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HomeMy WebLinkAbout0115 BRENTWOOD LANE - Health 115 BRENTWOOD-Lp(U6_ BARNSTABL E V q. n - . � r + ,r ,- � a .:eF r �' _ .rat • r 'r + I J t t 009 Commonwealth of Massachusetts 33 3- 'd 0'P Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c !% 115 Brentwood Ln Property Address Anthony& My-le Raggio Owner Owner's Name information is 1'• required for every Cummaquid f1gerd Ma. 02637 6-2-20 I page. Cityrrown State Zip Code Date of Inspection t '7 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 cS/„# lq<&(& on the computer, use only the tab Michael Sears key to move your Name of Inspector cursor-do not Robert B Our Co INC. use the return Company Name key. 363 Whites path Company Address South Yarmouth Ma. 02664 City/Town State Zip Code r 508-477-8877 S114430 Telephone Number License Number B. Certification I certify that: I am a DEP approved 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. -S1 (11 OF t)kqss1,���'i 2. ❑ Conditionally Passes ' .�C! MICHAEL yN 3. ❑ Needs Further Evaluation by the Local Approving Authority $o: SEARS *: No.SI14430 0 4. ❑ Fails 4���asr Nul pp�\�����. 6-2-20 Inspector's Sign- re 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts �� Title 5 Official Inspection Form h_ �; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments � 115 Brentwood Ln Property Address Anthony & My-le Raggio Owner Owner's Name information is Cumma uid Ma. 02637 6-2-20 required for every a page. City/Town 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: 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 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts ,,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ............. 115 Brentwood Ln u- Property Address Anthony & My-le Raggio Owner Owner's Name information is required for every Cummaquid Ma. 02637 6-2-20 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 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): 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 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: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 r Commonwealth of Massachusetts w Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Brentwood Ln Property Address Anthony & My-le Raggio Owner Owner's Name information is Cumma uid Ma. 02637 6-2-20 required for every q 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: ❑ 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 AM' Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 115 Brentwood Ln Property Address Anthony & My-le Raggio Owner Owner's Name information is Cumma uid Ma. 02637 6-2-20 required for every q page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/.day flow ❑ ® 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 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 2000 gpd- 10,000 gpd. ❑ ® 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. 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. 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 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �� 115 Brentwood Ln Property Address Anthony & My-le Raggio Owner Owner's Name information is Cummaquid Ma. 02637 6-2-20 required for every 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 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts ,,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u!