HomeMy WebLinkAbout0068 CHICKADEE LANE - Health 68 CHICKADEE LA., BARNSTABLE
;
F ,
a
;
r •
tr r V + �, , i. ^ y� ;. `+ - '•. 0,. �.,f'a � .. .ry ;.b a ..y a rr
w ,
4
, r
0
it
• „
r
r - ,•
,
Commonwealth of Massachusetts
Title 5 Official .Inspection Form
Not for Voluntary Assessments
,M Subsurface Sewage Disposal System Form Yed
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
1. Property Information:
68 Chickadee Ln.
Property Address
William Cartmill ��/
Owner's Name -
same
Owner's Address
Barnstable MA . 02630
City/Town State Zip Code
Date of Inspection: - 8/15/08
Date
2. Inspector:
Matthew L. Childs
Name of Inspector
same
Company Name s,
4 Orchid Ln.
Company Address _
W. Yarmouth MA 02673"`�
" City/Town State Zip Codes w {
' 508-989-1479 Ti
Telephone Number ,z
._x
Certification Statement:
I certify that I have personally inspected the sewage disposal system at this addres and that:the r—
information reported below is true, accurate and complete as of the time of the insp ction. l h inspection
.was performed based on my training and experience in the proper function and mai' tenance of on site
sewage disposal systems. I am a DEP approved system-inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The'system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
—? 8/15/08
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 is a shared system or
has'a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner,
and copies sent to the buyer, if applicable, and the approving authority. ,
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
,:> Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection For
Not for Voluntary Assessments, ,
Subsurface Sewage Disposal System Form
A. Certification (cont.)
68 Chickadee Ln.
Property Address
Barnstable MA 02630
City/Town State Zip Code
William Cartmill 8/15/08
Owner's Name Date of Inspection
Inspection Summary: Check,A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
passes
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired.The system,-upon completion of the replacement or-repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain:
❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or.tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as-
approved by the Board of Health.
*,A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
N/A
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of.Massachusetts
Title 5. Official Ins edion
� p. Form
W° Not for Voluntary Asse§sments
Subsurface Sewage Disposal,System Form .
A. Certification (cont.:) Y. _
68 Chickadee Ln.
Property Address
Barnstable MA < 02630
City/Town w 4State Zip Code
' William Cartmill a y 8/15/08
Owner's Name Date of Inspection `
f .
B) System Conditionally Passes (cont.): f
❑ Observation of sewage backup.or break out'or high statiewater 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 g.
❑ obstruction is removed
❑;, distribution box is leveled or,replaced
ND Explain: e
N/A
❑ 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 ofthe":Board of Health);'
❑ ,broken.pipe(s) are replaced = a
obstruction is removed .
ND Explain:
N/A
C) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to.determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the.environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh-
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
68 Chickadee Ln.
Property Address
Barnstable MA 02630
City/Town State Zip Code
William Cartmill .8/15/08
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cone.):
2. System will fail unlesi 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 aseptic tank and SAS and the SAS is le_ss than 100 feet but 50 feet or
more from a private water supply well".
r Method used to determine distance: N/A
**This system passes if the well water analysis, performed at a DEP certified laboratory, for
coliform bacteria and volatile organic compounds indicates that the well is free from pollution from
that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm,.provided that no other failure criteria are triggered.;A,copy of the analysis must be attached
to this form.
3. Other:
N/A
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification cont.
68 Chickadee Ln.
Property Address
Barnstable MA 02630
City/Town State ZipCode
William Cartmill 8/15/08
Owner's.Name Date of Inspection ,
D)System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
0 ® 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 town overloaded or clogged SAS or cesspool
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® 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 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the
presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm, provided that no other failure criteria are triggered.A copy of
the analysis must be attached to this form.]
Yes No
El ® 3The 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.
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
Commonwealth of-Massachusetts
H Title Official Inspection Form
Not for Voluntary Assessments ; -
,M Subsurface Sewage Disposal System Form` 1
Y
A. ,Certification (cont)
68 Chickadee Ln,
Property Address
Barnstable - _ MA 02630
City/Town *- State Zip Code
Milliam Cartmill 8/15/08
Owner's Name Date of Inspection
E) Large Systems: To be,considered a large system the system must serve a facility with a
design flow of 10,600 gpd to 15,000 gpd.
For large systems,you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section'D.
YES NO
❑ ❑ the system is within 400'feet of a surface drinking water supply
❑. ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any.question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or.failed under Section D shall upgrade the•
system in accordance with 310 CMR 15.304. The system.owner should contact the appropriate'
regional.office of the Department.
