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0244 BOULDER ROAD - Health
r_3 244 Boulder . i a 0 e f i i S � , f Commonwealth of Massachusetts -Ik� Title 5 Official, Inspection Form ,h} Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments � 244 Boulder Rd. Property Address '�=g Heidi Hudson Owner Owner's Name required for is every Barnstable _x required for eve MA 02630 12/5/2018 a page. City/Town State Zip Code Date of Inspection . Inspection results must be submitted on this form. Inspection forms may not be altered in any'. way. Please see completeness checklist at the end of the form. Important:when filling out forms A. Inspector Information on the computer, use only the tab Paul C. Martin key to move your Name of Inspector cursor-do not Cape Cod Septic Services Inc. use the return Company Name key. 350 Main St. Company Address West Yarmouth MA 02673 City/Town State Zip Code RIM) 508-775-2825 S15016 Telephone Number License Number B. Certification I certify that: I am a DEP approv ed.system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 12/11/2018 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how-the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Boulder Rd. " Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 12/5/2018 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: system in working condition. 2) System Conditionally Passes: ❑. One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or,".'not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent..System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20years old is available. ❑ Y ❑ N ❑ ND (Explain below): I, t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ,a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 12/5/2018 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ .ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain.below): ❑ The system required pumping more than 4 times a year due to broken or obstructed ptpe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Healthdetermines 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: i t5insp.doc-rev.7/26/2018 Title 5 Official{!Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 I Commonwealth of Massachusetts 19 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 12/5/2018 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: El 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. c. Other: 4) 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 0 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name . information is required for every Barnstable MA 02630 12/5/2018 page. Cityrrown State . Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No i ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid.depth in cesspool is less than 6" below invert or available volume is less '/z than day flow ❑ ® Required pumping more than 4 times in'the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or . tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply. well, ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable,water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no othe{failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] 0 ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. I The system fails. l have determined that one or more of the above failure ❑ ® criteria exist as described in 310 CMR 15.303, therefore the system fails: The system owner should contact the Board of Health to determine_what will be necessary to correct the failure. 5) Large Systems. To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. l For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400i feet of a surface drinking water supply i ❑ ❑ the system is within 200,feet of a tributary to a surface drinking water supply the system is located in� PPY a nitrogen sensitive area(Interim Wellhead Protection ❑ Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 i Commonwealth of Massachusetts . Title 5 Official Insp ectiori Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 12/5/2018. page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner).provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ❑ Existing,information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts l Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 12/5/2018 page. City/Town State Zip Code Date of Inspection D. System Information 1. 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): 110x3.= 330gpd Description:. Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes. ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ .Yes ® No Water meter readings,if available (last 2 years usage (gpd)): 2016=277gpd 2017=134gpd Detail: Sump pump? ❑ Yes ® ;No Last date of occupancy: Current Date t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts -p Title 5 Official Inspection Form 11e Subsurface Sewage:Disposal System Form -Not for Voluntary Assessments 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for eve ry Barnstable MA 02630 12/5/2018 page. . City/Town State Zip Code Date ofinspection D. System Information (cont.) 2. Commercial/Industrial.Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): gallons per day(gpd) Basis of design flow(seats/persons/sgft, etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No } Water meter readings, if available: p Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No Records Was system pumped as part of the inspection?' ❑ Yes S' No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5lnisp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for every. Barnstable MA 02630 12/5/2018 page. City(Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system. ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy.of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: 1995 Per BOH records Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 51" Depth below grade: 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.): Line was checked.with sewer camera. Line found to be clean, properly pitched with no sign of root intrusion. I t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 12/5/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 40"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: 1000Gal Sludge depth: 6-8" Distance from top of sludge to bottom of outlet tee.or baffle Scum thickness 2-3" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity; liquid levels as related to outlet inverti evidence of leakage, etc.): 1000Gal tank in good condition. PVC tees in place. Tank at normal operating level. Covers 12'.'. below grade. t5inap.doc-rev.7128/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments V 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 12/5/2018 page. City/Town State Zip Code Date of Inspection' D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El 'metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition; structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene , ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts F. Title 5 Official' Inspection Form to Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 244 Boulder Rd. - Property Address ~ Heidi Hudson Owner Owner's Name information is Barnstable required for every MA 02630 12/5/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No .Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): o„ Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 DB-3 with 1 line in and 2 lines out in good condition. Box is clean and level with minimal solids carryover. Outlet inverts equal. No sign of overloading or hydraulic failure. Cover 6" below grade. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 12/5/2018 page. Cityrrown State Zip Code Date of Inspection D. System Information-(cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Forme Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,• � 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's.Name information is required for every Barnstable MA 02630 12/5/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 1-6x4 Pit and 1-6x6 Pit. No more than 6"of effluent in pits. No evident staining. No sign of . overloading or hydraulic failure. Covers 24" below grade. 12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions.of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u � 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 12/5/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . 13. Privy.(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts —IA Title 5 Official Inspection Form I'o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments - .� 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 12/5/2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 1.00 feet. Locate where public water supply enters the building. Check one of the boxes below: El hand-sketch in the area below ® drawing attached separately t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form ' la Subsurface Sewage Disposal System Form -Not fo r Voluntary Assessments 9 p Y y t 244 Boulder Rd." Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 .12/5/2018 page. City/Town State Zip Code Date of inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar Shallow wells • Estimated depth to high ground water: +13'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: Hand auger did not encounter water at 13'. Max bottom of pits is 91 . Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 18 Commonwealth of Massachusetts ----,'? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 244 Boulder Rd. Property Address Heidi Hudson Owner Owner's Name information is required for every Barnstable MA 02630 12/5/2018 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. Z B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1; 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included i t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Assessing As-built•-,ards 1 Page 1 of 2 TOWN OF BrjSTABLE _ v LOCATION --�(Ju , U ll-cr b`Or SEWAGE 11 ) � o r ASSESSOR'S MAPdt LOTLLLER'S NAME dt PHON�NO. 7� SEPniC TANK CAFACrrY-J o c)o C=,l 1� C�%1X n l d �rt^l/1C6 LEACHING FACIIITSC:(type)V'vJ(nk(o P;' (size)tia X G NO.OF BEDROOMS BUILDER OR OWNER 11 jj-� PERWrDATE: '( +tato I COMPLIANCE DATE.o 6�S Separation Distance Between the:Maximum Adjusted Groundwater Table and Bottom of Leaching Facility a ���f .k Feet Private Water Supply Well and Leaching Facility (If any wells exist J�l on site or within 200 feet of leaching facility) d�+�^� Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facili Feet Furnished by SCy M � f� �o viJPt� 3`� http://www.town.ofbamstable.us/Assessing/HMdisplay.asi)?maDDar=315035&sea=1 , 10/1 R/201 R �jHE Town of Barnstable • Department of Health, Safety, and Environmental Services '"MMAMA`"B'E' Public Health Division ib39 P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO Nh FAX: 508-790-6304 Director of Public Hea April 10, 1998 Heidi and Dana Basset P.O.Box 169 Barnstable,MA 02630 RE:244 Boulder Rd.,Barnstable d Dear Mr. and Mrs.Bassett: On December 26, 1995,the Barnstable Public Health issued the Certificate of Compliance for the repair of the septic system at the above referenced property. The property at 244 Boulder Rd.,Barnstable is now considered to be in Compliance with Title 5 and the town of Barnstable regulation pertain to on-site Sewage Disposal. Enclosed please find a copy of our computer records which were recently corrected to show that requirement stated in the April 3, 1998 letter were met. Sincerely, s A.McKean Director of Public Health i a - 1 , , . F Ht ] 41 H E A L T H M A S T E R ] HELP [ ] R E C O R D ] ACTION Cl For Parcel Number 3151 0351 ] ] Rental Property(Y/N) [ ] Owner Name BASSETT, W DANA & HEIDI H ] Zone of Contrib (Y/N) [ ] Location 244 BOULDER RD BARN ] Contaminant Rel (Y/N) [ ] Business Name [ ] Area Number Contact Person [ ] Phone [000] [ ] Fuel Storage Tank Permit [ ] Card on File [ ] Perc Test Well 01871c55, File/Permit No. [ ] [ ] Issuance Date [ ]Completion Date [ ]Last Communications [ ] (MMDDYY) Comments [REPAIRED- NEW 6'X6' LEACHING ] Cancel [ ] NEXT SCREEN [HM ] ACTION [ ] PARCEL NBR [ ] [ ] ( ] TANK NBR [ ] ] ( ] m SENDER: I also wish to receive the ;g ■Complete items 1 and/or 2 for additional services. u+ ■Complete items 3,4a,and 4b. following services(for an ■r A your c name and address on the reverse of this form so that we can return this extra fee): ■Attu i this forth to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address d ■Wnte'Retum Receipt Requested'on the mailpiece below the article number. 2.❑ Restricted Delivery N ■The Return Receipt will show to whom the article was delivered and the date a C delivered. Consult postmaster for fee. 0 v 3.Article Addressed to: ` 4a.Article Number d o, G� 4b.Service Type ❑ Registered �; ertified W / ❑ Express Mail Insured o ❑ Return Receipt for M 44, D a 4 7.Date of Deliv w z 7 5.Re i ad By:(P tName) 8.Addressee's a (Ohl .ifrequested c W ` / and fee is pjilldy t 6.Signatu :(Address or,A!g7fi nt 0 X PS Form 3811, Decem—Far 1994 102595-s�-so,7s Domestic Return Receipt NOMW First-Class Mail UNITED STATES POSTAL SERVICE /' t ,; p• 4 Postage&Fees Paid . .._. _ 'USPS �" Permit No.G=10- ® Print your name, address, and ZIP Code in this box ' I i Public Health Division Town of Barnstable P.O.Box 534 I Hyannis,Massachusetts 02601 d Z 263 498 829 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mait..See reverse _ Sentt N ber Sta e, ZI Postage $ Certified Fee Special Delivery Fee . Restricted Delivery Fee Return Receipt Showing to Whom&Date Delivered a Return Receipt Slowing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees is s M Postmark or Date 0 a rn a Stick postage stamps to article to cover First-Class postage,certified mall 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). m i 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the QQ) return address of the article,date,detach,and retain the receipt,and mail the article. I U) 3. If you want a return receipt,write the certified mail number and your name and address 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 y4. 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. 