder Road - Barnstable Lot 23 .........---•--.__...--Boulder-..Road ...........•---... ....... .... --•-. .......................................................... Location-A dress a or Lot No. n �Ow e Address (7� » a ......•..... ....•--------•-----------------•----•-- --•-----•----•------------.................-•--•--••--...--------••-----------••--•-•--------••-•- Installer Address d Type of Building Size Lot..... 8_:_880.........Sq. feet Dwelling—No. of Bedrooms.......-3..................................Expansion Attic ( ) Garbage Grinder (Nd Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures ---------------------------------------------- W Design Flow..55.....................................gallons per person per day. Total daily flow.......330_____..........._....._......gallons. WSeptic Tank—Liquid capacity..l0..... ons Length._.8'6��._. Width.4'10"_.. Diameter................ Depth_..5_'4"___. x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..... Diameter----12'--------- Depth below inlet.... ...... Total leaching area.....251......sq. ft. Z Other Distribution box (X) Dosing tank ( ) '-' Percolation Test Results Performed by......T.---E.-..Kelley_.._..._-72i�______________________ Date......5-30-80...-.............. Test Pit No. 1................minutes per inch Depth of Test Pit ....._.-.......... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water-.--_-..._------._--_--. •------•--•------------•......................•------••----•---.....----••----------••-------•---•-•........................................................ 0 Description of Soi1..T_J- #1 0-60" Loam and subsoil. 60"_-88" Layers__of fine med._ sa x ________________w/iron__oxide, 88"--144��Fine__sand._ .. P._��2_-___ .. 36" Loam_.. subso' W ______________ ________ -_36_____124 _med_ sand___-_124- _144_- Dense sand __ clay mixture.______________ eyG x �� ooeR U Nature of Repairs or Alterations—Answer when applicable.-_-..... ......... ......... ..--......__ PA p N 1 jc)l N1- ICZ _. ....plo.3@420 �+ Agreement: •ate-P, CIVIL 0 The undersigns grees to install the aforedescribed Individual Sewage Disposal System in acco •`a`` the provisions of i . ; 5 of the State Sanitary Code— The undersigned further agrees not to place S E� rd of hea h. �n o erat• n•u t' a e >ficate of Com lianc been issued b e boa U P / .. p igned..._t Date LL A on proved BY •------------------------------•------- ----- Date Ap"lieation isapproved for the following reasons----------------------------------------------------- ---------•-----------------------------•------ ermitNo........................................-................ Issued---------------................. Date r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......TO N................OF........BA_1dsT'tl<_Bhi . ---._..... Appliration for Bhipuiial iVorkii Tomitrnrtiun thrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal , System at: Boulder Read - Barnstable Lot: 23 F .....................••---------•-•-•---•--..".......---.....--••----•-•-•-•--••.-•-•�•--------•. . ...--- i -•---•••....--••--•--•-••------------••--.. Lo ation j��d,ress ``__ \, or t No. {� } 1 �v,C. V O W S ? ` �!.. B O N S r a �6s•_.1.'4.. ... .... ------ -- Own ' Ad.............airA................ dress W Installer Address 33,880 Type of Building Size Lot...........................Sq. feet V Dwelling—No. of Bedrooms.......................................�_-___Expansion Attic ( ) Garbage Grinder J#,-) '44 4 Other—Type of Building No. of persons............................ Showers —.Cafeteria a' ther fixtures ............................ Design Flow............................................gallons per person per�Oay. Total dailylflow____.__�'........_..........___..._..__..gallons. c4 Septic Tank—Liquid capacity_.1000_gallons Length__ G_____. Width 1.l_........__ Diameter________________ Depth__}_-_--___. W Disposal Trench—No..................... Width.,;._............... Total Length.................... Total leaching area..__...._...........sq. ft. x Seepage Pit No.___t____ --_---_.- Diameter.................... Depth below inlet...:° ''�...•... Total leaching area.. 2'L q._.._....s ft. Z Other Distribution box ( ^ ) Dosing tank ( ) '-' Percolation Test Resu ts, Performed b T. Kelley ----------------------- Date____5':-7 G`_b0 Test Pit No. 1________________minutes per inch Depth of Test Pit.................... Depth to ground water........................ (X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Sii_T,P T6Ia "` Laainxzd �Zb�vil E 4 - t La ors irlr+c; -7,iron oxi de; c�- -i ter Zne �s�nd. l4L 0 a`I' Q 36" o£1Xfl & st!ha t%"O�"I� v 36";I2 'T met sand Ili" 14�+9A tense sand clay mixture; W ....................------------------------------- -------------------------------- ----- ---------- .... -- -•-•••-- - U Nature of Repairs or Alterations—Answer when applicable................................................................... .. PAUL o Mf�HTlt�lffCZ ""----"-----..."------------•--•--""---"---"-"-•-----------------•--------------------"-"----"--"--"--•-•------.._.._.__......_..---------"•----....---•--•------••-•-•-•-•- ... ....Mn.3 20 Agreement: ,off-tF CIVIL The undersign grees to install the aforedescribed Individual Sewage Disposal System in the provisions of :. , : 5 of the State Sanitary.Code—The undersigned further agrees not to a e t opera n a tincate of Complian een issued b3We board of hea th. o g. 83 igne, ..... ................................................. ............D................. ca ion roved B `^'� /�" e�J,,/�.��.� PY -• -- ""-------"--""-"•----•-••-•-•-•--•-••-----....... r Date Ap lication isapproved for the following reasons--------------"-"------"-"-----------"---------------"--"--------------------------•-•--•------••-----......•---- ... .................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BARD OF KtALTH 1 .........>..................O F.....................-:...:.......................................................... Trtifiratr of TuntpliFatta THIS IS TO CERTIFY/�at he ?divyy al ewa e Disposal System constructed � or Repaired ( ) by................................................. ..-----------•-------"---"-----......--•-------."...-------"-.....--•---....-----•--.......-"---- at-••• L..... �!`�\�di/ _-t!•r- ---------- 8 nsta er��1,L----.....--".-"-------"--"---"--"-----"--"..........................."----------- has been installed in accordance with the provisions of T 17 V. The State Sanitary Code as described in the application for Disposal Works Construction Permit \'o-----...l_..__._--�___..��_____________ dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM WI� F NCTION SATISFACTORY. /` DATE........ ..yl......................... Inspector.... ._ THE COMMONWEALTH OF MASSACHUSETTS BOARD ® HEAL r � ` .. No. ................... FEE........................ Dispos a1 r� n L Uan anti# Permission is herebygranted , to Construct or Repair ( ) an Indivi al Sewa e Disposal System atNo.......L C►: � ?► .. �.\�+`v.: - � �o� -------------•------------•....••....----•---...-•---•-•-•-•--••-••••.................... Street as shown on the application for Disposal Works Construction Permit No-----.7-......1_s__.`...