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
68 Chickadee Ln.
Property Address
Barnstable MA 02630
City/Town State Zip Code
William Cartmill 8/15/08
Owner's Name Date of Inspection
Check.if the following have been done.You must indicate"yes" or"no" as to each of the following:
YES NO
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
® Have large volumes of,water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the7system 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?
Z ❑ 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, depthof liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
Z El 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(3)(b)] • -
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
Title 5 .Official_ Inspection Form_
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information
68 Chickadee Ln.
Property Address
Barnstable MA -_ 02630
Cityrrown State ` Zip Code
William Cartmill 8/15/08
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): - 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd.
- 2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate#inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2'years-usage (gpd)): N/A
9 ( Y 9
Sump pump? ❑ Yes ® No
'Last date of occupancy: N/A
Date
Commercial/Industrial Flow Conditions:
N/A
Type of Establishment:
-Design flow(based on 310 CMR 15.203): - N/A
Gallons per day(gpd)
Basis of design flow(sea ts/persons/sq.ft.,-etc.):. N/A
Grease'trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑: Yes ❑ No
N/A
Water meter readings, if available:
N/A
Last date of occupancy/use: Date
Other(describe): N/A
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont)
68 Chickadee Ln.
Property Address
Barnstable MA 02630
City/Town State Zip Code
William Cartmill 8/15/08
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of:information: owner
Was'system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
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)
❑ . Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
4/27/92 compliance issued
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16•
Commonwealth of Massachusetts
rF Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
68 Chickadee Ln.
Property Address
Barnstable MA 02630
City/Town State Zip Code
William Cartmill 8/15/08
Owner's Name Date of Inspection
Building Sewer(locate on site.plan):
Depth below grade: feet
Material of construction:
El cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line; feet
x
Comments (on condition of joints, venting, evidence of leakage, etc.):
All in good working order at time of inspection.1.5'
Septic Tank(locate on site plan):
Depth below grade: `. feet
Material of construction:
® concrete-, ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age' years
Is age confirmed by a.Certificate of"Compliance? (attach a copy of ❑ Yes '❑ No
certificate)
Dimensions: ' 8'x5'x5'outside 1000 gal.
Sludge depth:
Distance.from top of sludge to bottom of.outlet tee.or baffle 2.9
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
.8'
How were dimensions determined? sludge judge
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
r •
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Not for Voluntary Assessments
Subsurface Sewage Disposal System form
' M .
C. System Information (cont.) '
68 Chickadee Ln.
Property Address
Barnstable R` MA 02630
City/Town State 'Zip Code
William Cartmill 8/15/08
Owner's Name Date of Inspection
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank shows no signs of leakage and appears to have been maintained regularly at time of inspection.
Grease Trap(locate on site plan):
T •
N/A
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass' ❑ polyethylene ❑ other(explain):
N/A
N/A
Dimensions:
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
N/A ,
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.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
N/A
Depth below grade:
Material of construction: .
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
68 Chickadee Ln.
-.Property Address
Barnstable MA 02630
City/Town State Zip Code
William Cartmill 8/15/08
Owner's Name = Date of Inspection
Tight or Holding Tank(cont.)
Dimensions: N/A
Capacity:" N/A
gallons
N/A
Design Flow: gallons per day
w
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order:'4. ❑-Yes❑ No
Date of last pumping: N/A
Date
Comments (condition of alarm"and float switches;etc.):
N/A
Distribution Boz(if present must be opened) (locate on site plan):
`Depth of liquid level above outlet invert 0.0'
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 level witf no leakage or solids carryover at time of inspection.
Pump Chamber'(locate on site plan): s
Pumps in working order. ❑ Yes ❑ No
Alarms-in working order: ❑ Yes ❑ No
t
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Not for Voluntary Assessments
,M Subsurface Sewage Disposal System Form
C. System Information (cont.)
68 Chickadee Ln.
Property Address
Barnstable MA 02630
City/Town State Zip Code
William Cartmill 8/15/08
Owner's Name Date of Inspection
Comments (note condition of.pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain-why:
Type:
® leaching pits number:
❑ leaching chambers number: ,
❑ leaching galleries number:
❑ leaching trenches. - . number, length: `
❑ leaching fields 4 number, dimensions:
❑ overflow cesspool number:
El innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
2 6'x6' precast pits with 2'of stone had 1' of water with stain lines at 2.5' and.show no signs of
hydraulic failure.
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
S. Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
4 M
C. System Information (cont.)
68 Chickadee Ln.
Property Address
Barnstable MA 02630
City/Town State Zip Code
William Cartmill 8/15/08
Owner's Name Date of Inspection
Cesspools'(cesspool must be "pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
r -
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Pi _ s
r vy (locate on site plan).
