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HomeMy WebLinkAbout0016 COVE LANE - Health 1 16 Cove Roadawe Bariistable { A= 351 060 No. 4210 1/3 BLU 10�I® . G - � � � ��� � , � � � � � i >� �F - { 4 J e5lotkyyvs 1 1 `t �".w� t�'3�✓a e�rR - :: tiry } y Y, H•{ St�:.p } alb 1. � 23 9 D 'Q l COMM.OlY YY El'11—i H bFM Sa3S1'iCfl i SEWS .•. ,Y - EXECUTIVE OFFICE OF ENVIRONMEN-i"AL 'F.�I S t bEPARTMENT OF ENVIRONMENTAL PR &l\/ED SE PQ1 2004 v TOWN OF BAR.NSTABLE HEALTH DEPT. TITLES OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM FORM. PART A CERTIFICATION:. ;SAP q PARCEL Property Address �, 1 1 mpt LOT aC Owner's Name: Owner's Address: 1, Date of Inspection gab, 7 K: Name of Inspector: please print) tie Company Name: ` Mailing Address: �� `tr►5 .�. Telephone Number: 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 the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.T am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15-000). The systern; Passes Conditionally Passes • x ,. Needs Further Evaluation by the Local Approving Authority Fails Of Inspector's Signature: Date: • C� The system inspector shall submit a copy of this inspection report to the Approvir'a 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. u Notes and Comments :` ****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. Title 5 Inspection Form 6/15/2000, page 1 , P Page 2 of I I OFFICIAL INSPECTION FORM-=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE IHSPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Cot/ L a Owner: o 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 15303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: - One or more system components as described in the"Conditional Pass"secti need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the follow' g statements.if"not determined"please explain. The septic tank is metal and over 20 years old*or the tic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank oved by the Board of Health., *A metal septic tank will pass inspection if it is stru y sound,not leaking and if a_ Certificate of Compliance indicating that the tank is less than 20 years old vailable. ND explain: Observation of sewage backup r break out or High static water level in the distribution box due to broken or obstructed pipe(s)or due to a brok settled or uneven distrilmtion box.System will pass inspection if(with approval of Board of Health): broken pipes)aumme.replar�d obstructiom its emoved distnbution box is leveled or replaced ND explain: The required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection' (with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND a lain: , 2 Page 3 of 13 OFFICIAL,INSPECTION FORM-NOT FORVOI:,IJ`NTARY ASSESSMEN'i S SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: l G Coilf- us�aGeJs Owner: Date of Inspection: 7 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to det ine 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 3 CMR 15.303(i)(b)that the system is not functioning in a manner which will protect public health, fety 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 we d or a salt marsh 2. System will fail unless the Board of Health(and Pub' Water Supplier,if any)determines that the system is functioning in a manner that protects the pu c health,safety and environment _ The system has a septic tank and soil abs orp n system(SAS)and the SAS is within100 feet of a surface water supply or tributary to a surface w r supply. — The system has a septic tank and SAS d the SAS is within a Zone I of a public water supply- - The system has a septic tank and S and the SAS is within 50 feet of a private water supply well. The system has a septic tank an SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**.Meth used to determine distance **This system passes if the we water analysis,performed at a D£P certified laboratory,for coliform bacteria and volatile organic ompounds indicates that the well is free from pollution from that facility and the presence of ammonia • ogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are trigge d.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of ll OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS y SUBSURFACE SEWAGE SYSTEM INSPECTION FORM PART*. CERTIMCATION(continued) Property Address: ! 6 e- ZA- Owner: �f tA Date of Inspection:. Sf D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for ail inspections: Yes No 6(( 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 pL 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''/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstrdcted 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 l 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.his system passes if the well water analysis, performed at a IDEP certified laboratory,for califivrin 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 S pprn,provided that no other failure criteria_ are triggered.A copy of the analysis mast he attached to this form.] A1d(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure: E. Large Systems: To be considered a large system the system must serve a fa with a design flow of 10,000 gpd to 15,000 gPd• a .. - a You must indicate either"yes"or"no"to each"ofthe f g (The following criteria apply to large systems in ad ' to the criteria above) yes no — — the system is within 400 feet of a ace drinking water supply the system is within 200 fee of a tributary to a surface drinking water supply the system is located a nitrogen sensitive area(Interim Wellhead Protection Area—lWPA)or a mapped ' - - - y g PP ° Zone R of a public supply well If you have answered' to any question in Section E the system is considered a significant threat,or answered ` "yes"in Section D ab a the large system has failed.The owner or operator of any large system considered a. significant threat er Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The cyst owner should contact the appropriate regional office`ofthe Department. F ' Page 5 of I l R OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: G!t A..-k Owner: 7pw_%& l 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 Iarge 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 NIA) _ 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?x The size and location of the Soil Absorption System:(SAS)on the site has been determined based on: , no 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)J 5 Page 6 of I I OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION'FO&M PART C SYSTEM INFORMATION Property Address: f 6 W Q.r =LIMA M".1 L-�f Owner 340VAAA Date of Inspection: FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents:_ Does residence have a garbage grinder(yes or no): 6� Is laundry on a separate sewage system(yes or no): rU6 [if yes separate inspection required] Laundry system inspected_(y^es or no): Seasonal use:(yes or no):Rd�/ o ac c�3(aas Water meter readings,if available(last 2 years usage(gpd))-. 02 �� Sump pump(yes or no)-�V Last date of occupancy: COMMERCIAUINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): �pd Basis of design flow(seats/persons/sgft,etc-): _ Grease trap present(yes or no):_ Industrial waste holding tank present or no): Non-sanitary waste discharged t e Title 5 system(yes or no): Water meter readings,if av " le: Last date of occupancy e: _- OTHER(desc e): GENERAL INFORMATION Pumping Records ,p Source of information: IV0 if)MP Mc-e L Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool , Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation.and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date m�ed(if kno and source of information: 1 a 13014 r_7 tf o Were sewage odors detected when arriving at the site(yes or no): . 