% 115 Brentwood Ln Property Address Anthony & My-le Raggio Owner Owner's Name information is Cumma uid Ma. 02637 6-2-20 required for every a page. City/Town State Zip Code Date of Inspection D. System Information, 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 0 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 ears usage d NA 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts �w Title 5 Official Inspection Form �1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u— 115 Brentwood Ln Property Address Anthony & My-le Raggio Owner Owner's Name information is required for every Cummaquid Ma. 02637 6-2-20 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 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: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 cam, Commonwealth of Massachusetts I? Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Brentwood Ln V Property Address Anthony & My-le Raggio Owner Owner's Name information is Cumma uid Ma. 02637 6-2-20 required for every a page. City/Town I 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: 3-24-99 #99-157 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: T 2"feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 115 Brentwood Ln Property Address Anthony & My-le Raggio Owner Owner's Name information is required for every Cummaquid Ma. 02637 6-2-20 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 7' Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 gal If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal 4" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 24 Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 12" Sludge gudge, tape How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I 1500 gal H2O inlet and outlet tees in place, inlet cover at 4"below grade, outlet cover at 6 6" below grade t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts a Title 5 Official Inspection Form 11 i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c � 115 Brentwood Ln u� Property Address Anthony & My-le Raggio Owner Owner's Name information is required for every Cummaquid Ma. 02637 6-2-20 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 ❑ 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.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 h Commonwealth of Massachusetts �n l Title 5 Official Inspection Form _ �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `............. !% 115 Brentwood Ln Property Address Anthony & My-le Raggio Owner Owner's Name information is required for every Cummaquid Ma. 02637 6-2-20 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): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D box is 20x24 H2O box is 7' 6" below grade with cover at 6" box has 2 outlet pipes i t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form �I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 115 Brentwood Ln Property Address Anthony & My-le Raggio Owner Owner's Name information is required for every Cummaquid Ma. 02637 6-2-20 page. City/Town 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.):. * 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: ® leaching chambers number: 2 ❑ 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 Title 5 Official Inspection Form III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a. � 115 Brentwood Ln u— Property Address Anthony & My-le Raggio Owner Owner's Name information is required for every Cummaquid Ma. 02637 6-2-20 page. Cityrrown 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.): SAS is 2- 500 gal drywells at 8' below grade SAS is clean and dry with no sign of failure 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 ' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 cam, Commonwealth of Massachusetts Title 5 official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Brentwood Ln u- Property