•✓Dated................t:7.44........... Board of Health DATE............... --------""-------------"--"-"--""-------................_....... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS r ASSESSORS MAP : � 5A PARCEL: - TEST HOLE - LOGS . __. a/ ---_---- _..__ 1 1) The installation shall cornl�� with Title V and Town 0(13*9 3oard of FLOOD ZONE: b SOIL EVALUATOR: ) Cam . 1 _ .._. _ ..__�.._...._-.-- .__. I lealth Regulations. REFERENCE: WITNESS : 2) The installer shall verify the location of utilities, sewer inverts and septic 4 �� _ :..__..e._ DATE: components prior to installation and setting base elevations. PERCOLAT I 0 RATE: t , 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per foot. The first two feet out of the d-box to the icaching shall be level. i by l�l ,Y. '- 1 - 4) This plan is not to be utilized for property line determination nor an other TH I TH-2 P P Y Y purpose other than the proposed system installation. 0 I D A I 5) All septic components must meet Title V specifications. f �U 6 p ID ) Parkin g shall not be constructed over H10 septic components. 7) The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total LOCATION MAP 3 ► 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. 9) The existing leaching or cesspools shall be pumped and filled with material per Title V abandonment procedures. Those within the proposed SAS shall or be removed along with contaminated soil and replaced with clean sand per Title V specs. fat P I Ho 10)System components to be 10 feet from waterline. Sewer lines crossing the r /„/ D'w water line shall be sleeved with 4 inch SCFI 40 PVC with ends grouted if r 4 r ► 3 rg,g / •� ' ,', � ,� d applicable. The proposed SAS is being installed below the water service `'! j f line. The line is to be sleeved as aforeme n��oned and maintained in place. SEPT C` SYSTEM t � , � � {, �� S TEM DESIGN 11) If a garbage grinder exists it is to be removed and is the responsibility of the �0 �/ owner to ensure such. FLOW ESTIMATE 12)The installer is to take caution in excavation around the gas line if SlIell exists. BEDROOMS AT ��D GAL/DAY/BEDROOM GAUDAY 13)Tile installer shall verify the location, quantity and elevation of the sewer t �, {' ' /n► / ' �� ' lines exiting the dwelling"rior to the installation. SEPTIC TANK 14)This plan is representative only that a system can fit on a property meeting Title V requirements. �V { 1 »' ,� \ r I GAL/DAY x 2 DAYS GAL y USE (C GALLON SEPT I TANK r .. x VA t --- --- - OIL Pt SYSTEM `h` 9 1 " r ,� �` r ) > .d�` t I• + l/�1��. , � � 1 + {, �'4-�{ ��r�i-'E�,F � � ��'C„i �lt'�1,e`�` ` _ � -� ;ti(�t•;�J`. _ I � 2 . X 7 r DAVID �,I DE AREA: �X Zb -i- ► � ?( 8/1 o t3 A ry BOTTOM AREA: Z 017 1 t I t l r, ' . ` }! 1 7 35 MASON 1 'S No.1066 -lit Q •�' - , ` 1 �' ` � � l i � ��_ �,�i _.� � ,_. SEPTIC SYSTEM SECTION q 0 p O ( tJIDDO o GAL SEPTIC T K V x {0�Nr _ I j '� '- __'DW�,�1-,►� Wyk Ile- d '� s "c '- � 11 � � � ►Zi SITE AND SEWAGE PLAN LOCATION : A% ,�Wuxz P PREPARED FOR : 0 a SCALE: i t DAV I D B . MASON R!) DATE: 2b 20 J DBC ENVIRONMENYAL DESIGNS u W EAST SANDWICH MA DATE HEALTH AGENT 508 833- 2 177 ig REVISIONS: TEST PIT DA TA = DATE CF TESTING - n- �G '- _ _ _- PERC. TEST DATA : SEPTIC TANK DETAIL : DIST. BOX DETAIL : LEACHING FACILITY DETAIL: NO. DATE TEST BY `=• `"` `= DATE OF TESTING - TANK TO CONFORM TO TITLE 5 REQUIREMENTS. TO CONFORM TO TITLE 5 REOU/REMENTS �r'o - � �-, _ — — T, P. WITNESSED BY .