6 I ' Page 7ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS EN''S SUBSIRfFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART C SYSTEM MORMAT'ION(continued) Property Address: " C vtlt, Leed Owner: _ Date of Inspection: BUILDING SEWER(locate on site plan) a Depth below grade: 912 - Materials of construction:—cast iron K 40 PVC_other(explain): Distance from private water supply well or suction line' Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: OC (locate on site plan) - Depth below grade:, Material of construction: concrete metal fiberglass polyethylene —other(explain) — — If tank is metal list age._ Is age confirmed by a Certificate of Compliance(yes or no) (attach a copy of certificate) / Dimensions: (-U Q�,1 Sludge depth: .11, Distance from top of slit _dge to bottom of outlet tee or baffle: { "` Scum thickness: Distance from top of scum to top of outlet tee or baffle: 6 , Distance from bottom of scum to bottom of outlet tee or baffle: IV How were dimensions determined: dot VK Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels , as related to-outlet. vert,evidence of leakage,et : OL,Jc Q. 40 '� ` t GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction: concrete etal._fiberglass polyethylene Jother . . (explain): Dimensions: Scum thickness: Distance from top of scu to top of outlet tee or baffle: Distance from bottom scum to bottom of outlet tee or baffle: Date of last pumpin Comments(on p ping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid.levels , as related to ou et invert,evidence of leakage,etc.): Page 8 of II w OFFICIAL INSPECTION FORM-NOT.FOR VOLU TARY ASSESSMENTS f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: V L J Wl , Owner: Date of Inspection: tsolna TIGHT or HOLDING TANK: (tank must be' ped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal a fiberglass_polyethylene other(explain): Dimensions: Capacity: allons Design Flow: gallons/day Alarm-present(yes or no): Alarm level: arm in working order(yes or no): ` Date of last pumping: Comments(condi ' of alarm and float switches,etc.): , DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depthliquid of level above outlet invert: _J&A4 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"): le �. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or Alarms in working order(y r no): Comments(note condi " of pump chamber,condition of pumps and appurtenances,etc): r - Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBS1j FACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: p Date of Inspection: 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,number,dimensions: overflow cesspool,number: " innovative/alternative system Type/name of technology. Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): 3 oc c.—, 4- CESSPOOLS: (cesspool must be purr as part of M-spection)(locate on site-plan) Number and configuration: Depth—top of liquid to inlet inv Depth of solids laver: Depth of scum layer: Dimensions of cesspool Materials of construct' n: Indication of groun ater inflow(yes or no): Comments(note ndition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)-- PRIVY: (locate on site pl Materials of constru/ion Dimensions: Depth of solids. Comments(note cof soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Page l0 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM-INFORMATION(continued) Property Address: 16 -e, , oft Owner:-��eA ; 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. �C., �� Page 1 I of I 1 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner, p Date of Inspection:_ 'L t$0( OC4 _ ' SITE EXAM Slope Surface water VIJ Check cellar Shallow wells 00 Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with Iocal Board of Health-explain: Checked with local excavators,installers-(attach documentation) Y Accessed USGS database-explain: You must describe how you established the high ground water etev ion: 04 lS� O � . v } ,- zng I OMMON�T,'EALTH OF SAC t E'I ` E�sECu'g'wE OFFICE OF ENVIRONMEiN"I'_�I,AFF RS T e DEPARTMENT OF ENVIRONMENTAL PROT - ED t�tAR z�1 p c�� :: (( of c�ct� SEP 0 1 2004 10'r TOWN OF BARNS FABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: t6 CA>ve_ Owner's Name: Owner's Address: 7 ��j� Date of Inspection: 3. Name of Inspector: pl print) Company Name: JAE& d•i � Mailing Address: Telephone Number:� }g��?�g Z�IN z� �' 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 the inspection_The inspection was performed based on my training and experience in the proper function,and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: _Y Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority _ k Fails 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. Notes and Comments . ****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. Title 5 Inspection Form 6f 15/2000 page 1 Page 2 of I 1 OFFICIAL INSPECTION FORD-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE 3NSPOSAL`SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: V6 C, vs _ Owner: —D cr f t/1 Date of inspection: 71.461W Inspection Summary: Check AAC,D or E I ALWAYS complete all of Section D A. System Passes: I have-not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below:. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section II be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the d of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following ments.If`not determined"please explain. The septic tank is metal and over 20 years old*or the sep (whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank a is imminent-System will pass inspection if the existing tank is replaced with a complying septic tank as" ved by the Board of Health. ;A metal septic tank will pass inspection if it is sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is a le. ND explain: ,. Observation of sewage backup or out or iaigh static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, ed.or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken p4*.$)= obstiivdiaa isymoved distribution box is lewlexl or replaced ND explain: The system quired pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection' with approval of the Board of Health): __ .. broken pipe(s)are replaced ; obstruction is removed explain: ` 2 Page 3 of i l OFFICIAL INSPECTION FORM,NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION PORN PART A CERTIFICATION(continued) Property Address- Co o V e Owner: Date of inspection: O — " C. Further Evaluation is Required by the Board of Health: Conditions exist which require Rather evaluation by the Board of Health in order to determine i e system is failing to protect public health,safety or the environment. 2. System will pass unless Board of Health determines in accordance with 310 CMR .303(l)(b)that the system is not functioning in a manner which will protect public health,safety a 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 salt marsh 3 3 2. System will fail unless the Board of Health(and Public ter Supplier,if any)determines that the system is functioning in a manner that protects the public alth,safety and environment: The system has a septic tank and soil absorptio ystem(SAS)and the'SAS is within 100 feet of a surface water supply or tributary to a surface wale upply. . _ The system has a septic tank and SAS the SAS is within a Zone I of a public water supply. The system has a septic tank and S and the'SAS is within 50 feet of a private 'Water supply well. _ The system has aseptic tank SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Me d used to determine distance "This system passes if the 1 water analysis,performed at a DtP certified laboratory,for coliform bacteria and volatile or compounds indicates that the well is free from pollution from that facility and'the presence of ammoni nitrogen and nitrate nitrogen is equal'to or less than 5 ppm,provided that no other failure criteria are trite eyed.A copy of the analysis must be attached to this form: 3. Other: , r 3 r Page 4 of i 1 OFFICIAL INSPECTION FORM—NOT'FOR VOLUNTARY ASSESSMENTS SUBSURFACE SERFAGE D100fiAL SYSTEM INSPECTION FORM' PART. CERTIFICATION(continued) �� . Property Address: CoG®d� fe On Ld 4trt Owner: Date of Inspection- 7 It D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or pondmg 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'/z 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 Zane I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. _g_ Any portion of a cesspool or privy is less than 100 fxi but greater than 50 feet from a private water supply well with no acceptable water quality analysis.IThis system passes if the well water.analysis, performed at a DEP certified laboratory,for=Wwm bacteria and volatile organic_compawads 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 S