Address Anthony & My-le Raggio Owner Owner's Name information is required for every Cummaguid Ma. 02637 6-2-20 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 ,p Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 115 Brentwood Ln Property Address Anthony & My-le Raggio Owner Owner's Name information is required for every Cummaguid Ma. 02637 6-2-20 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 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 t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form lI; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 115 Brentwood Ln Property Address Anthony & My-le Raggio Owner Owner's Name information is required for every Cummaguid Ma. 02637 6-2-20 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: 3-16-87 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: Plan 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 115 Brentwood Ln u" Property Address Anthony & My-le Raggio Owner Owner's Name information is Cummaguid Ma. 02637 6-2-20 required for every — page. City/Town 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. ® 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 �d a boa ,- ar s*•S , r 9i(J Gevin wa,F1n f •�, 3 I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 I� f BPI �-ti1 tc)00) � L-F- 0��Nr i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpliration for Misposal *pstem Cunstrurtion Vermit Application for a Permit to Construct( ) Repair 04) Upgrade( ) Abandon( ) ❑Complete System t4lndividual Components Location Address or Lot No. S k7dewrWo od Ls0-h 6- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 333 16 O 3 ®O 1'p `1 �'� mil L� /� ��'►�O Installer's Name,Address,and Tel.No. !rlb V Y 77 V'17 ,f Designer's Name,Address,and Tel.No. A/P1 Type of Building: ,r�v) r j Dwelling No.of Bedrooms { Lot Size 'I 125 sq.ft. Garbage Grinder( ) Other Type of Building Stn!de- C4A-ttkU No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) it- gpd Design flow provided gpd Plan Date (p " 02 Number of sheets Revision Date Title 14-'Lo h . (� 11-w O bvoe-. , �'►� Size of Septic Tank 1 Ob Z-0 Type of S.A.S. C2) lj'� �� 37-7 �. �. Description of Soil L D 4-^- j 3 4 0. d &/,.!i /V&tfl S ge S p a t,^1- Nature of RZ rs or Alterations(Answer when applicable) (�!e7-C.�. `� d, � I a !L ut 1-� '1 c� s 7UoSc Date last inspected: lzm 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 Certificate of Compliance has been issued by this Board of Health. Signed Date (o Z." �Zo 2-D Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �� Date Issued No. t Fee THE COMMONWEALTH OF MASSACHUSETTS Entere d in computer: PUBLIC HEALTH DIVISION - TOWN ,OF BARNSTABLE, MASSACHUSETTS Yes 2ppYication for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System rgIndividual Components Location Address or Lot No. t r.�.�' kVei rW o Oct t!41,7 6 Owner's Name,Address,and Tel.No. ' J .-� j L.fr Assessor's MapTarcel 33.3 O a 3'/ ,Ob�o 1 uf4f ��`�v'ryy v - 'f" tl- c��? Installer's Name,Address,and Tel..No. r !,a It 7-7 t f_7•7� �/(( Designer's Name,Address,and Tel.No. 7(o 3 u r t e-5 /'��`� S 7 '^W" /tM Type of Building: I l Dwelling No.of Bedrooms / Lot Size Ll Q),1 7 S �-- sq.ft. Garbage Grinder( ) Other Type of Building 1�;i ryj e J ;No.of Persons , Showers( ) Cafeteria( ) a Other Fixtures r Design Flow(min.required) gpd Design flow provided gpd S Plan. Date (0 - 0-2 - o Z ) Number of sheets Revision Date - Title W�_e O 14 Q.4•r.e.