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
'7M
C. System Information (cont.)
68 Chickadee Ln.
Property Address
Barnstable MA 02630
City/Town State Zip Code
William Cartmill 8/15/08 ,
Owner's Name Date of Inspection
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system.including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
A-141' B-1-16' '
A 2-50' B-2-13'
A-3-60' B-347' f. p
68-
/S
f .
idhi
cc a ee Ln.
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont )
68 Chickadee Ln.
Property Address
Barnstable MA 02630
Cityrrown State Zip Code
William Cartmill 8/15/08 =
Owner's Name Date of Inspection
Site Exam: -
Slope
Surface water
i
Check cellar:
t
Shallow wells
Estimated depth to ground water:
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 15', 7' below bottom of SAS'and did not encounter groundwater.
i
Cartmill.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
WARD TITLE 5
P.O. BOX 1934, MANOMET, MA 02345
508-224-5749
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 6 �'
PART A
• _ CERTIFICATION 9 '
PROPERTY ADDRESS: 68 CHICKADEE LA
BARNSTABLE MA. Y�
02630 9
NAME OF OWNER: JAMES MACHABY
ADDRESS OF OWNER: 15 CLEARWATER DR
PLYMOUTH HA t
02360
DATE OF INSPECTION:8/24/99
NAME OF INSPECTOR: DAVID M. WARD
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR.,
15.000)
COMPANY NAME: WARD TITLE 5
MAILING ADDRESS: P.O. BOX 1934, MANOMET, MA 02345
TELEPHONE NUMBER: 508-224-5749
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 on-site sewage disposal systems. The system:
® Passes
❑ Conditionally Passes
❑ Needs Further Evaluation by the Local Approving Authority
❑ Fails
INSPECTOR'S SIGNATURE 2%�J`�� DATE:8/24/99
The System Inspector shall submit a copy of this inspection report to the Approving Authority
(Board of Health or DEP) 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.
NOTES AND COMMENTS:
Revised 9/2/98 Page 1 of 11
WARD TITLE 5
P.O. BOX 1934,' MANOMET, MA 02345
508-224-5749
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PROPERTY ADDRESS: 68 CHICKADEE LA BARSTABLE MA.' 02530
OWNER: JAMES MACHABY
DATE OF INSPECTION:8/24/99
INSPECTION SUMMARY: (Check A, 87 C, or D) '
A•SYSTEM PASSES:
® I have not found any information which indicates that any of the failure conditions
described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated
below.
COMMENTS:
B•SYSTEM CONDITIONALLY PASSES:
❑ One or more system components as described -in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as
approved by the Board of Health, will pass. "
Indicate yes, no, or not determined (Y, N, or ND) . Describe -basis. of determination in all
instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector
with a copy of a Certificate of Compliance (attached) indicating that the tank was
installed within twenty (20) years prior to the date of the inspection, or the septic
tank, whether or not metal,, is cracked, structurally unsound, shows substantial
infiltration or exfiltration, or tank failure is imminent. The system will pass
inspection if the existing septic tank is replaced with a . complying septic tank as
approved by the Board of Health.
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) .
- r i
❑ 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
Revised 9/2/98 Page 2 of 11
WARD TITLE 5
P•O. BOX 1434, MANOMET, MA 02345 °
508-224-5749
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PROPERTY ADDRESS: 68 CHICKADEE LA BARSTABLE MA• 02530
OWNER: JAMES MACHABY
DATE OF INSPECTION:8/24/99
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 IN ACCORDANCE WITH 310
CMR 15.303 (1) (b) 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 surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt
marsh•
'2) SYSTEM WILL FAIL UNLESS 'THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY)
DETUMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC
HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a
Zone I of a public water supply well•
❑ The system has a septic tank and soil absorption system and the SAS is within
50 feet of a private water supply well•
❑ The system has a septic tank and soil absorption system and the SAS 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• Method used to
determine distance (approximation not valid) •
3) OTHER
Revised 9/2/98 Page 3 of 11
WARD TITLE 5
P•O. BOX 193411 MANOMET, MA 02345
508-224-5749
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PROPERTY ADDRESS: 68 CHICKADEE LA BARSTABLE MA• 02530
OWNER: JAMES MACHABY
DATE OF INSPECTION:8/24/99
D• SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as
described in 31 0 CMR 1 5.303• 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•
Yes No
❑ ❑ Backup of sewage into facility or system 'Component due to an overloaded or
clogged SAS or cesspool• ,
❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface
waters due to an overloaded or clogged SAS or cesspool•
❑ ❑ Static liquid level in the distribution box above outlet invert due to an
overloaded or clogged SAS or cesspool•
❑ ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less
than 112 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 Soil Absorption System, cesspool or privy is below the high
groundwater elevation.