ppin,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] ' v�v (Yes/No)The system fails,I have determined that one or more ofthe'above failure criteria exist as - described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of - Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with gn now of 10,000 gpd to 15,000 gpd. r You must indicate either"yes"or"no"to each of the foIlo (The following criteria apply to large systems m addition criteria above) . yes no _ the system is'within 400 feet of a, ce drinking water supply y = _ the system is within 200 of a tributary to a surface drinking water supply the system is located a nitrogen sensitive area(Interim Wellhead Protection Area*—IWPA)or a mapped Zone H of a publi r supply well if you have answered es'to any question in Section E the system is considered a significant threat,or answered.. F "yes"in Section D ve the large system has failed.The owner or operator of any large system considered a. significant threa der Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The ern owner should contact the appropriate regional office of the Department 1 • t f Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection Check if the following have been done.You trust indicate"yes"or"no"as to each of the following: Yes No — Pumping information was provided by the owner,occupant,or Board of Health _ t 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? lT _ Were the septic tank manholes uncovered,opened;and the interior of the tank inspected for the condition othe baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? N _ Was the facility owner(and occupants if different from owner)provided with information on the proper nc 'F maintenae of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based ow , Y no — Existing information-For example,a plan at the Board of Health-- Determined in the field(if any of the failure criteria related to Part Cis.at issue approximation of distance is unacceptable)j310 CMR 15.302(3)(b)} 5 2 Rage b of I I OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:. W _ t Owner- A AA Date of Inspection: S,I Y di FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Ito Number of current residents: O J� Does residence have a garbage grinder(yes or no) Is laundry on a separate sewage system(ye or no):VqJf yes separate inspection required] Laundry system inspected(yqs or no): Seasonal use:(yes or no):AV Water meter readings,if available(last 2 years usage(gpd)) Sump pump(yes or no): s ' Last date of occupancy: COMMERCIAL/IMDUSTRIAL Type of establishment: , Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sgft,etc.)- Grease trap present(yes or no): Industrial waste holding tank present s or no): Non-sanitary waste discharged a Title 5 system(yes or no): Water meter readings,if av 'able: - t Last date of occupanc e: OTHER(desc ): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_,gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system' _Single cesspool _Overflow cesspool —Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) -Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): /�D ' Page 7 of I I OFFICIAI. INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(continued) Property Address: ( C Cove- Owner: a renQA Date of Inspection: pC/ BUILDING SEWER(locate on site plan) . Depth below grade: _ Materials of construction:_cast iron K 40 PVC other(explain): Distance from private water supply well of suction liner Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: DC (locate on site plan) , Depth below grade: $ Material of construction:4concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age._ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) C ADO a l! • Dimensions: G Sludge depth: 0 u Distance from top of sludge to bottom of outlet tee or baffle: 3C) Scum thickness: l Distance from top of scum to top of outlet tee or baffle: r, Distance from bottom of scum to bottom of o tlet tee or baffle: How were dimensions determined: yr Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as rej!y4 to outlet invert,evidence of leakage,etc GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete tal_fiberglass_polyethylene_other (explain): Dimensions/pumpireconunendations, Scum thick Distance fro to p of outlet tee or baffle: Distance fro to bottom of outlet tee or baffle: Date of last Comments( ecommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to evidence of leakage,etc.): Page 8 of i 1 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: o tw' ZCA Owner: L Date of Inspection: TIGHT or HOLDING TANK: (tank;must �Pum:pedat ' of inspection)(locate on site plan) Depth below grade: Material of construction: concrete glasspolyeth other(explain): Dimensions: Capacity: ons Design Flow: allons/day Y Alarm present(yes or no): Alarm level: in working order(yes or no): Date of last pumping: Comments(conditi of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) µ Depth of liquid level above outlet invert: $r/&l Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage' to out of box,etc.): Tt 605k- { PUMP CHAMBER: (locate on s' ) Pumps in working order(y no):. Alarms in working order es or no): Comments(note con ' on of pump chamber,condition of pumps and appurtenances,etc.): 8 . Page 9 of I 1 - OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SURSUI'ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C-10-01C - Owner:_,j)cKv.AA , Date of Inspection: --y_1 p SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Ty e leaching pits;number leaching chambers,number: leaching galleries,number: leaching trenches,number,length: Ieaching fields,number,dimensions: }` overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,4damp soil,condition of vegetation, etc.): _ /7C CESSPOOLS: (cesspool must be pumped as tnspection)(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 groundwat inflow(yes or no): Comments(note con on of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):, PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note c dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc:): - ,. e.7_n _ a,6. Page 10 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ` PART C SYSTEM INFORMATION(continued) Property Address• CA:)j c Owner: �e"— AA Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM 4 Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.I ocate all wells within 100 feet Locate where public water supply enters the building. Po f - - Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM FIFO TION(continued) Property Address- �o t , Owner: Date of Inspection: (j SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _feet Please indicate(check)all methods used to determine the nigh ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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 trust describe how you established the water'gh round wat t dVlAL" B a g -C elevatL 1 s • _� - COMMONWEA_U1.41 OF MASSACIIUSF,'.I''1'S EXECUTIVE OFFICE OF ENVIRONMENTAL l-PTAIRS I)F.PARTM_Ii NT OF ENVHZONME FAL FRUTELTION ONE WINTER STREET, BOSTON MA 02109 (617) 292-5.50 r F RL k � D .T)Y� F, �N 1 COX Al NSp 350 MAIN STREET '1' Ofpp' ,Secretary ARGEO PAUL CELLUCCI WEST YARMOUTH, MA DAVi,D"BfSTRUHS Governor 508-775-2800 \ Commissioner cc SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION - MAP 351 PAR 060 PROPERTY ADDRESS: 16 COVE LANE, CUMMAQUID ADDRESS OF OWNER: DATE OF INSPECTION: SEPTEMBER 8,'2000 DONALD CONRAD NAME OF INSPECTOR : JAMES D.SEARS I am a DEP approved system inspector.pursuant to Section 15.340 of Title 5 93%CMR 15.000) COMPANY NAME: A&B Canco MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673 TELEPHONE NUMBER: (508)775-2800 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: X PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY`' FAILS INSPECTORS SIGNATURE: DATE: SEPTEMBER 11,2000 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: SYSTEM MAIN HOUSE REPORT ONE OF TWO SITE OVER ALL PASSES, INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME ` OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM. revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIVICATION (continued) Property Address: 16 COVE LANE, CUMMAQUID Owner: CONRAD, DONALD Date of Inspection: SEPTEMBER 8,2000 INSPECTION SUMMARY: Check A, B, C,orD: A] SYSTEM PASSES: X I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/A 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 is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. 