�? � �___. _ _ TEST 8Y-' ,� , . NO. OF OUTLETS - ED �I . l� d,. _ � � .dh E OVEABLE COVER W I TNESS BY '��,�,r�,c;� _ -7i , / / — -T ��\ R M - - - _ �. ter . /� �r� J"�j'- `� � � ` \ �\��i �\ � � t f 12 ��MANHOLE BROUGHT TO �� • "_ _ 2 PEASTOAF La4M 9 FX L /2 MAX, LEAR+' . • , :3 FlN/SH GRADE. " — - .. • ---- ---- ------ 3 C CLEAROUTLET a r 6"MIN. 2'MIN. 6„MIN " r II AS REOU/R/EDS DEPTH of TEST �2 r,= _ _ - 'i - ' INLET I r �/ I }� D/ST. RA TE� � T/./,yr�r �i�svr /�.'G,4r •' /O�M/N ( 1 \ 1 , •. .I ( BOX _ -- —-- — -- INLET TEE ,' ,^ OUTLET TEE �•�II / —_ � /000- GAL. INLET AND OUTLET 4'0" MINIMUM OUTLET TEE DEPTH SEPTIC TAAW I. L IOU/D DEPTH /4 AT L/OU/D DEPTH OF 4' 2 6 P ECAST OR BLOCK TEES TO BE CAST - R na v.r c e`' R �?•-+ „ /'" " CONCRETE SEEPAGE PIT IRON, SCHED. 40 i /9 5 »° I. DEPTH OF TEST .'...+A; 24 6, '. CONSTRUCTION /O' I . P. OR CAST/N �� "` � •' °' � � � ' PLACE CONCRETE 29 „ T >. ° . 1 . .....•.. MIN. - PIV CONCRETE <. 34" " " " " 8' BOTTOM ON LEVEL STABLEBASE • ' RATE - CONSTRUCT/ON � i�. � i.• ', •. - r (WA TER Y/GNT) INLET TEE PROVIDED WHERE SLOPE FOUNDATION `, -- •..;t ,,•. .►^_o OF INL ET PIPE EXCEED S 0.08 % OR ~` ':..•,':'.t• °—•-�__' "� :..,.► TANK TO RE48LE TO WITHSTAND { -- 'BOTTOM OF TANK ON LEVEL STABLE BASE y-IOLOAD/NG UNLESS UNDER /N A PUMPEO SYSTEM. 20 M/N. — _! / I / 'WASHED STONE I PAVEMENT OR IN DRIVE.H-20 I I r e. 'ed .x eN L OA D/NG UNDER PAVEMENT OR � I I c Y YV4 i? DRIVE. I I //o G�•pT ,;,.,iT - RECOMMENDED MANUFACTURER G�i`✓''�..�?*�''= _ RECOMMENDED MANUFACTURER �::_..��,/,-'`r.•7."".e:c. (OR APPROVED EQUAL J ( OR APPROVED EOUAL) NOTES : PLAN VIEW : INVERT ELEVA TIONS: THIS PLAN IS FOR THE DESIGN AND CONSTRUCT/ON OF THE SEWAGE DISPOSAL FAC/L/T Y ONL Y. SCALE / = /NV. AT BUILDING /oo.s' 2. A L L CONSTRUCT/ON METHODS AND MA TER/AL S SHALL CONFORM TO _ _INV AT SEPTIC TANK(/NI o MASS. D.E.0.E. T/TLE 5 A ND THE ._- .,. �.:- -t, - -_ BOARD OF _ _INV, AT SEPTIC TANK(OUT) ��- � _ - HEALTH REGUL ATIONS. INV, AT DIST. BOXONI 91? : ---- IN AT D/ST. BOX(OUT) 3 . _ - _ 220. oo q pl l� y AT LEACH/NG FAC/CITY in_2_ ' ea ¢s; po, � j' BOSTON MASS. WORCESTER, MASS. h ! r �� ! �� /r r .' ,, '' s \,/ h�`�t 4r-;e e.c 4. .X7<'r.- A' p-. F.`' HALIFAX, MASS. NORWELL, MASS. 11 BEDFORD, MASS. LEXINGTON, MASS. - / r 7 - '-�-'- -�. `---�•-- ----` =h ; HYANNIS, MASS. MANSFIELD, MASS. R ,.----�. ___ ._ ;• ?C / CRANSTON, R.I. DERBY, N.H. 01 • SCALE: / "= ` I { PROFILE' � ; � III , 1 I B l.. '"" .ram"""•• �"'� �\ I ft V ,a � S ----- - --- -- --- - — t i p, ti , � I / DESIGN DA TA • �` '� v ! ___ _._ l , t I I �I f 'C� ,`�,. y- ,J ,` a y <� DESIGN FLOWS t tl1 38,E _ p I .1 ..., , I I I I • { 0 Of - �� i I M►e ` ! --�--.1_."_ I + _ - - _ 4 ��~ t ` i� , ! :. REQUIRED SEPTIC TANK.* 07Y�i J } 1 �� 'e ; ` +._\ ? d�'��i r,..•� K ��<s /t7 = GAL. I SEPTIC TANK PROVIDED = GAL. CAPE COD SURVEY --- CONSULTANTS REQUIRED SIZE LEACHING FACILITY: -_---- P O. BOX 56 ll 7a.� �,: -- --- HYANNIS MASS. 02601 p I I I { I �. t •` I I I t ' t_. .- .__ - -- - �' ._ / ��: - - ----- - - 617' 775 -7155 - t b — °/'� DIVISION OF / ,Q BOSTON SURVEY CONSULTANTS INC. \ _IIV j Y ~ • ,� t` ,, ✓� SIZE OF LEACHING FAC/L/TYPROV/DED: ENGINEERING • SURVEYING. • PLANNING _ - TITLE: ' TYPE SYSTEM ECT IO/V ' SCALE• / = - i ! • - t �../�. �.;: �" � � a . � , ! —'----- '' f' '.r'� -� ---_ _ -------- V i ,A 0� -' , - �. _ _ _ ; b �', ., � .� ;� , .� �_ • _ SEWAGE DISPOSAL SYSTEM ^r .� ' ••✓•�"•�~ / - ...-. f f ! � �-.�r� • �" :� �-,,-: �-� DESIGN kl,,� / 01 LOCUS PLAN: .•--� .r. ,tick I D} 0R - ` . _ ^_•-,...._-- `" =_.....) ;C-.y� ,-.._ \'.. �UTC• /",-.{." FOR: Lr.✓'.+✓',eS'.1� ''�+��L., G�Aec../L�. SCALE: AS SHOWN METERS E��/�,:' ( FEET 0 to ! i DATE: .+�'GrG�. ? wr COMP./DESIGN: CHECK: - LlA TV M' DRAWN: FIELD: E3lSll::7v -- --- �G�"�•-'yTia�i ,goo.�v .��.�"1„r��rC3 -'�' FILE NO: DWG. NO: S JOB NO: SHEET: i OF: I