❑ ❑ 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
❑ ❑ Any portion of a cesspool or privy is less-than 1 00 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.
E• LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with. .a design flow of 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:
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 11 of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance
with 31 0 CMR 1 5.304(2) • Please consult the local regional office of the
Department for further information.
Revised 9/2/98 Page 4 of 11
WARD TITLE 5
P.O. BOk'M4, MANOMET, MA 02345
508-224-5749
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
.iµ CHECKLIST
PROPERTY ADDRESS:, 68- CHICKADEE LA BARSTABLE NA. 02530
OWNER: JAMES MACHABY
DATE OF INSPECTION:8/24/99
Check if the following have been done: You must indicate either "Yes' or "No" as to each of
the following
Yes No
® ❑ Pumping information was provided by the owner, occupant, or 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.
® ❑ As 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
® ❑ The system does not receive non-sanitary or industrial waste flow,
® ❑ The site was inspected for signs of breakout.
® ❑ All system components, excluding the Soil Absorption System, have been located on
the site.
® ❑ The septic tank manholes were uncovered, opened, and the interior of the septic
tank was inspected for condition of baffles or toes, material of construction,
dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption •System on the site has been
determined based on:
® ❑ Existing information. For- example, Plan at B•O•H
® ❑ Determined in the field (if any of the failure criteria related to Part C is at
issue,, approximation of .distance is unacceptable) EI 5.3020) (03
® ❑ The facility owner (and occupants, if different from owner) were provided with
information on the proper maintenance of Subsurface Disposal Systems.
Revised 9/2/98 Page 5 of 11
WARD TITLE 5
P-0• BOX 1934, MANOMET, MA 02345
508-224-5749
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
PROPERTY ADDRESS: 68 CHICKADEE LA BARSTABLE MA. 02530
OWNER: JAMES MACHABY `
DATE OF INSPECTION:8/24/99
FLOW CONDITIONS
RESIDENTIAL:
Design flow:110g•p•d•/be.droom•
Number of bedrooms (design) :4 Number .of bedrooms. (actual) :4
Total DESIGN flow:440
Number of current residents:4
Garbage grinder (yes or no) :NO
Laundry (separate system) (yes or no) :NO If yes, separate inspection required
Laundry system inspected (yes or no) :-
Seasonal use (yes or no) :NO
Water meter readings, if available (last two year's .usage (gpd) :NA .
Sump Pump (yes or no) :NO
Last date of occupancy:PRESENT
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: gpd (Based on 15.203) ;
Basis of design flow:
Grease trap present (yes or no) :
Industrial Waste Holding Tank present (yes or no) :
Non-sanitary waste discharged to the Title 5 system (yes or no) :
Water meter readings, if available:
Last date of occupancy:
OTHER: (DESCRIBE)
Last date of occupancy:
E
GENERAL INFORMATION
PUMPING RECORDS and source of information:
PUMPED IN 92 PER OWNER
System pumped as part of inspection (yes or no) :NO
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
® Septic tank/distribution box/soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ I/A Technology etc. Attach copy of up to date operation and maintenance contract
❑ Tight Tank Copy of DEP Approval
Other:
APPROXIMATE AGE of all components, date installed if known ,and source of, information:74-91
Sewage odors detected when arriving at the site (yes or no) :NO
Revised 9/2/98 Page 6 of 11
WARD TITLE 5
P.O. BOX 1934, MANOMET, MA 02345
508-224-5749
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
, SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 68 CHICKADEE LA BARSTABLE MA. 02530
OWNER: JAMES MACHABY— , Q
DATE OF INSPECTION:8/24/99
BUILDING SEWER:
(Locate on site plan)
Depth below grad'e:30"
Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain)
Distance from private water supply well or suction line:OK
Diameter:4"
Comments: (condition of joints, venting, evidence of leakage, etc. )
GOOD
SEPTIC TANK:®
(locate on site plan)
Depth below grade:8" ON OUTLET END OF TANK
Material of construction: ® concrete ❑ metal ❑ Fiberglass ❑ Polyethylene ❑ other(explain)
If tank is metal, list age Is age confirmed by Certificate of Compliance .(Yes/No)
Dimensions:1000 GAL
Sludge depth:6"
Distance from top of sludge to bottom .of outlet tee or baffle:20" .
Scum thickness:6"
Distance from top of scum to top of outlet tee or baffle:7"
Distance from bottom of scum to bottom of outlet t.ee or baffle:14
11
How dimensions were determined:TAPE ,AND ROD
Comments:
( recommendation for pumping, condition of inlet and outlet toes or baffles, depth of liquid
level in relation to outlet invert, structural integrity, _evidence of leakage, etc.)