5. Enter fees for the services requested in the appropriate spaces on the front of this E receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. LL8 6. Save this receipt and present it if you make an inquiry. t o25s5-s7-8-ot 45 d 75 Town of Barnstable q� Department of Health, Safety, and Environmental Services I tttrvafrAat e MES. Public Health Division �EDr. P.O. Box 534, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health t April3, 1998 Dana and Heidi Bassett i P.O.Box 169 Barnstable,MA 02630 ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 244 Boulder Rod, Barnstable was inspected on December 13, 1995 by,Troy Williams,a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following: • Leaching area was in hydraulic failure You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code,Title 5 within (30)thirty days of receipt of this notice. You are also directed to bring the septic system into compliance within sixty(60)days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A.McKean,R.S.,C.H.O. Agent of the Board of Health q\health\dbfiles\titles i.doc 0 SENDER: 1 also wish to receive the o ■Complete items 1 and/or 2 for additional services. H ■Complete items 3,4a,and 4b. following services(for an y ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. 00i j ■Attach this form to the front of the mailpiece,or on the back if space does not 1. ❑ Addressee's Address — d permit. d ■Write'Return Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery (p ■The Return Receipt will show to whom the article was delivered and the date a 1 C delivered. Consult postmaster for fee. I 3.Article Addressed to: 4a./A7rticle Numbercc m `t// G. v3 E E< 4b.Service Type m I a C/ i�— � ❑ Registered ® Certified � N ❑ Express Mail ❑ Insured M �- /Z ❑ Return Receipt for Mer COD jlGA/���-°� 7.Date of Delivery a Z O '� T �l p 5.Received By:(Print Name) S.Addressee's cadre igreq, .es d c W and fee is paid)' i i 6 F 6.Signatur . (Ad see or Agent) X °a. � aA� p w PS Form 3611 December 1994 Domestic a urn Receipt P UNITED STATES POSTAL SERVICE -Fir ail =Pt%c 8 P Ejaage.,AS,-F�es e M qs T. rn 2 Q JA� 0 Print your name,,Qdrq6e, and ZIP C • Nedth Department Town of Barnstable P.O. Box 534 H fannis, Massachusetts 02601 Fax(508) 775-3344 Phone(508)790-6265 Town of Barnstable B� Department of Health, Safety, and Environmental Services MASS,�, Public Health Division 9 A88. 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean FAX: 508-775-3344 Director of Public Health January 23, 1996 RTC Trust CSW Assoc., Inc. c/o Crown North Corp., Inc. 12750 Merrit Dr., Suite 1015 Dallas, TX 75251 ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 244 Boulder Road, Barnstable was inspected on December 13, 1995 by Troy Williams a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Leaching area in hydraulic failure You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. r 4 ► You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health f <A - - TROY WILLIAMS JAIV SEPTIC INSPECTIONS. m.R 2 1996 v�1Y90A4d tr�X Certified by MA Department of Environmental Protection (508) 760-1819 40 Old Bass River Road South Dennis,MA 02660 ,�' ry A-A COMTO weatth Of Massachusetts Executive Office of Errkonnvi d Affairs Department of Environmental Protection WItllarn F.Wald David IL Struhs SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION T Property Address: /,3o U i a c- / Address of Owner. R r c /i'� G S W /9 S f o -.Zi, n c . Date of Inspection: a//J �YS (if different) a v C.V �,, �o r f� L�r� 7 Name of Inspector. j rG (^J i 1(- " Company Name,Address and Telephone Number: /.Z 7 S O /f/1 crr �r, S✓ �d I J` • I/ Ul/us, �X . 7 d5 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection.-The inspection was performed based on my training and experience in the proper function and maintenance of o"ite sewage disposal systems. The system: _ Passes _ Conditionally Passes Feeds Further Evaluation By the local Approving Authority Fails Inspector's Signature: Date: Ss- The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A. B, C,or D: A) SYSTEM PASSES: IVIA I have not found any information which indicates that the system violates any of the failure aheria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. e) SYSTEM CONDITIONALLY PASSES: A/114 One or more system components need to be replaced or repaired. The system, upon completion of the replacerncru or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of detemsination in all instances. If'not determined', explain why rKxj The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or e>dihration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Ire�l•ed !/15/951 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 02 YY do A t r Owner: /7'T r✓ S -�- Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The svctem has a septic tank ano soli absorption system and is within 100 feet to a surface water supply or tributary- to a surface water supply. The s\•stem has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D) SYSTEM FAILS: V I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backupof sewage into facility or stem component 8 tY Y due to an overloaded or clogged SAS or cesspool. /V Discharge or ponding of effluent to the surface of the ground or surface waters due.to an overloaded or clogged SAS or cesspool. ,evised 8/ls/951 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 0?1-/1/ 13 ov 0.4r