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 pa pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is leveled 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 ` r revised 9/2/98 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 16 COVE LANE,CUMMAQUID Owner: CONRAD, DONALD Date of Inspection: SEPTEMBER 8,2000 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A 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 16.303 (1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY) DETERMINES 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 1 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 and is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 3 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 16 COVE LANE,CUMMAQUID Owner: CONRAD, DONALD Date of Inspection: SEPTEMBER 8,2000 D]SYSTEM FAILS: N/A 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 310 CMR 16.303. 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 over- loaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than%day flow 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 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. w 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. 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: N/A You must indicate either"Yes"or"No"as 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further,information. revised 9/2/98 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 16 COVE LANE, CUMMAQUID Owner: CONRAD, DONALD Date of Inspection: SEPTEMBER 8, 2000 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X 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. X As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components,including the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site Has been determined based on: X Existing information. Ex.Plan at B.O.H. X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)11 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. a revised 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 16 COVE LANE,CUMMAQUID 4 Owner: CONRAD, DONALD ; Date of Inspection: SEPTEMBER 8,2000 „ FLOW CONDITIONS RESIDENTIAL: h Design flow: 440 g.p.d./bedroom for_S.A,S. Number of bedrooms(design) 4 Number of bedrooms(actual): ,, 4 Total DESIGN flow Number of current residents: 4 y Garbage grinder(yes or no): NO Laundry(separate system) (yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no): YES ' Seasonal use(yes or no) NO Water meter readings,if available(last two(2)year.usage(gpd): 1999 133,000>2000 192,000 Sump Pump(yes or no): NO 14 Last date of occupancy: N/A COM M ERCIAL/INDUSTRIAL: Type of establishment: Design flow: Gpd(Based on 16.203) 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: s OTHER:(Describe). Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: N/A System pumped as part of inspection:(yes or no) N0 _: a If yes,volume pumped: gallons Reason for pumping TYPE OF SYSTEM F ' X Septic tank/distribution box/soil absorption system Single cesspool .A Overflow cesspool > •; Privy Shared system(yes or no)(if yes,attach previous inspection records,if any) y " 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: NEW LEACHING 1997 Sewage odors detected when arriving at the site:(yes or no) - NO o - ; revised 9/2/98 6• n b • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 16 COVE LANE,CUMMAQUID Owner: CONRAD, DONALD Date of Inspection: SEPTEMBER 8,2000 BUILDING SEWER: N/A (Locate on site plan) Depth below grade: P Material of construction _ cast iron _ 40 PVC _ other(explain) Distance from private water supply well or suction line Diameter Comments:(condition of joints,venting,evidence of leakage,etc.),. SEPTIC TANK: X (Locate on site plan) Depth below grade: 40'9 Material of construction X concrete _ metal. _ Fiberglass _ Polyethylene _ other(explain) If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 29" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle: 14" How dimensions were determined TAPE AND ASBUILT 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.) MAIN TANK AT WORKING LEVEL,OUTLET BAFFLE.OUTLET COVER 20"BELOW GRADE. GREASE TRAP: N/A ,y (locate on site plan) Depth below grade: 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: 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 9/2/98 7 n .. r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION continued Property Address: 16 COVE LANE,CUMMAQUID Owner: CONRAD, DONALD Date of Inspection: SEPTEMBER 8,2000 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to,or 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/day Alarm present Alarm level: Alarm in working order Yes; No a Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) h DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,) DISTRIBUTION BOX NEW 1997,REPLACED AT TIME OF NEW LEACHING.DID NOT OPEN BOX DOWN 4'-5'BELOW GRADE NO SIGN IN TANK OF OVERLOADING. PUMP CHAMBER: N/A (locate on site plan) p, 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 8 ' F • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 16 COVE LANE, CUMMAQUID Owner: CONRAD, DONALD Date of Inspection: SEPTEMBER 8, 2000 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not located, explain: Type. Leaching pits,number: Leaching chambers,number: X 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 ponding,damp soil,condition of vegetation,etc.) FOUR INFILTRATORS WITH 4'STONE.LEACHING IS NEW 1997. CESSPOOLS: N/A , (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:: (note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.) PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) revised 9/2/98 9 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) i Property Address: 16 COVE LANE, CUMMAQUID Owner: CONRAD, DONALD Date of Inspection: SEPTEMBER 8, 2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 10.0'(locate where public water supply comes into house) 4,1 \o 33 t. revised 9/2/98 10 ,. SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 COVE LANE, CUMMAQUID n Owner: CONRAD, DONALD Date of Inspection: SEPTEMBER 8, 2000 NRCS Report name Soil Type - Typical depth to groundwater ' USGS Date website visited " Observation Wells checked ' Ground water depth: Shallow Moderate s• _ Deep SITE EXAM Slope JF A Surface water Check Cellar Shallow wells s. Estimated Depth to groundwater Feet Please indicate all the methods used to determine High Groundwater Elevation:•„ Obtained from Design Plans on record Observation of Site(Abutting property,observation hole,basement sump etc.) Determine it from local conditions + Check with local Board of health _ Check FEMA Maps y A` Check pumping records * ' Check local excavators,installers w ' Use USGS Data a• Describe in your own words how you established the High Groundwater Elevation.(Must be completed) y NOTE: LOT HIGH x r • � A rs Rt e ti a a revised 9/2/98' r Z 203 498 754 US Postal Service Receipt for Certified Mail No Insurance Coverage Provided. Do not use for International Mail See reverse Sent to aa/`• 1 0 ��. CO 7 no.�. Street&Number- -/A a v !-d-v' Post Office,State,&ZIP C e gg Postage $ Certified Fee Special Delivery Fee Restricted Delivery Fee Retum Receipt Showing to Whom&Date Delivered n Return Receipt Showing to Whom, Q Date,&Addressee's Address 0 TOTAL Postage&Fees is Pos ark or Date _ J 0- Stick postage stamps to article to cover First-Class postage,certified mail fee,and N charges for any selected optional services(See front). 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address leaving the receipt attached, and present the article at a post office service window or hand it to your rural carrier(no extra charge). a� 2. If you do not want this receipt postmarked,stick the gummed stub to the right of the ) return address of the article,date,detach,and retain the receipt,and mail the article. LO 3. If you want a return receipt,write the certified mail number and your name and address rn on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a RETURN RECEIPT REQUESTED adjacent to the number. Q 4. If you want delivery restricted to the addressee, or to an authorized agent of the C addressee,endorse RESTRICTED DELIVERY on the front of the article. M 5. Enter fees for the services requested in the appropriate s aces on the front of this Ir qP E h receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. .0 LL 6. Save this receipt and present it if you make an inquiry. 