-nx Size of Septic Tank 1 5-00 Gt L /4 LO Type of S.A.S. �`�) 5-U,) 17;k Z.. el. e Description of Soil o 4-ro Li 5 4"0. d Gba L/ /1J t' tYt l�t S+ �`�Ga ►� Nature of Repairs or Alterations(Answer when applicable) _Z.o Y^ 1C Date last inspected: - J i.Xlt2 .e�2 4 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 Certificate of Compliance has been issued by this Board of Health. Signed Date 1� Z '2.0 Application Approved by i, Date Application Disapproved by / Date for the following reasons ,4 11 Permit No. p. I Date Issued �. _i .-..,�.�.....,.��_- ._�-�._:._ _,-me.µ ,�..�,� - �.......,�...4..,..�, •--.,s. ., _...v. . _ ........- .-_-. _.-,-...-. ---�-.,. ...__. _.: -----•- ---•---- ---_ _ _.._.. THE COMMONWEALTH OF MASSACHUSETTS - i BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(k Upgraded( ) Abandoned( )by t 1' at 115- Pac-e N- k.) n-.r,_c t,;j has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No?6)t, dated (n - ! Installer I�Anx,2_'t- raj. 0,>JL.- LQ Designer J A v #bedrooms `= Approved design flow Al `f gpd The issuance of this permit shall not be construed as a guarantee that the system will'func`tion as designj Date j.,/ {'/,Z tf Inspector -------------------------------------------- No. Z- •Fee - } ^;'°"' r THE,COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION BARNSTABLE;MASSACHUSETTS " Misposal 6pstem Construction permit Permission�is hereby granted to Construct( ) Re air O Upgrade( ) Abandon( ) System.located ate--�� lti c3 �^' IA1�/)l� ( �Yt r1-y A. V. and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with P � Title 5 and the following focal provisions or special conditions. k. ' � 0�^� Provided:Construction must be completed within three years of the date of this permit. "r.!� Date `". " .. . ,> C� "�` l A roved b V PP Y j TOWN OF BARNSTABLE` U LOCATION (3rF j (,0*209 A A WO SEWAGE # VILLAGE tPl '- 16D ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. M rttA iv'� SEPTIC TANK CAPACITY fixes a 0 l 'LEACHING FACILITY: (type) X"`40 CAA wkWAA (size)1,61 3-" q A 2 , NO.OF BEDROOMS -BUILDER OR OWNER inaft A• Rya 9tri y PERMIT DATE: COMPLIANCE DATE: R h/zf* 6 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 o tsite 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 C1� • r i i 1 i No. Fee _ } THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipplic tion for Mkgpool *potem Conotrurtton; Permit Application for a Permit to Construct Repair )Upgrade( )Abandon( ) 1GC=omplete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 6 Brr.�vTtu00b CA. YY�v !' thin �D Assessor'sMap/Pazcel 333 3—� a dv 0� � 61( Installer's Name,Address,and Tel.No. Desi ner's Name,Address and Tel.No. .J. C+0 1 LL4er. pe1B�Y, z58 ' 7 W , YR,-Md-_J114j MA oZ 7 Type of Building: AA '' Dwelling No.of Bedrooms Lot Size *8 m b sq.ft. Garbage Grinder(W) Other Type of Building No. of Persons, ( ) Cafeteria( ) Other Fixtures Design Flow L---) gallons per day. Calculated daily flow t gallons. Plan Date l Number of sheets Revision Date TitleStT5--: PIRA ► - rr !-r1 M`0xvx Q Gsi n Lorlo 40riE'uTw--c_-_,n Uiuia , CUr>7M,4�uid� Size of Septic Tank nh3o U Type of S.A.S. ShD►� Dry, Ltf' S Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue Pby t 's oar f Health. Signed Date l��z Application Approved b Y Date { Application Disapproved for the following reasons Z i Permit No. Date Issued •af'No.