Owner. uV 7—C Tr J s k Date of Inspection: /-� // 3 / 9s DI SYSTEM FAILS(continued): Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. l�l Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to dogged or obstructed pipe(s). Number of times pumped N Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. N Any portion of a 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 I of.a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. N 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. EI LARGE SYSTEM FAILS: 111119 The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/9S) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: /3oj �d D t of Inspection: �.z/i3 / ys Check'if the following have been done: -v/Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ZAs built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. _ZThe system does not receive non-sanitary or industrial waste flow ZThe site was inspected for signs of breakout. ZAII system components, excluding the Soil Absorption System, have been located on the site. ZThe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. ZThe size and location of the Soil Absorption System on the site has been determined based on existing information or . approximated by non-intrusive methods. L/The facility ONN-np• (and ocCupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. 'revised 8/15/95) 4 l C SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMY`i PART C SYSTEM INFORMATION Property Address: Y,y 9, 1 J Owner: Date of Inspection: R T r S is/f3 /9s FLOW CONDITIONS RESIDENTIAL: Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 0 Garbage grinder (yes or no): Laundry connected to system (yes or no):�E S Seasonal use (yes or no): ^/o Water meter readings, if available: y r = / 6 ,o00 Last date of occupancy: Oc )I� C1$ COMMERCIAUINDUSTRIAL: A1117 Type of establishment: Design flow: Aallons/day Grease trap present: (yes or no)_ industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title S system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) ast date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: 1 �o �� /J, r�G �, rD a..�ci i v.4p U T a.- r A,6 /t �✓ System pumped as pan of inspection: (yes or no)/,/c- If yes, volume pumped Qallons Reason for pumping: FYPE QF 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) Other (explain) APPROXIMATE AGE/ � of all components, date installed (if known)) and source of information: 0. Sewage odors detected when arriving at the site: (yes or no) NO )revised 8/15/951 5 e b;. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: T L Tr v s Date of Inspection: SEPTIC TANK: 1� (locate on site plan) S � Depth below grader ' Material of construction: i/concrete _metal _FRP—other(explain) Dimensions: ' K ' /p o o f. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: a 16 '' Distance from top of scum to top of outlet tee or baffle: D Distance from bottom of scum to bottom of outlet tee or baffle: c,& 1 a-It- f Tte. Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural ntegrity, evidence of leakage, etc.)"'-< 4- o&.1 /-C u r o� �/t hs 6 7" t r. J,, a t J l $ ✓ Ir4 f n.u G i l c-cA, c� ✓ GI- c. a, "A-A v ,l f lcJ G un :arc '—ur vim: a4A,o Ko L) op " Q �.,t 0L/ A 01)-, �.� p /� C' &-j tt S c a 6/cr v GREASE TRAP:/V/4 h< < d< 6A a locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: ,cum thickness: Distance from top of scum to top of outlet tee or baffle: �i!tance from bottom ni crk"'n (n hnpnm OI ou?let tee Or bartie- omments: recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural nlegrity, evidence of leakage, etc.) y revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM `V•:`'_ PART C SYSTEM INFORMATION (continued) Property Address: o� Id r . Y ay e Owner. Date of Inspection: 1a/i3/ ys TIGHT OR HOLDING TANK:LY,//1 (locate on site plan) Depth below grade — Material of construction: _concrete _metal_FRP_other(explain) Dimensions: Capacity: aal Ions Design flow: aallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_V locate on site plan) Depth of liquid level above outlet invert: I?�' Comments: .note if level and distribution is equal, evidence of solids carri,over, evidence of leakage into or out of box, etc.)_ _,�— X PUMP CHAMBER: &11/q (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a y Y Owner. Date of Inspection: /2/13 /7 S SOIL ABSORPTION SYSTEM(SAS):_z (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits, number: ok<- leaching chambers, number:_ r° leaching galleries, number: leaching trenches, c es, number lengt h: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) t -'�')C-4, k o.t _ u C - *—v L k _ L c t-, .o r.J CESSPOOLS: A�h ;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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: L11-9 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.) 