102595-97-B-0145 U) t �THe Town of Barnstable Department of Health,Safety, and Environmental Services • s�uvffreet,e, • Public Health Division ,' �� 367 Main Street, Hyannis MA 02601 �EDMfd� Office: 508-790-6265 Thomas A. McKean, RS, CHO FAX: 508-790-6304 Director of Public Health Donald Conrad December 2, 1997 16 Cove Lane Cummaquid, MA ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 16 Cove Lane, Cummaquid was inspected on October 30, 1997, by James D. Sears, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: a Back-up of sewage into facility or system component due to an overloaded or clogged soil absorption system. o Liquid level in pit was less than 6" below invert. You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis)that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within(14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty(30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health f ti Town ®f Barnstable Department of Health, Safety, and Environmental Services MAW Public Health Division t639. A'F0 N10�p 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A.McKean,RS,CHO FAX: 508-790-6304 Director of Public Health To: n fe, 4 !S� o i-.a nq— DATE: 2 , / en hn O ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at j(� ��Up, Ln . Cuw °d wa§ inspected on CjG.V , 309,97 by32,qA Snrs , a Massachusetts licensed septic inspector. The inspection of your septic, system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) dur the following: Lo over You arldirected to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health q%Wth\dbfdcftt10i.doc —� COMMONWEALTH OF MASSACHUSETTS �'�a-- 7l 7 l+� EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL P CTION !�� ONE WINTER STREET. BOSTON. NIA 02108 617.29 0 c VC WILLIAN4 F.WELD )04V 1997 i cv UDY COXE Govcmor 350 MAIN STREET r '%i HOST,, ' Secrccar. ARGEO PAUL CELLUCCI WEST YARMOUTH, MA T ID B.STRUHS Lt.Governor /�4ar= 508-775-2800 � Commissioner CS���� �4��+,55..00''�LLL��JJ � SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO PART A 351 Ot�o CERTIFICATION ZO f 7 PROPERTY ADDRESS: 106 Cove Lane, Cummaquid ADDRESS OF OWNER: DATE OF INSPECTION: October 30, 1997 Donald Conrad NAME OF INSPECTOR: James D. Sears I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000) COMPANY NAME: A& B Canco ' MAILING ADDRESS: 350 Main Street, West Yarmouth, MA 02673 TELEPHONE NUMBER: (508) 775-2800 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 X FAILS NOTE: SEE LAST PAGE D-BOX& L CHING NEED TO BP REPLACED. INSPECTORS SIGNATURE: _e� � n DATE: October 30, 1997 p The system Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. r INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: N/A I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B SYSTEM CONDITIONALLY PASSES: N/A 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 b the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or NO). 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 is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. Page 1 of 10 (revised 04/25/97) DEP on the World Wide Web:http://www.magnet.state.ma.un/d SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 16 Cove Lane, Cummaquid Owner: Conrad, Donald Date of Inspection: October 30, 1997 B]SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT 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 to 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 1 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 and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 16 Cove Lane, Cummaquid Owner: Conrad, Donald Date of Inspection: October 30, 1997 D]SYSTEM FAILS: X You must indicate either"Yes" or"No" as to each of the following: X I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303.The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an over- loaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in pit is less than 6" below invert or available volume is less than 'Y2 day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s) Number of times pumped X Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: N/A You must indicate either"Yes" or"No" as 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 mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/25/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 16 Cove Lane, Cummaquid Owner: Conrad, Donald Date of Inspection: October 30, 1997 Check if the following have been done: You must indicate either"Yes" or"No"as to each of the following: Yes No X Pumping information was provided by the owner, occupant, or Board of Health. X 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. N/A As built plans have been obtained and examined. Note if they are not available with N/A. X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout. X All system components, including the Soil Absorption System, have been located on the site. X The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: X The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal System. X Existing information. Ex. Plan at B.O.H. X Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 16 Cove Lane, Cummaquid Owner: Conrad, Donald Date of Inspection: October 30, 1997 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g.p.d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: Garbage grinder(yes or no): NO Laundry connected to system es or no): YES Seasonal use(yes or no) Water meter readings, if available(last two(2)year usage(gpd): 1996-97 157,000/1995-96 149,000 Sump Pump(yes or no): NO COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day 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: GENERAL INFORMATION PUMPING RECORDS and source of information: N/A System pumped as part of inspection:(yes or no) If yes, volume pumped: gallons Reason for pumping TYPE OF SYSTEM X 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. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known)and source of information: AGE UNKNOWN Sewage odors detected when arriving at the site: (yes or no) NO (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 16 Cove Lane, Cummaquid Owner: Conrad, Donald Date of Inspection: October 30, 1997 BUILDING SEWER:N/A (Locate on site plan) Depth below grade: Material of construction cast iron 40 PVC other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: X (Locate on site plan) Depth below grade: 40" Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No) Dimensions: 1,000 GALLON PRE CAST Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 331, Scum thickness: 3" Distance from top of scum to top of outlet tee or baffle: 11" Distance from bottom of scum to bottom of outlet tee or baffle: 12" How dimensions were determined TAPE MEASURE 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.) TANK AT LEVEL, OUTLET BAFFLE, OVER 20" BELOW GRADE,SIGNS OF BEING FULL OVER OUTLET PIPE UP INTO RISER. GREASE TRAP:N/A (locate on site plan) Depth below grade: 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: 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 04/25/97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 16 Cove Lane Cumma uid P Y � q Owner: Conrad, Donald Date of Inspection: October 30,1997 TIGHT OR HOLDING TANK: N/A (Tank must be pumped prior to, or at time, of inspection) (Locate on site plan) Depth below grade: Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain) Dimensions: Capacity: Design flow: gallons/day 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: X (locate on site plan) Depth of liquid level above outlet invert: 0 Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.,) D-BOX IS 16" X 21" 40" BELOW GRADE SIDES OF BOX ARE GONE, BOX LEAKING NEEDS TO BE REPLACED. PUMP CHAMBER: N/A (locate on 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.) 