� �/ ` Fee THE COMMONWEALTH OF MASSACHUSETTS ' `Entered in computer: Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01p.prication for Migogai *pgtem Congtructiori Permit Application for a Permit to Construct(/Repair( )Upgrade( )Abandon( ) ld'complete'System El Individual Components Location Address or Lot No. L �? Owner's Name,Address and Tel.No.Mr -; t- ,)t 1 1 O Assessor's Map/Parcel -333/ 3 -- G L ��W, Z 6 Installer's Name,Address, and Tel.No. Designer's Name,Address and Tel.No. �O�f�G4l�/' C'ddr.ST R .J. �A01 -1AC ,�t~a, JCS w . Y ae�Y, vtt 4, f a26 73 Type of Building: Dwelling No.of Bedrooms Lot Size 4-6 ?,rA 6 sq.ft. Garbage Grinder(P4� Other Type of Building No. of Persons' Showers( ) Cafeteria( ) Other Fixtures Design Flow b gallons per day. Calculated daily flow 148 gallons. Plan Date I z 101 Gl Number of sheets 2 Revision Date ' Title.St n-- ylr+} , A"Aa o l b , 43AQ q L or 6 l�r a n (.Aroma . Co r'h frt Arr tf i U Size of Septic Tank 15o U r Type of S.A.S. �h�P � �1'c, WP►�_C _^ � Description of Soil -�r�t.t S f c� 6o!r `tz, l� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been is"ysar Health: Signed Date �/2 �7 Application Approved by Date c Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,'that the On-site Sewage Dis,osal System Constructed"( )Repaired ( )Upgraded( ) Abandoned( )by �O/ at �-dt h t c� �.` �. Al / i has been constructed in accordance r. i,. r y with the provisions of Title S an the for Disposal System Construction Permit No dated G y ' ry Installer Designer _ The issuance of this permit o shall/not be construed as a guarantee that the sys 1in_cM _as designed.//,.' ,, �j 1 fl , Date� A/i!I 1 Inspector / � �,d{/r/ �1 r�;�., �: No. Fee ---- — -------------------------- ---- 2 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS ligponl *pgtem Con! truction Permit Permission is hereby granted to Construct(Repair( )Upgra/de( )Abandon( ) System located at L/�7`' l�1' �,7 G1Jl�D✓) !-/�,�! fg 14/rJ/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 provi is ons or special conditions. Provided: Construction must be completed within three years of the date of thi t. Date: Approved —� �� pp .:.:t'�'aq a.-:"$' T t. t'x',��°af.� r 8 �#�cc,�- "�'•{'I'"'s'fti'A'-.r�'=�'��. ,e�, `,�;'�''"' ttf.t���?. k -" w--fz y4 -, K"'."^�,�.,'e�Knw.��'e-i.. fb"�.5"•��i,�'" �'�'"e•a M.�� 1 i."e. ` r TOWN OF BARNSTABLE LOCATION C4 4" G►0, SEW _ +� VILLAGE �i fit'1�)S'" t� � ! aS3 ASSESSOR'S MAP&LOT 1.7 A,Ste INSTALLER'S NAME&PHONE NO: r '��!ice, ry SEPTIC TANK`:CAPACTTY- e. t o LEACHING FACILrr Y: (type) �► ,,� , fA��.w (size) s = s t` NO.OF BEDROOMS t' �� a BUILDER OR OWNER a y ,'A *n' gin 4&1 PERMITDATE: COMPLIANCE DATE: .P it 1.2.t i e.i Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Pri��te Water Supply Well and Leaching Facility (If any wells ezisr ontsite or.w.ithin 200 feet of leaching facility) _ Feet Edge�f Wetland,and Leaching Facility(If any wetlands exist w�tlu6;I feet ofjeaching.facility); Feet Furrushed by _ l t wow- ✓� 10 . LOCUS IS IN THE. RF--•-1 ZONING DISTMCT NCrT r0 5C ALE ,,► A"ND THE AQUIFER PROTECTION OWRLAY #. LOCUS IS A.M_ 333, PARCEL r3--6: BENCH MARK--TOP PK �IAIIL SET , � 10� .1 • 0 EDGE �AVE►�tENT=100.00 ASSIGNED l GO.G Di,STRICT AND APPEARS 'TO BE SUBXC1 !' C� ` 2. ELEVATIONS SMdWN :ARE ASSIGNED. TO CONSTRUCTION YARDS •QF: 1 3. LOCUS IS IN FLOOD ZONE G ON FIRM DATED AUGUST 19, 1985. ra A1thea ©r. " ` - -- 1G0 1 ;��.C,: FRONT YARD 30' a 4. ALL PIPES TO BE 4` SCH 4-0, AND PITCHIED AT 1/4" PEP FOOT, (UNLESS WTED) rp SIDE YARD 1� 5. MUNICIPAL WATER IS AVAILABLE. LOTS WITHIN 100 ARE ON TOWN WATER, � 9G.� x'99.8 9w REAR 'YARD 115' 6. COMPONENTS TO BE AASHTO H-••-10, VNLES5 N,0TCI1' MAX. BUILD HEIGHT OF 30' OR , 7. INLET TEE TO PIRC?JECT' DOV1iN 13", UU�LET � p41r1�1 14". 8. IF TWO OR MORE LINES, WATER 'f`I~�ST D-SOX FOR EQUAL FLOW x -99:6 �' .� 1/� STORIES, WHICHEVER IS`LESS. , D-13�OX EXIT PIPES TO BE LEVEL FOR FIRST TWO FEJET, Rte. 6 '�" j� �, 9 ;; 9H.1 ACTU, L ZONING DETERMINATIONS MUST 9. DEPTH OF COMPONENTS HOT TO EXCEED 3'. OR 'VENTING MUST 5E PROVIDED. > tl BE MADI BY TO P?l •ZO IIN i FFIGAI . 