'revised 8/15/95) 8 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: a y y Owner: Date of Inspection: RT c— �, S 71- 13 /y s- SKETCH OF SEWAGE DISPOSAL SYSTEM: indude ties to at least two permanent references landmarks or benchmarks locate all wells within 100' i 817' 33 DEPTH TO GROUNDWATER Depth to groundwater: feet adjusted high groundwater level method of determination or approximation: i /-,i a 4- o-1 )-,, b O 1—' revised 6/15/951 9 t 4. THE7MMONWEALTH OF MASSACHUSETTS PUBLIC HEALTK JIVISION - BARNSTABLE, MASS,., __:,iUSETTS (Certificate of (compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed by for )or repaired/replacedf(/)on �,� 16 with the provisions of Title 5 and the for Disposal System onstruction Permit No. _ has been'constructed in accordance Use of this system is conditioned on compliance with the provisions set forth below: ^ dated �_Z, TOWN OF BAARNSTABLE e� LOCATION C., � l_►l��t� l;C,��, .SEWAGE # VILLAGE \,)G — e ASSESSOR'S MAP&LOT _( j INSTALLER'S NAME&PHONE NO. \ SEPTIC TANKi CAPACITY LEACHING FA'CILTTY: (type)NO.OF BEDROOMS (size) BUILDER OR OWNER . PERMITDATE: 1 COMPLIANCE DATED Separation Distance Between the: Maximum Adjusted.Groundwater Table and Bottom of Leaching Facility /k Private Water Supply Welland Leaching Facilityf Feet on site or within 200 feet of leaching facility) any wells exist Edge of Wetland and Leaching Facili c � ty(If any wetlands exist Feet within 300 feet of leaching facility Furnished by S(v}� Ms J' / Feet I\Y-Ul ��� TOWN OF BARNSTABLE Lf�°ti'TTION �bU�U� �J,` SEWAGE# ✓v L/�/lJ V:i.LAGE b i G ASSESSOR'S MAP&LOT " -6�) INSTALLER'S NAME&PHONE NO. Pn rC7, U , SEPTIC TANK CAPACrry V l qX< LEACHING FACILrrY: (type) We-W (O o (size) 6 X G L,, NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 9I dk i 5 ST COMPLIANCE DATEXJ d7 AS v Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ,y��e n ` Feet Private Water Supply Well and Leaching Facility (If any wells exist �J,on site or within 200 feet of leaching facility) d v Feet Edge of Wetland and Leaching Facility(If any wetlands exist 1 within 300 feet of leaching facility !� � Feet Furnished by SCy ^� ' II c YyJ Ell- c- -�' TOWN OF BARNSTABLE LOCATION �� ��� I to 9-0— led • SEWAGE # VILLA ASSESSOR'S MAP&LOT S INSTALLER'S NAME&PRONE NO. �� c- k Oda- 5 Ahv-le- S SEPTIC TANK CAPACITY f7 O J LEACHING FACILITY: (type) (size) NO.OF BEDROOMS .3 BUILDER OR OWNER PERMTTDATE: O/Y/9 COMPLIANCE DATE: Separation Distance Between the:. Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist o ithin 300 feet of leaching cility) Feet J urnished by e+ ^O � � � ,� ,� i' xi i i ;� .`' .— v � `� � � t.� � � �� _ ,, ;� ,. c 316 LO.GE dLA,TION c{t� SEWAGE PERMIT NO. o T r ocs �r��. 1? 76 VILLAGE 4 � z I N S T A LLER'S NAME i ADDRESS r1l S U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED _ _ W a C �1.. � � � e •, `I � � - v, ��� � � ..o_.� : _ _ t . .. . � � te3SJRS MAP NO: PARCEL NO.: Ni Fps............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............OF................. C•r, Ap- p raftaat for Diipusal Works Toustratrtion rantit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................-- .�. .. .. •; �. --------- - .. .. ... . Location-Address 000'. _._. / Owner Address a ----------------------------------------•---- -•...............-- .....•------••-•-•-••-•--------...-•---•--- PQ Installer Address UType of Building Size Lot----------------------------Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) PLOOther—T e of.Building No. of,persons............................ Showers — Cafeteria a' Other fixtures ............................ . ---• ------------- W Design Flow..•............................... gallons per person per day. Total daily flow........_.... ... .. ..._._....gallons. 1" '-' '00- 1:4 Septic Tank—Liquid capactt 4 s&Lfgallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--___-_------..___--sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet_ ................ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( Z /1_ e aPercolation Test Results Performed by__________________f..� ....._ Date...... ..___.. a Test Pit No. - -�o__minutes per inch Depth of Test Pyt _.._......_. Depth to ground water______________________ _ L14 Test Pit No. 2. .............minutes per inch Depth of Test Pit.................... Depth to ground water...--______-_-_---___--. 9 ••-•----•-----------------•---•---------•---•-----••---••_.... ••- 0 Description of Soil...................................................•-- v J/� � ' ------------ / l - W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------------------------------------------------------------------------------------------------------------------------------------•------------•-•----•-..........--.•-- Agreement: The undersigned agrees to install the-aforedescribed Individual Sewage Disposal System in accordance with the provisions of TiTF.