4 (revised 04/25/97) Page 7 of 10 F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 16 Cove Lane, Cummaquid Owner: Conrad, Donald Date of Inspection: October 30, 1997 SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan, if possible-, excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: 1 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 ponding, condition of vegetation, etc.) 1. 4' PIT, PIT 44" BELOW GRADE, COVER 20" BELOW GRADE, PIT FULL TO COVER NOT LEACHING, LEACHING NEEDS TO BE REPLACED. CESSPOOLS: N/A (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments:: (note condition of soil, signs of hydraulic failure, , level of ponding, condition of vegetation, etc.) PRIVY: N/A (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 Cove Lane, Cummaquid Owner: Conrad, Donald Date of Inspection: October 30, 1997 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100(locate where public water supply comes into house) b �c lc Z1 Ll I- ply' D Cava ,t/y (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 16 Cove Lane, Cummaquid Owner: Conrad, Donald Date of Inspection: October 30, 1997 Depth to groundwater N/A feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained fro Design Plans on record Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) (revised 04/25/97) Page 10 of 10 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) MA- I 1��C&L DATA . r TOWN OF BARNSTABLE LOCATION COVE 1....APIF— SEWAGE # VILLAGE ASSESSOR'S MAP & LOT 3 5/ INSTALLER'S NAME & PHONE NO. C ' CC'ti'SI�.'l•z"TIC /�� -�"l J SEPTIC TANK CAPACITY LEACHING FACILITY:{type) 1/'L (_11.1,7 /.110&4ccr,nl�(size) 6,'C0 6-ALc.cll / ' NO. OF BEDROOMS 0 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER r'';"" :!%;��/ �7C,tr"L� /�LViIJ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No J J�Ivir ,• � 'i Cl� FtCL 1,5 INC- �4 (OCO evA��UnI ��-►�iIC -1 r\N tit:.-��sc ti-iT ' �� 3'a ti �z<�an►� TOWN OF BARNSTABLE LOCATION ,V )J SEWAGE # i4 N VILLAGE OUV M A.GUI C� ASSESSOR'S MAP & LOT .INSTALLER'S NAME & PHONE NO. A- & B C M 775-6264 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) bv/i 1 frll-k'3 size) qL X I( ' Z NO.OF BEDROOMS ,PRIVATE WELL,OR PUBLIC WATER BUILDER OR OWNERS vL� DATE''PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: 'Yes No �/ L _ lJ aj i - d•L R 2 . r -, sue; A. i. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes / PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS ✓ 01ppliLAttou for Mi.5po al 6pgtem Con!6trurtton Permit Application for a Permit to Construct( )Repair(/)—Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No./6 oe_ 1m) Owner's Name,Address and Tel.No. Assessor's Map/Parcel ' l va ��rVl C��a� Installer's Name,Address, N.50.CANDO Designer's Name,Address and Tel.No. 350 Main Street W.Yarmouth, MA 02673 Type of Building: Dwelling No.of Bedrooms Ll Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers(, ) Cafeteria( ) Other Fixtures / Design Flow t �6 gallons per day. Calculated daily flow o gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank (O X"5,w n Type of S.A.S.1 to ; i 2 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1ASIAlt 2di if+rl+Fo r ry� e t �( � x (t' x j ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boabof�ealth. Signed � iJ _ Date /J °V- 7 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued i •�.+`r .., _. ♦r�. ,+ r�` ,r"a.^' n. "' •.,�i• `•- r �w•.�,.-'L.�,,�.. .�'��... • i�f,s .i •. �A- .. rt )Nd/ , , Fee a7 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 3pplicatiou for Miopogar *r5tem Co,ngtruction Permit Application for a Permit to Construct( )Repair(,'Upgrade( )Abandon( ) O Complete System L1 Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel CU M fM G !L t/r�; Jd1 �Wl J Gt lX Installer's Name,Address,an 1 Designer's Name,Address and Tel.No. 350 Main street W.YarmmuW MA 02#33 Type of Building: ' Dwelling No.of Bedrooms '7 L-.Lot,$_ilze.,., sq ft. »Garbage Qrinder,.( )�•._ Other Type of Building No. of Persons w Showers( ) Cafeteria( Other Fixtures ' / -r? Design Flow "1�6� gallons per day. Calculated daily flow J U gallons. Plan Date Number of sheets Revision Date, ) Title l Size of Septic Tank form x�s 4 ; Type of S.A.S.i,' sr;., a Description of Soil t jty Nature of Repairs or Alterations(Answer when applicable) _ 111 i 14 f744ar Date last inspected: - Agreement: . The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until'a Certifi- cate of Compliance has been issued by this Board of Health. } Signed Date /J c 19'7~ Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued' THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance - THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( L,.Yupgraded( ) Abandoned( )by ef—ef 4 16 e:) at / has-been constructed in accordance with'the provisions of Title 5 and.the for Disposal System eonstruction Permit No. 1ffdated Installer Designer tib4f The issuance of this permit shall not beconstrued as a guarantee that the system w 11 function as designed. Date 3 n - 1 Inspector, ; ——.--————-.- ———— ——-————————— ———-— No. ' / Fee Sd THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Vn Mi.5po$ar *pztem Construction Permit Permission is hereby gr/anted to Construct( )Repair( .�Upgrade( )Abandon( ) System located at �(� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his er duty to comply with Title 5 and the following local provisions or special conditions. Provided:Co structi n.must be completed within three years of the date of, pe Date: Approved by //� ra / SEPTIC DESIGN BZD Hs AT .._1�. GAL/DAy1BcD E = -q*GALI DAYw s P?'IC TANK --YkO GAL/DAB' x. 2 DAYS GAL ► Usg /Ooo GALLON SZ.F 'IC TANK 4.eer 4 IILWHING ARZA.' Usff 4,INFILTRATORS HAXIMI ZZR CHAMB�ReS VITH 0 oi' STONE ALL R IND (347.3 x ff z Z DZlrP) sID3Z - CAPW � /� r 4� q i" r- 10/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ,ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated concerning the s. property located at /(Q (©tom 14,k t �,t4 c,A . meets all of the following criteria: ./ • There are no wetlands located within 100 feet of the proposed leaching facility /There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed -� • There are no variances requested or needed. �If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will 114t be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) Q B)Observed Groundwater Table Elevation(according to Health'Division well map) SIGNED : V L 1 DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert j� s i o f TOWN,OF BARNSTABtE IOCATION ' 3BWAGB = QV� nJ # 1 XILLA(3B A ASSESSOR'S MAP & LOT .....,,.INSTALLER'S NAME &PHONE NO. A & B CANOD 775-6264 . `'SEPTIC TANK CAPACITY- -LEACHING FACILITY:(type) /NJ;1hra w�►I�IW�(size) '�O X (' . NO :OP BEDROOMS PRIVATE WELL OR PUBLIC-WATER >•BUILDBR OR OWNER .,..DATE PERMIT ISSUED: : DATE COMPLIANCE ISSUED: VAIAIANCE GRANTED: Yes No " �.. if 1'r 1. •' , f w _ - A, � {, 'iy �' : 7 r s,.,— — ESTER Town 01 Barnstable - Department of Health,Safety;and Environmental Services I n.n NN Public Health Division i Ali 367 Main street Z 203 4-9 8 7 5.4 c c DEC!z'yi - Hyannis,MA 02601 �F K ryry�ry� ( ��A 6138443 `` r iald Conrac �ve Lame , C ,� f 3 •..-, Q/VOV 131 Mel ugt ley Cyf4jClr�a ' � . ry t!� n. m SENDER: I also wish to receive the 0 :Comp items t and/or 2 for additional services. following services(for an T r• ■Complete items 3,4a,and 4b. i v ■Print your name and address on the reverse of this form so that we can return this extra fee): card to you. _ ■Attach this forth to the front of.tha mallpieFe,or on the bads if space does not 1. ❑ Addressee's Address Z permit. d ■Write'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ ReStrictBd�DeliVery N _ tom. ■The Return Receipt will show to whom the article was delivered and the date Consult postmaster for fee. a c delivered. 