TANK AND OLD PIT NEEDS TO BE PUMPED BAFFLE GOOD
GREASE TRAP:❑
(locate on site plan)
Depth below grade:
Material of construction: ❑ concrete ❑ metal El Fiberglass El Polyethylene ❑ other (explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and .outlet tees or baffles, depth of liquid
level in relation to outlet invert, structural integrity, evidence of leakage, etc.)
Revised 9/2/96 Page 7 of 11
WARD TITLE 5
P•O. BOX. 1934, MANOMET, MA 02345
508-224-5749
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 68 CHICKADEE LA BARSTABLE MA• 02530
OWNER: JAMES MACHABY
DATE OF INSPECTION:8/24/99
TIGHT OR HOLDING TANK:❑ (Tank must be pumped prior to; or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction: ❑ concrete ❑ metal ❑ Fiberglass 0 Polyethylene ❑ other(explain)
Capacity: gallons
Design flow: gallons/day
Alarm present:
Alarm level: Alarm in working order:: Yes❑ No ❑
Date of previous pumping: '
Comments:
(condition of -inlet tee, condition of alarm and float switches, etc• )
DISTRIBUTION BOX:®
(locate on site plan)
Depth of liquid level above outlet invert:O
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage
into or out of box, etc• )
BOTH LINES HAVE EQUAL DISTRIBUTION
PUMP CHAMBER: ❑
(locate an site plan)
Pumps in working order(Yes or No) :
Alarms in working order (Yes or No) :
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc• )
Revised 9/2/98 Page 8 of 11
.WARD TITLE 5
P•0• BOX' 1434, MANOMET, MA 02345
508-224-5749
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 68 CHICKADEE LA BARSTABLE MA• 02530
OWNER: JAMES MACHABY
DATE OF INSPECTION:8/24/99
SOIL ABSORPTION SYSTEM (SAS) :®
(locate on site plan, if possible excavation not required, location may be approximated by
non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:2 6X6 PITS PLUS STONE
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of pending, damp soil, condition of
vegetation, etc• )
OLD PIT NEEDS PUMPING FLOW WAS GOOD ON 91 PIT
CESSPOOLS:❑
(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 pending, damp soil, condition of
vegetation, etc•)
PRIVY:❑
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:.
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of
vegetation, etc•)
i
Revised 9/2/98 Page 9 of 11
WARD TITLE 5
P•0• BOX 14341 MANOMET, MA 02345
508-224-5749
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: h8 CHICKADEE LA BARSTABLE MA. 02530
OWNER: JAMES. MACHABY " r
DATE OF INSPECTION:8/24/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 1OO1 (Locate where public water. supply .comes into house)
y;2�1
Revised 9/2/98 Page 10 of 11
WARD TITLE 5
P•0. BOX 1134, MANOMET, MA 02345
508-224-5744
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
PROPERTY ADDRESS: 68 CHICKADEE LA BARSTABLE MA. 02530
OWNER: JAMES MACHABY
DATE OF INSPECTION:8/24/99
NRCS
Report name:
Soil type:
Typical depth to groundwater:
USGS
Date website visited:
Observation Wells checked:
Groundwater depth: Shallow Moderate ❑ - Deep ❑
SITE EXAM
Slope: OK
Surface water:OK
Check Cellars:OK
Shallow wells:OK
Estimated Depth to Groundwater:7 feet
Please indicate all the methods used to determine High Groundwater Elevation:
❑ Obtained from Design Plans on record
® Observed Site (Abutting property, observation hole, basement sump etc• )
❑ Determined from local conditions
❑ Checked with local Board of health
❑ Checked FEMA Maps
❑ Checked pumping records
❑ Checked local excavators, installers
❑ Used USGS Data `
Describe how you established the High. Groundwater Elevation• (Must be completed)
TEST PITS ON OTHER LOTS
Revised 9/2/98 Page 11 of 11
15
LCCQiSE\IV'6►`�E PERMIT !J0
77
IMS-T•ALLER ,S WN1 AE ADDRESS
&UILDER 5 Q L.MTEE ADDRESS
DINE PERtAl 155UED ��- 2. L/-7`� - - --
D ATE COMPLI &t�;CE ISSUED 71-1
i
-� r1
o
i
1
. . ..
e
.� � �� \
�� � �� �'
��
\` ��`
��, ,
\� `,;
�/�
C�.
�'' ��
�r��
.+ �f. y �.
� _.
Z L TOWN OF BARNSTABLE
/1 LOCATION C
.Lk s -SEWAGE #nn Q- I&C>
VILLAGE ASSESSOR'S MAP Lgup�,
INSTALLER'S NAME & PHONE NO. �1�,►�'` Zi�Lc�ll �� - gg�
SEPTIC TANK CAPACITY i Cl.>
LEACHING FACILITY:(type),� r_LA-,+ (size) _(jQC__�
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER �,J,:�) Oj )
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes NoX' w,
r�
�-
� �i .. !