+. p 5 of the State Sanitary Code— The d ne rti.er grew not to place the system in operate n until a Certifi to of Compliance has been issue t oard heal Si . ................................. � • -� Application Approved By•........... -- •--••••-• ...... • ...............::.•-- ---- $ f. • -- ate Application Disapproved for the following reasons:.............................................................................................= _ j ------------------------------ ----------------------------------------------------- �,vo� Date Permit No......... ... �� 1------.. Issued....................................................... Date Y' tom.• - iv►`j, ' No................_..... FRs....... z ...-7Set THE COMMONWEALTH OF MASSACHUSETTS �...--- BOARD OF HEALTH ...............OF................ Appliration fear lisposal Works Tonstrnrtion thrntit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at /. �`% ""•v - '.. - •- Location-/Ad res� �►f � Lot �/ l a� { � =_ �.I�1 /oJ[--G.1� _.. J r----- 10 re. Address a •---•-•.............•- -- --....._ 1<Inst.---•----•---•-•.........--••-•......-^--.... --------•-••-----••----•---•--------------•---•ddre"'s------•------•..-•......-._.._..----------- InstaLer Address Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage'Grinder ( ) Other—Type of Building ............................ No. of ersons.........._..____.__:_....__ Showers i . a g p -------------- ( ) � Cafeteria ( ) dOther fixtures ------------------------------------•--•---•-----------••••--•---•-------••--•......---. Design Flow.................................. ...*:.gallons per person per day. Total daily flow__._._..__ WSeptic Tank—Liquid capaci �'.gallons Length................ Width................ Diame er__-_____...._._. Depth................ x Disposal Trench—NTo. ......:............. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--_---------------- Diameter-------------------- Depth below inlet ................. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ,.�-- Percolation Test Results Performed by----------------- ............... Date...._/Z -• .... Test Pit No. _,_ ---minutes per inch Depth of Test P' ____________________ Depth to ground war r-._______ ______--_--_-. rX4 Test Pit No. ..............minutes per inch Depth of Test Pit.................... Depth to ground,,ivater____•_---_---•_-•-______ a ------------------------------------- -----•. .. ---------- ••......................... ---. --•--•----•--•--... .--------- 0 Description of Soil.................................................... --•-' w UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------------•-------------•----•-...-----.....-• .................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i-.LI,, Doi the State Sanitary Code—The dgr : neOfurther grees not to place the system in operat n until a Certi'- to of Compliance has been issu t board heal fC tf Sign 1''--- - ---- --- - --------- - .................................. •-- -- ��'. ! _, - Application Approved By------------ . _�- ..•-• ... •••.... ..._ t - _ P7� Date Application Disapproved for the following reasons:----•-----------•-•-----------••----•--•----•-----------------•-----------------•---•-•-•-•----••-•-...--••--. Date PermitNo. - - - _ Issued....................................................... Date r. THE COMMONWEALTH OF MASSACHUSETTS .--�-^-', BOARD OF ALT :12�' 0 �Z -;ple�: I Cprrtifiratr of f Omplianrr THIS I O Y, That the `: ' 1 Sewage Disposal System constructed ( ) or Repaired ( ) by - -.- ._.......- I C. Install iat t+modt7C'l has been installed in accordance with the provisions of i I_i iZ j of The tare Sanitary Cod as d scribed in the application for Disposal Works Construction Permit No.. d?..`_"7 dated_..'I Q_•_---. --_-•. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT YHE SYSTEM WILL FUNG N SAT.IS FACT-O----RY. DATE.. - Inspector...... --------------------------------------------------.----•------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF :HEALTH !'."' .'..................OF...... .� .. -'._.r ............._.: N .. FEE. .................. Raposal IV hp #rmtjm-_ rntit Permission is hereby granted.................. ........ ..�............ to Construct ( ) or Repaiy ( ) an I vid 1 ewage Dis System x at No..------------------•• •� ✓ ,/,rr4...`.�-F�-�r!'- ..... e4C•• . -------------•----......-.... Street as shown on the application for Disposal Works Construction 'Permit N�4�'_��__ Dated...��.�1.���.............. / Board of Health DATE..............- •- •-= --..... ............................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS • - - :• f Al A 4 .Z t / Sr/ 7f C ` •I I r+�M n SST.. 7-0 /ZIn�Gciv71sv .f 1 rs:,2o F�Et (;acre.. r_; _ —_` _—_ --�- _._.it _1 .� ., ;I/_; m�►�._ ,,:... /.2� ' - 1 9 . SONGS 3 /37-- - . ` ., � 2. r 1 w 71 Q n �. 4q3� 7. fH \ 10 r'. �` �435� r s�=•' ( .. ' � ;�_ 9tys`o.oo , � � s �s�,3S s�� y� • HD 301. F2UNT /P A U L' �G ' k11 No.