0 3.Article Addressed to: a., Number d r � 71 , 4b.Seniice Type � - - d n`-' ❑ Registered Certified Gc � p,Express Mail Insured N❑ Return Receipt for Merchandise ❑ COD 7.Date of Delivery10 a z 5.Received By: (Print Name) 8.Addressee's Address(Only if requested j W and fee is paid) tt g 6.Signature:(Addressee or Agent) f � X i PS Form 3811, December 1994 102595-97-B-0179 Domestic Return Receipt 1— / ,� of WE r Town of Barnstable 'o De artment of Health, Safety, and Environmental Services P ,a,,,� , ; Public Health Division v$ 367 Main Street, Hyannis MA 02601 Office: 508-790-6265 Thomas A. McKean, RS, CHO FAX: 508-790-6304 Director of Public Health Donald Conrad December 2, 1997 16 Cove Lane Cummaquid, MA ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE, TITLE 5. The septic system owned by you located at 16 Cove Lane, Cummaquid was inspected on October 30, 1997, by James D. Sears, a Massachusetts licensed septic inspector. The inspection of your septic system showed that your system has failed under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: o Back-up of sewage into facility or system component due to an overloaded or clogged soil absorption system. o .;Liquid level in pit.was less than 6" below invert. You are directed.to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of a proposed system to the Town of Barnstable Health Division Office (Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance with 310 CMR 15.00, The State Environmental Code, Title 5 within(14) fourteen days of receipt of this notice. You are also directed to bring the septic system into compliance within thirty (30) days of receipt of this order letter. You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic system to prevent discharge of sewage or effluent into the buildings, onto the surface of the ground, or in to surface waters. Any person aggrieved by any order issued by the local approval authority may appeal to any court of competent jurisdiction as provided for by the laws of the Commonwealth. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health � o ' TOWN OF BARNSTABLE-- LOCATION" 16, C6VG LANF, SEWAGE # t , VILLAGE CUMM 1 QUtD ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. Nf C0AJ5-102X77o&1/3�,Z-`937 SEPTIC TANK CAPACITY /000 6AL40A LEACHING FACILITY:(type)ac•CA- ST 600 size) GiJ 6ALt-0n1 PI NO. OF BEDROOMS OFFICE PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 2055 966,�/ / STEVE/J 6-11-UfAl DATE PERMIT ISSUED: S DATE COMPLIANCE ISSUED: " VARIANCE GRANTED: Yes No �� 15Ile 39 .© �' ►3 r low S-Ml i c TAN t� 600 GPHLL-ON �12E^C�+ST p i T v� 3'C4 z SSa N C� ASSESSORS MAP NO: ' No... PARCEL NO: FEz....................ti THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE AVV irFatioat for Uiopooaal Workri Tatuitrnrtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -------------•- -----------gymA.e ...................... --------------------------....---- 1- -_t �N ocatton-A dress .n� or Lot No. wGr - � '� '----- _�e.-._.._.>� n .............................. Address Installer Address d Type of Building Size Lot.................._.........Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ___________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures ------------------------------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons_-_--Lengt __y_____________ 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. 1________________minutes per inch Depth of Test Pit__:_________________ Depth to ground water........................ (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ --------------------------------------------------------------------------------------------•------.....--------...-------•--------------------.....-...----- 0 Description of Soil........................................................................................................................................................................ x W -------•------------------ ----------------------- ------------------------------------•----------------------- ------ ----------------------- ------------------- U Nature of Repairs or Alterations—Answer when appli ble._ _ ___�: ��t��J:______-__L�.'_ 1.:.:::........ ._ -c _..._ A.11a_.•---•---?-�-�'--------= c-------- (ACC�-1���� ����'� � ���e------�� Agreemen� 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 Compliance has bee ssued y the board f he th. Signed :�rrn.,�. t,,.�`: ... `/ �_.�: ?.1........................ Date Application Approved By_ ------- ' r." ------------------- ------- .......... ---------- Application Disapproved for the following reasons- ------------------- ---------- ---- ------- ....-............ ...................-........-...........--- --------------------- ------------ ------------------------- ........... ................. ...... .................. -...-......... - ...... ........................................ � �Permit No. r�.. � . ..... Issued C...6...... ` ��1�............. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Diti-poottl Workii Tonotrur#inn rrutit . - Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at;: ............... -fin I -- ---[A n evr:..-•---............. ......................................1 - . oration-Address or Lot No. i. #• �� c��. '� �>` .K =s`' ��ti !(� =� P l A��-------------•.._..............------........-- . ----- O her (/e Address a ' ����. s ICJ r+ �\.C- A,J,.I�e ..0%,--------------------------------------- �- ---------_ � � Installer Address d Type of Building Size Lot............................Sq. feet U ,., Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) pay, Other—Type of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( ) a Other fixtures -------------------------- =......................... W Design Flow............................................gallons 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 ( ) a Percolation Test Results Performed by----------_-------- --•-•---••--•---••-•-----•--•-------•---------------- Date........................................ \ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water_--__-.-.---_-_---_- riq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P+ •-----•--•-•-----------------------•----••-••-------•-•--•-•---••--•--•-----------•-------------••-......................................................... ODescription of Soil-------------------------------------------------------------------- ---•-------------------------------------------•--------------- ................................... U .....................................................-................................................................................................................................................... -------------------------------•_---•-••---------_---.----_---_-_-.-------•--•-••_•---_•---_-___--_----_-_-__.__-_----_,�i--------------------•_-_--•-----:1..A U Nature of Repairs or Alterations—Answer when applicable_ _ .__-� _. _S l�_�,:_____._.n.c .t��.---:--�_4_ . IUdr� ..0-00 �J�.....-----?-�}'--------.+1)------------ar:s �c�e.._... :--o c P ��'c�c F------c�•bv.�J�� �(�� ►���2 t Agreemenr. V 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 Compliance has been issued by the bo2�� d of h Signed . -s..�<-- ..............)`�'-G �. i` `. ..�..... .......... y - '� C! ( `—� ( Dare �! Application Approved BY --------. ............... - ..... ........' '2' - ... --------------- ...`-`aj�.-�'....�' Daze Application Disapproved for the following reasons: ...................................... .. ..............----.-------------------------.-. ------------------------------------------------------------------------------------------------..................._....------------------------------ _ �j Issued ..----- " .Permit No. .... . ............. :. ..:........... Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C1er#ifi ate of Graplia nre THIS IS TO CERTIFY, That th,: Individu I Sewage Disposal System constructed (. ) or Repaired ( ) .------� �1_ ,�� by ------------------------------- k� .� �� � Insta ler at --------------e� ...... a ------ / .._.. .-.`��i -/t�'' s 9. �---------------------------------------------------- has been installed in accordance with the provisions of TI' L of The State Environmental Code as described in the application for Disposal Works Construction Permit No.Y44..... dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B'E CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �� ---- Inspect r- ----�✓ -------- DATE ------ .. ... ----------------------- r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.9 .... /�1 TOWN OF BARNSTABLE ......�.... FEE.. --•-•-•............... Uiosttl orko Unn trrt' n hermit Permission is hereby granted._..... e .---------•---- � ... to Construct ( ) or Repair ( an Individual)Sewage Disposal Syst at No.---- ./1...