� �c�/�
�-- -�.
e� �"
4� °�—
s ''
...�
.-
�h
No.7�=��_ •• Fps.. .........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALT
TOWN OF BARNSTAB - ��
Appliration for Uiopoii ai Works Ton tra� � ��q�.
Application is hereby made for a Permit to Construct ( ) or Repair (/) an Individual Sewage is osal
System at
....L,.,�......................................... -------------------- -------------------------------------------
Location-�ress or Lot No.
.�1�1N.... _.... .l ....tl. -------------------------------•-•--- ...........................................................................................---..........---------------•--------- ---•------.._.....•-----••••-•-------•....__..N-•---
-�- wner Address
a ---... 1..�.rta_au i ------------------------------------------------ ------------------------------------------7------------------------------------------------------
Installer Address
Pal
Type of Building Size Lot____________________________Sq. feet
V Dwelling—No. of Bedrooms___3.....................................Expansion Attic ( ) Garbage Grinder ( )
•+
Other—Type of Building ______ No. of persons____________________________ Showers — Cafeteria
p-' Other fixtures ------------------------------------------
d - ---------------------------------------------------------------•--------•------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter_______________.Depth................
x 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 ( )
PercolationTest Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
(z, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------------------------------------••-------------------------••-----......--------------------.........................................................
0 Description of Soil........................................................................................................................................................................
.x
V •--•-------------------•-------------------------------------------•--------------------------------•---••••-----------------------------------------------------------•--••----•----•-••-•------
W ---------------------------------------------------------------------------..........................................-------------•-•---••--•--...-----•--- -•-------------------------------•----
UNature of Repairs or Alterations—Answer when applicable__A_�.�_►.�_ _____ s .__�1C._____________________________
-----------------------------------------------------•---- •••--••-•_..._._._..__....----------•---•-------------------------------•-•--•----••---••--••-------•-------------------•-••-•------•------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of CompliaM has been is ued b e board of health.
Signed........ 7D - ------------------ `
Date
Application Approved By ..............
-------.--- --------------------------------------...............................................------------ ----- ---------......Date--...'-'.—......
Application Disapproved for the following reasons- -------------------------------------------------------- ---------------------------------------------------------------------------
........................................
Permit No- ----*--? f�p D Issued
...........................................................I........
Date
3 Y
Fim
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE./ ,
Appliration for 11ispnsal Works Tomitrnr rrntit Y 02�-� qt
Application is hereby made for a Permit to Construct ( ) or Repair (� an Individual Sewage Disposal
System at• l' r
...�.. /_E C!�t. U. .L:N....................................... ...................�? a:c� ..P.� ------------------------------------------
.I.
..
Location-.Address .--.--.---or Lot No.
T �
g6vner Address
-------•-•--------------------------------- - ------•------•--------••------.--------------••-•-•-•-•----•-----.-------.........---•-------••---
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___3....................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ___________________-___---- No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures .....................
W Design Flow...::.......................................gallon s per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid*capacity-------.....gallons Length................ Width................ Diameter................ Depth................
x 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_-___-__--_-_-__-- --.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.................-......
•-------•-------------------------••----••-------------•----------..........--------......--.......
..........................................
---------------
0 Description of Soil........................................................................................................................................................................
U .--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------'-"-
W ..........................................................................................................................................
....................I............._.........................
U Nature of Repairs or Alterations—Answer when applicable.... _+.ti j......__n'tic..k_...... ..............................
-••------------------------------------------------••-----.._.......----•----•--•-•••--•--.........-•-••••---•-•-------------------•....--•----•-•--...................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code.—The undersigned further agrees not to place the
system in'operation until a Certificate of Complian has been issued by the board of health. {
Signed ... I� 'liU..O 11...f--.----------------------------
...
-I
- ! Dace
Application Approved By ---- JD Date
Application Disapproved for the following reasons• -------......................................-----------------...............................................----------------------
---------------------------------------------------------------------- --------------------- --- -------------------------------------------------------------------------------------------------------- --------------------------------------
Dace
Permit No. ........ ..................------- Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE ti
Certificate of 01-10raylianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by.................... _...... ...................--------..---------........-......-......................................................------------------------------ �—
�I - ................................................
Installer
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .......:7.-;L.-..../' 6)............ dated ----------------------------------------- --_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... ...................... y?. 9 x_..-----------............. Inspector ................... -..,r .
I Li
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
! �..^J. FEE........................