8!JIIJ� UP C7VER5 TO WITHIN 1 OF GRADE. MORTOR CHIMNEYS IN PLACE. r � �s r ''' ONE COVER OF TANK TO BE WITHIN 6"'OF GRADE, ,�,�,jj,, ti AP x -,",1 14. STpNF Ta BE DOUBLE WlSi IED 3/4O 1 1/2" WITH " IvII1VE. / TO 1/2" PEASTONE IAA TOP. �.. e�► M x $ v t� a 11. IF UNSUITABLE SOILS, 3R SOILSDIFFERING FROM TIDE SfXIL LOG ARE FOUND, 1 vo � x OR R. 1 CADILLAC. t 9 'Aid 1G3.2x 3 z / CONTACT THE $0•ARD OF HEALTHY R.J. "1^15.o i �', `' �" 12. IF A14 CVERDIG IS GALLED, FOR BELOW, FILL MATERIAL FOR ;5' AROUND A1NO UNDER 1EACHING '� �( � JAMS & DARLENE', IS TO E3E CLEAN GR,ANDULAR SAND MEETING SPECIFIC,A110NS OF 310CMR 15,.255(3). C. c " `14. ALL, CONSTRUCTION TO MEET TOTLE 5 AND LOCAL REGULATIONS. phone / . .� rn�. Q 104n8 ` TIIERI DEPTH (nGhes El1EV.Qaet) electrl 0 1g.4 •a >s 99,7 TEST HOLE PATE: i�ir cfi tC, 1987' Woad doom 8 Na 106. PERFORMS BY: Edviord E. Kelle 1 5. 4Proposed tdp foundatipn WITNESSED BY. Jerry' Durlr�in Aa,ard of He(Eh s�kssztil Co 104, C<` [:fNCH MARK>•�-•TOP tRAV SE �^� _ a I , a ~" *./ '� 1 C15.5 tSE=112f26 ASSIGNED / pERC RATE: ,/ ►.ch x b . N 404 " 33.4 Invert 0.35 x 1 :5 .:" ���a x Q� 0 Proposed Invert 96.38 � s �,.`c' � � � Use Gas Boffie b Q g61 1 G „ 10 .' Inv rt. 9,6.1:5 5 COIITACTOR 1 OO'S tine sana Proposed �T.4 S=v(jrie2 TOP ILI A STOME �/F• t d 1500 Gail. t5` t 0 se 1 to f T x �. ' >� !'Ce r1d JOHN & GERTRUDE 10� ��.:,:: �eG � x 1 Q ,6 1 5. � 24'0 102 x x'Ci3. '1 12, Invert 96.6 C *� 111 : x 113:• Q Y105.5 1 Pr osed .Ia2 FEIN Irf 632 Invert 96.a2 Usk 5" Skone onder froppsed Proposed 1 .6 Bot'tarti 7 • 105.f1 - . x 1 a l x l:05:2 �' ...... .r 1 I _� 1 10•� 1s7 ,1 r - , , .�. I 11 Jam' 1 1T BOOR x 114 2 �S Bottom 11'N 1=85,4 FAMILY ROOM I ES 1 J j DINING ROOM 1 GRADE SALE Tc3 x 1t2. �' x 1 :`�. x 10 :� x 14. % 106.5 BEDROOMS: �} 1•E�► AREA KITCHEN ) x c .� x o .� 1 PANTRY (84 SF) 1 CONDUCT RUNOFF N � x 11; � CARSAI E GRINOEER� 111t� � S£- S!WG�REY-€3RY LttS -STET / - �3EF�i_ _ 1 .AROUND ,HOUSE.. REQUIRED L"/`<Cy0rCI7Y: 4� GP1� $' APART lY�lO 'WETH 4" OF STONE x 11 .rS1 ' x 1 3.5 ST1C TANit: 1 StJO GAL. ALL AF2CfllNi , pd / FflR A �3' X 12'--1�" '.�?ND �'t�t�QR 1 r I BOTTOM LEACHING AREA: 423.4 SF X 2' DEER BEACH AREA. x 11.0.; x x In 8,3 j E J' C 121.83)) 3 OEDROOMS 3, x 10` 1U6.i3 x 109.5 x 115.2 I') R• SIDE. I.EAGHING AREA: 183.3 `�' �� �1��E�V�'►C. � U� 'R�JOM 1� 11 .1 11; `TOTAL ROOMS 9 [2(1 .$3 33 j X 2.' IEEP) 11 .; DIG A 5' ALL ARC}tl�Vb AND UNDER N 1•�2.5 DESIGN CAPACITY: 4als REMOVAL ISO Vi: TO TINE SAND. x 1 ow.+~ �4� y U423.�4 SF + 183..3 SF) X .74 GPD/SF] ROUND i I:N'N TO f` 4 BEDROOMS / x 1 Ctg 4- �a i� r-/ CAN 103.8 � -�•��� '�- 1�Y ,LOT 6 T. x 1o1.9 -�Y5T _ICOid TRUC`fif 1 I U - x o �7 y� w 0,-6 �Z PRIOR TO SETTING ANY SEPTIC / 1G2.r_, (11.Y 0 x 1?..c COMPONENTS CALL R.J. CADILLAC x 'cs.5 TO EXAMINE SOILS IN PROPOSED / DAII ?AFL LEACH AREA. X 109 6 '�2 x '.r FIRE DISII OT x 113.8 x 108,2 ,. 109. S '� 11z•" - MAN / l FOR k 1-2, 1. 0 114. x 10,3.E " 113.4 P . S A VALID �C} �14 ' F IT STARS x 2.a- .A�.IS , �`k.' D STAIV7 , .v T 1F F' y( x 11 G,� 1.�` PL Sq �Qr. � ` '1IUALD oy S' RONALD c2 AN 1 rioNy D. RA%7%m7jw 111,4 4- JAMES x 1G9 79 �`9®� LOT , R N LANE, WW ' I , ADILLACLA $pg , N 8 . x 109.2 F . Ajo Vi 9 TEST HOLE LOCATION, NUMBER BENCH MARK-•--1'OP TRAVERSE 12 g� 0a w WIC, PLC RS P'f�OPOS'Ed WATER SERVICE STAKE=115,38 ASSIGNED• GAS Lif'�E MARKINGS CIF SHOWN) --�•-•�--- _ x .5 11.0 EXISTING 8c PROPOSED ELEVATIONS ('X' MARKS POINT) ► F LAW 'A _ MUM` ' ITAM EXISTING CONTOURP.O. �- • PROPOSE[ CONTOUR %0 'YARM+U" , MA. Oa'7 CJ CONCRETE BOUND (508 '5-97 00 HEALTH AGENT APP �.' PACE 1 OF I C' 19951 BY RA. CADILLAC