•�� ' p A. 1005C O qr r Ak- LEGEND EXISTING SPOT ELEVATIONOito CERTIFIEJ •LGY IpLAhI vEXISTING CONTOUR — 3s - "Lo - I - 3 ` APPROVED BOARD OF .HEALTH No. t �. 1'N1 y , Alt � `J A L DA TE Fa Ff ZEV AGENT SCALEs. � i 40 DATE S 61 x LEVY & ELDREDGE ASSOCIATES, INC. Nic L.uG.i4 CLIENT. I CERTIFY.: THAT THE PROPOSED i ENGINEERS-LANDSCAPE ARCHITECTS $ ® BUILDING $FO®W N O;N THIS .. L AQ ' PLANNERS-LAND SURva;Y®RS J� Np, ,. TO THE ''ZONING __ + --- -- ---� .0 F ®AR N S TA®L E MASS. rr b t 7 2 M A 1 N S.TR E t , . f i ET; # h CH'®Y �� ' t A ei .µ SHEET"' '' ® •. m EG. LAND SJRVEY®RiAEs I t .a; �_ s - ,�,M-l✓;,fin _ .. ""r� 4 7� �k;oARE MORE.' A/V/< 0 7iqAE�Ar-7 W, .7' -e-v r SAEL 0.4v 77-�,5 ��j�7 7 jF-e COIVC&4r7� COP4,e i. r To 4)rA z>,=. '-4 N Z�,Y7-RA sNA4,4 .0o&aq7, & ''y 0":- ;pj CONCIR49!I— I . 4 - bVOW VA=-)R' -F,�W,4.4 I- Ag�- USED AY 6,4 V Y CAST 7 , ir�4 0 CLEAN -5'ANO 6A 2"LAYER 0 OF , parm jwr.�.� 0c YU.rAMIG 41A 5,Ye-0 smmr -4 _3 WASNA7P 57O*E AP EC OR .4 5 SAX-2-57 3 7.=, 7 5.J�s "'y - ----------- IMMEATAT.AWLD/Afa- 40 (5--Z 7A&L,11-A 77)0,V,) FT /Z". VIAM. /IV4,6-70� JWPrIC TANKi CO3p4e!7T 7 V071-ETSEPTIC TAN/4 5,13, pr t r.. 12 INLIFr 4iP.*57R/Asl,7/0H '80lY' 7 GROVND .4 Tel? 7AALE SiSC7 10AI Oic' aox i�14,E 7' L rA CY I AlCr. ADY 7 . -rA8411-A7740eV 1.ZA CHIlVa J=/7' A $CA I-E !Zi --0 61MEN510M DRSISN CRITERIA -10-r-, 'SOIL. 1-0& 1. TESL TOTAL- E-'rrlMA-rF4) -=4(-OAV-336..G,44.1,0.4v , S011- 7-,E57' #/ . SO/4 7r-s7_4#_Z NUM&ER OF 4,df4Cqf1Va j0/-rS 7g OA 7-C OF 5 0 11- TEST.or- gr SID-=4eACA41A16 A�,z-Ac R1 7' $47, RESULTS AV17-AlAffSS-=Z> 60 7-rO/W L.641 CHINa RArer.01 MIA11INCH TOTAL J-eACH11V'Cr AR_-,4 21', S47 -r ..A D FXf �CWMCO 4A 77 0 j0V RA7-AC jk 2 p- A U L A. LEVY F No. 0��0, 11 71 A/--A h1l ✓ 29 MDr - E No. 19 357 LEVY& ELDREDGE ASSOCIATES; INC. -7j.,a t4AIAIr S7.- AV qy Al f5. MA-5 ul� CISTIL A, LL N 0 Cr MO 1//vf 0 j-VA rA A 11015 No. l0.;a!Fa SHE.ETOF ✓ v Y p 1e4.1... t i d - JQ 7 q 4 !: + kill , 2 f s ; 1' 1 31 i MAI A its! f a Y ( t low all No 5� k q , , i. i i i } P 7-4 wA LZ Eli �+. :_. ld .".� i, - x.. ..• .,.:... ��>,..:;w ..ti:;. v:- ':! :'°`• �.r�L '!'-:t � '.-: h '`+�, --",�3' .:: s ri-.a7 5- J� -.,�j"Si?yx :_� sec..• ..,SzY� - :,. r MY•_ �.q. _ � - ,ay.j ;'' ;� ti a :,;, ,y, r„ �...V� i F" ,.."& �',�.� T..r`:J.� ? :f, i .'h •3.�a:'J'�` § _ ��-.. 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',. rL. 1 f :...-s Y :...,, ;,, L ,r,r.✓ •:. w, .y rti", :}� +Lr r �' •�.�' t::: I - 'v+rs.>h�..0 k fit.: t� �, k � p - d 3 ._, ..fill u+ � ' � f 4 vT¢ ��,� Y^�r�5 �w�k:+^-�'=q•"�iR J,s,�y �' z'�� �'���i"F;ji�,cr_fa fi , f ' ��' � :.< r .. .... ::} .� � t c- _F��ya r �.�}•ryv" ��,�,��1.,z� ''Ii t ,_;,i x t ii- yy _'s?.�`xaa i pA��`.�;,"so k ',"�,',W i, t �_'G:... .-:. ,;': a. "�' �" 4"w''4'-�j'�a•�...'-. ,r . v '•:• .. C� sew .; �,..t i�;�Y ,.�G;.•.:$` ?}�,�v:1y+�? - .^�,' r'x`s: •r�• -,e� t r ra,s s4�� 5 r7>.r.a._. . - 4 WINDOW SCHEDULE © Qs Q SYM. MANUFACTURER'S UNIT ROUGH OPENING REMARKS e A ANDERSEN A251 2'-4 7/84x2'-0 5/8" o B ANDERSEN TW2442 2'-6 1/8"x4'-5 1/4" g C ANDERSEN TW2432 2''6 1/8"x3'-4 7/8- o 4r YLALL m REMODELED YrM1017C CAP Tt1 p . LIN GAD. !y affoucall Q NOTES ;. EX Ic EW 36' RAILING r (A I. 'ALL ANDERSON WINDOWS b DOORS TO BE 400 SERIE9 ( IW) ' AT4 w•■r• ^ 0 �tiet oN I - e 2. ALL ANDERSON WINDOWS TO HAVE SNAP-IN VINYL GRILLES.AC4ES { W W pNCLa�wp ISAMA .SEE ELEVATIONS FOR GRILLE PATTERNS. • y 1 O I Fyy! NeUfS a.DR.J O ►IIOVIO! N PAN - - 7. O DOOR SCHEDULE = SO CORE AT WAfNR H,C. HOLLOW CORE 2x4 WALL THICKNESS UNLESS NOTED OTHERWISE f+1 ......CL O __ 7r .-QUILT-1!N ' Ci.. °C �� °�' CL ' Y' SYM. MFR'S UNIT WIDTH HEIGHT THKNESS CORE PANEL DOOR REMARKS - SWING o 1 TO HATCH EXISTING 2'-b" W-S'I 13/6 1 2 0'-0"' b'-S" 1 3/6 BY rip azI 9 4'-0" b'-0" 1 3/6 BY FOLD. m z Y I-AN 4 4-013/8 BY FOLD EXISTINGcn I- Y A � R / SECOND FLOOR PLAN _ INTERIOR DOOR HARDWARE SCHEDULE: �\J/'S—CALE:I//lr=r-& _ TO MATCH EXISTING ALL DOORS TO BE PRE-HUNG SOLID JAMB UNCASED-TYP. W V ROOF PITCH Z TO MATCH EXISTING � A aO..q wW ATO At S Ot�� ai o� R.C. 5 ^ � z � 191� FELT P4To rER ON TYVEK F'IOUSC WRAP o �' • E4 Qwpmm� ALL TRIM TO Q E 4 ZI E�-I MATCH EC. � W�v3 .. REUSE EX. ALUMN. - - _ cn cn GUTTERS '?Z z as rrrl w F oa DATE 08/0flo8 FRONT ELEVATION RIGHT SIDE ELEVATION REAR ELEVATION REVf51 N SCALE:1/4"=i'-0" SCALE:1/4'=1'HT SCALE:1/lr=141' DRAWN BY DRAWING NO. N�mE DRAWINGS AS SHOWN ARE FOR ILLUSTRATIVE PURPOSES ONLY. CONTRACTOR IS TO SITE VERIFY ALL EXISTING VS PROPOSED CONDITIONS PRIOR TO AND DURING Al CONSTRUCTION AND TO MAKQ ALTERATIONS,AND/OR,ADJUaTTO WORK AS IT PROGRESSES TO PROVIDE FOR A COMPLETED PROJECT' IN COMPLIANCE WITH DESIGN PARAMETERS AND MINIMUM STANDAItO6`SIlT FOkTH:'IN MA STATE DUILDING CODE AND APPLICADI"C TOWN_CODCB/ORDIMANCC6..,-CONTRACTOk-.TA..,V,ERICX.ALL.,DI.FICNSIONS PRIOR TO BEGINNING OF CONSTRUCTION.