Disposal Works Tun#rnr#ion "pantit
Permission is hereby granted-....---- . ..wZ..!-e?.t�arQ�l.........................••--•--................--•-•-..................-•---.........----
to Construct ( ) or Repair ( � an Individual Sewage Disposal System
atNo. •-• - 1 =`cL�l:� G.:. -•.............................................•-•-•-•--------.................
Street
as shown on the application for Disposal Works Construction Permit No..��.:;� .... Dated..........................................
�. ...........................................................
o Board of Health
DATE.................... y'f ................................
FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS
r
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION �` -SEWAGE #
VILLAGEg 17 ASSESSOR'S MAP 6 L 9
INSTALLER'S NAME & PHONE C,�
SEPTIC TANK CAPACITY
LEACHING FACILITY-(type), �i �� •,} 7;}5 lsize) ,��uC�
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER e) `t}
DATE PERMIT ISSUED: - 7�
DATE COMPLIANCE ISSUED: -��• `� "�
VARIANCE GRANTED: Yes NoX
P
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=234069&seq=1 7/23/2019
1
Ec
LCac&T10IQ 5EW&C.4E PERMIT MO,
1IvSTALLER 1J�►�/l A DRESS ,
15UILDER5 Q &VAF- ADDRESS
DfaTE PERMIT ISSUED r�`"�a�=7`f
DATE COMPLI &MCE ISSUED :
01 �
S N,
No... Z�.�.-•--- Fix.. .... ....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town. .... . .........OF.......Barnstable... ----------------------------_--------------------
AvOira#ion -for :41,svu,ittl Workfi Tomitrurtion Vrrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
... Q=er._Q axed._9xanbe --L ea.. ............lpt 1-34---•---•---------------------------
Locatioon-Address or Lot No.
...._Kej.n--P._.F11-a----------------------------------------------------------- 53Q-M.--�a n_- �---� S.---------------------------------------
'f,7 //�,Q✓yv�ner 4 j,� } Y1K�dr-d�ress
W N Z�e�E..F--- -• ------. _ .i.a��' � '...':'S�a ..!_Oak.Prb.Y':l1•.�r..-------••--•-•--•--•-------------------
a >�s.----- .............
Installer Address
Q Type of Building Size Lot------1-7_, --------Sq. feet
U DwellingNo. of Bedrooms_:._.__ -_-_.Ex Expansion Attic Garbage Grinder— P ( ) g ( )
aOther—Type of Building ............................ No. of persons_--____-----____-------_.-- Showers ( ) — Cafeteria ( )
W Other fixtures -----
d
W Design Flow...........................5Q............gallons per person per day. Total daily flow................3M.....................gallons.
WSeptic Tank—Liquid capacity_hU0callons %Length________________ Width.__--......... Diameter... Depth.-_.-._-_--_-
Disposal Trench— Width.................... Total Length_-_-___-____-----_. Total leaching area--------X--_--_sq. ft.
x 1- &00 gal -ess-Too
Seepage Pit No.stong-�i ffn, r____________________ Depth below inlet......___.. .__.... Total leacliin are a-----------------.s(l. ft.
Z Other Distribution box ( ) Dosing tank ) Q,� P' — 71
~" Percolation Test Results Performed by----- ------ -----�k__l-el-------------------------------- Date----------.-.-------.--.-----------.....
Test Pit No. 1................minutes per inch Depth of Test Pit--.________-_-_-_- Depth to ground water...-_-_---_--_-.__.-__--
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water................_----._.
P4 ---------- -------------- ----------------- ---------X----------- '
Description Pf Soil_j ._ Jo.... ...... a- - ---------------
U ------------- A- = 1 i•*�t+�' - �' `� �'- itil�....:'
UNature Off Repairs or Alterations—Answer when applicable______________________________..._._'_._. ..__________........_..____........__.___---.-_-__-
-------------------------------------------------------------------------------------------------------------------------------------------=-----------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate,of Compliance has been issued by the board of health.
Lige d '----- --�----------------------------------------------------------- te---- ----- --- ------- --- ------------------Application Approved BY ' . 1 to
7�aL�
...�
Application Disapproved for the following reasons----------------------------- ----------------------------------------------------------------------------------
.................................................
_ Date
Y
PermitNo......................................................... Issued........................................................
Date
ke
y. THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T .......own
F.......B MA.. e........... .................................-----
Applirtttion -for Uhipolitt1 Works Towitrurtion Prruift
Application is hereby made for a Permit to Construct ( X) or Repair ( ) an Individual Sewage Disposal
System at:
------�orner._af___th Chickadee ex�'�t.����::-....-...Lot--#--34-----------------------------•-----------•------••----_-____-_------
Location Address or Lot No.
.-__.-Revin ...-_Friel -------- •--------•---••-------•-••--•---•-----•-• 3 - _. a .h_. ....-..
ner Address
�JzLt a ........................... -Parker=_saris•Ds_tier_shem-Ile.........................................
~ Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms------3------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Q, Other—Type of Building ____________________________ No. of pegsons............................ Showers ( ) — Cafeteria ( )
Q,
Other- fixtures .....---------------------------------------------------------------------------------------------------------------------------------------------------
W Design Flow________--50`.... ._____ __::,______._gallons per person per day. Total daily flow.................3L.00-------------------- allons.
Septic Tank—Liquid capacity_J'�_QD9allons tLength................ Width--------- Diameter---------------- Depth................
W Disposal Trenc , li___________________ Total Length__________________-_ Total leachingarea.... 2_--------s ft.
x; P h1�0�•ga�,;;ic�ss,� . - ------ -------- Total eachi � trea-_�.-----_-___sq ft.
Seepage Pit .No._ eter___________________ Depth below inlet____
rStone-pSCP P g t 1
Z; Other Distribution box ( ) Dosing tank ) Q� �!i/ �- ��,
~' Percolation Test Results Performed by-___K_ '__-_ �_!_��________________________________ Date_____________-_-__-_________________- ..
Test Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water.-_-______-______-__.--.
Test•Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water__-_-_______________----
Pa'
� -aD , w Y ------------------------
Description escrptonPfoi-T---_ .... ...... ....... - - --------- -----`-- •-
..
x
r------ -1' --- - ----------------------------------------------
U Nature 6f Repairs or Alterations—Answer when applicable_....__ ___________________ _________________ ___ ____. -.
-------------------------------------------------------------- ------- ---•--------------- ----t.._
Agreement:
The undersigned agrees *to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of,Compliance has been issued by the board of health.
igrie ................................. . .- ..... ...
- -, ate
Application A roved B �` 11.__ .l�
PP PP Y
-1--
ate
Application Disapproved for the-following reasons:...-•••--•->-•=••-••-•--••- ----------------------•-.------------•----------------------------
}
---------•--•....•-- -•-•-•-----------•------•-•-------•-------•--------••-••-•-•••---••••----------•---••-•-----
i ql�d / �� �r r -7 fZY
ate
Permit No. ;.....:........ Issued.�d;•----•--•-- /---•••....._ ....••--•-----
J' Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........To rn.:::.............OF.......Barnstable......................-..-........................-
�`.:.`:.� . ... err#ifirtt�r ,ttf�fP�nnt�littnrr � .
THIS IS TO CERTIFY That_the Individual Sewage Disposal Sy�ceop structed ( X) or Repaired ( )
Wal tee F
by -- --=-------------------•-• .................. :.
,.sc.
Installer
at _Ut__#_34..Q.Q=eYr O'f---GfMckadfte .and-__Cranbei 7._Ianes Ceritervim e----------------------------------------------
has been installed in accordance with the provisions of Article..X?II of The State Sanitary Code,as described in the
application for Disposal Works Construction-Permit No.-"._.____.J-1J ........ dated-1 '
..y/ -____.__
r T
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON TRUED AS A GUARANTEE THAT TH, E
SYSTEM WILL
FU�NC: �TIONr SATISFACTORY.-DATE. Inspector
Ins ector-pal,�
_
THE 1 't
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�✓ ................° ..................O F.-...Barnstable---------- ---------------...--------•--........-.-.
No.y J FEE--4 10----•-•----•-
.
Permission is hereby,granted__._. ...... i
to Construct ) o6 Repair ( an Individual Sewage Disposal System
at No___________________4-__•orner:of--hi,ckadee.-and-•Ca=nbxzg..Lanes--- .eratexle:: :::_:.
----------•-------
Street
as shown on the application for Disposal Works Constructio rmit _.. Dated__ _ ____
-�'
0P1
ik
AV
.- -
' Board of Health 1
DATE s.,..
; _
-------------------------------------
FORM 1�255 HOBBS &WARREN, INC.. PUBLISHERS _
4
-T
tc
L�4
Jr
1 1-71.
ma
I
t �
I-A 4
J- I
T--T
� _-- -��;�-- -�_- _ __-- Jam- _ �_ J- -- -L- -I- -- -- ---
I � � � I I � � � T j I ;�
f � I , � I .r :.�.,.� I �._ I
I '� - I -� T I
IF
i j I , I j ;--}- -I � j - I I
I -� �1 -4-- 1 4- --4 -
-7<5i d
J I I
I� I
i I
I I I
I I , -� i � i I ► I
I
y '
I I
-I-
lilt
IT
i I
-
I
I I I I