-�' l/ �l�J ,�� e • ----------------------........................................... Street ���� / < as shown on the application for Disposal Works Construction Permit No _._.��_:. n_ ed.....�1' ---------------- I ^ ^,///! Board of Health DATE................ �,L........!_._.. ._1.. ..... ---------------•-- FORM 38.30E HOBBS 6 WARREN.INC..PUBLISHERS L C T1014 SEWAGE PEOC1T p0. 04-tr Iq T LLER'S MACE b ADDRESS D U It D R OR 0 h DATE PERMIT ISSUED DATE COCIPLIANCE ISSUED gJ��` �cl L _ 3 � i .. s' r f .i �p gip,.,.�z !" � �� 3aG �q�� .�� )� S r i .� .. n 'Its, w _ A10i 4 v4 y O ' --/-O 7- sr y G 4? 0 1 \ LEA CN DIS �� PIT , X, L3� >6 C I tZ.4/3 �riyZ R1 i RESERVE R,5 D E Z, 4/.9 4-s 5 CERTIFIED PLOT PLAN LOCATION �- �` DATE �c�1/Z �9 79 r/ SCALE . . : . . . PLAN REFERENCE 47✓77.77Ze? . . . . . . . . . . . . ARD torn 2' f 1 CERTIFY THAT THE SHOWN ON THIS PLAN I THE GROUND AS SHOWN HERE CONFORMS TO THE SETBACK RE Q F THE TOWN OF . . . . . . . . . . . . . . . . . . . WHEN CONSTRUCTED. T/9M�� 7M �DG G`�UX DATE PETITIONER: �,q-j�,,57�.•��CJ ��'�, REGISTERED LAND SURVEYOR N59345 NOTE -- /�yrPex�Vio✓.5 ��3L-� s/4C-:� Z_a.� 5144;d'�°".3 To GiE- e=vED Foe ft /5 TOP OF FOUNDATION of 77/ " LEA// P/T p,,.a-PG19iCED W1,11 C1611-1a s'¢" D CONCRETE COVER CONCRETE COVERS •'; 4' CAST IRON PIPE (OR 12 MAX. 12"MAX. • 1/ MIN. 4"ORANGEBURG(OR EQUIV) FAUN PIPE- MIN. LEACH PITCH 4"PER. PITCH 1/4"PER.FT PIT PRECAST LEACH I N G o' INVERT a ''e EL.44,Zr�.... INVE T INVERT oe w PIT OR ;1, SEPTIC TANK �; DIST. EL EQUIV. a INVERT BOX .. � �� ��. /oo o GAL. INVE T o; EL.' 4.$.. EL 9 8o INVERT M w w o: :; 3/4"TO I I ore EL47 �� �q WASHED w STONE 6'DIA. PROFI LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM - NO SCALE SOIL LOG WITNESSED BY : DATE e*�q,A.9j!�78. TIME.!O'3c?. . . . G .��!� �hf. BOARD OF HEALTH TEST HOLE I TEST HOLE 2 �-ID 7As �'- 7.LE f%e--. E N G I N E E R ELEV. .-!'. !J'.Z. . . ELEV. .4o,44 SAY✓ �_ �z�/ ,�Gs. 40 DESIGN . . .DATA ' �/� S�BSoiL NUMBER OF BEDROOMS 3 TOTAL ESTIMATED FLOW . . 3- n. . GALLONS/DAY BOTTOM LEACHING AREA 78��. . SO.FT. /PIT SA,vD SIDE LEACHING AREA . . . SQ:FT./ PIT Ssl�v GARBAGE DISPOSAL (50% AREA INCREASE) w ?AULE �4�9 TOTAL LEACHING AREA SQ.F_T PERCOLATION RATE Z6U 7711"' . Z. . MIN/INCH LEACHING AREA PER PERCOLATION RATE SQ.FT. !✓o. .WATER ENCOUNTERED NUMBER OF LEACHING PITS APPROVED . . . . . . BOARD OF HEALTHS/DES- . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . DATE . . . . . . . . . . AGENT OR INSPECTOR OF LA EY 77,4 PETITIONER �q \. �T W:lv"1 TO APPt'ti#ovA ,3F BARNSTABLE CONSERVATI` $ No...._ 2 COMMISSION ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD' OE HEALTH � •�:�-aG.........---------------- AVV iration for Bis)jlusa1 Works Tomitrurtion Prrmit Application is hereby made for a •Permit to Construct (Al'or Repair OpWan Individual Sewage.; Disposal Systcan — ..1 .... ................ �... ... __...._.____..... ... ... T ...._ ... ........... Location-Address or Lot No. / 47!✓ -.....f...1.. 5 Owner Address $no S. �/ S/^y�7��i� •-••--•-•-•----•-------...--•..............................•......---•-•-••---...---•---- Installer Address �� /� Q Type of Building Size Lot_.____..y.................Sq. feet Dwelling—No. of Bedrooms..... ..................................Expansion Attic ( ) Garbage Grinder (4) Other—T e of Building ............... No. of persons............................ Showers — Cafeteria Q' Other fixtures .---•-----------------------•--• --- W Design Flow........ .------l.ljP.........gallons per person per day. Total daily flow---- ..........................gallons. WSeptic Tank—I.iquid'capacity_!Boo..gallons Length--- 0........ Width....!—- .... Diameter................ Depth................ Disposal Trench—No. .................... Width...................... Total Length.................... Total leaching area....................sq. ft.: Seepage Pit No...... .....:...... Diameter.....e�p......... Depth be19w iinlet. .... To a hing area.y C...sq. ft. Z Other Distribution box ( ) Dosing tank '-' Percolation Test Pi/test NoRl2zse�e•_esults Performed inch Depth Test�P.��..��.��..... Depth to water�!'¢�.�...____. a Test Pit No. 2................minutes per inch Depth of Test Pit..___............... Depth to ground water........................ ,.� P P P g : f� P P P ---------------------------•-------------•---------•-------•--------------................--•----•-•� •--------------••-----� -------------------- 0 Description of Soil.• Cu�-s dr _VA,,C1 -f '! - � -••-•--- x W ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -----------------------------------------------------------•----------------•••••.......-----.•.....•-----••--•----••----------------•--------------------------------•------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITTLE 5 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. Sied-- --•-•--•--.............................................................. ................................ Date Application Approved By•-•-. •...--- .. . ............................. <- Date Application Disapproved for the following reasons:-------•---••••-•-••-•----.....••-•---•••--•-•---------------•--------•••......----........................... .................•-•-•-•-•....---•--......•--••-....-----•••••-•-•-•••----...-••-•-•-•---••--••-•--•-••--I--------••-•••••-••-------•------•----••-•-•---•••--•-......---••-----••-•-•-••--••------------ c.� Date Permit No......................................................... Issued..:...f._._:�.L Zij4. Date E X. r .,s • THE COMMONWEALTH OF MASSACHUSETTS BOARD OF EAL._TH .......................................OF......................................_..__...................--------•---------.... •-• Appliratiaan for Bis'usal Marks 6witrnrtuan ramit Application is hereby made for a Permit to Construct (A _or Repair ( an Individual Sewage Disposal System -= 4 -------------------•----------•------------ ---------------- ---•--••- •� - - atio -�e ss or Lot No. Ar ......................—.......................................................................... ............................................. ......•'-........................................... Owner Address ....._---•.............................•-----.....-------•-•;•-----•-----_._....__•----•-•-•--•-•- ............................ ..... .....------.....------......... ..------ Installer Address v w.; Q Type of Building r Size Lot---------------------------Sq. feet Dwelling—No. of Bedrooms....:.......................................Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) IQ Other fixtures -----------------------------------•-----•-•--•----•--••-•-•--...-•••-------••..._...._...•--•-------•-•-.....•----------•.._..._--------------------•f`, W Design Flow............................................gallons per person per day. Total daily flow............................................gallon,i WT Septic Tank—Liquid'capacity......_._...gallons Length................ Width................ Diameter---_............ Depth............... I, Disposal Trench—No.�........... ..........Width.................... Total Length.................... Total leaching area___.._....___....._.sq. ft. ' Z � Other Distribution box ( ) Diameter---Dosing tanD Depth below i�e�� ._........ Total leaching area..................sq. ft. Seepage Pit No.---____---_.-.. Percolation Test Results Performed by.......................... ...-................ Date......`........__..-------------- Test Pit No. I................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........................ ---••---------------------------------------•------••------•--......................---•-----_----••................................. ---------- O Description.of Soil_________________________ .' _...-•-•---------•........................•---•----- --------------- ----------------------------------------------------------------------•----•-----------------------------...-----------------------------•-•------•--------------------......____-•--•- U Nature of Repairs or Alterations—Answer when applicable. ----------------,__.__.--_____-_-______._-_--___-_----•---__ ................................ •------••-----------•------•----•-••----•------------•---••------••••-••••••--•••...............:".........-•-----------------------------•----------•-----•-------------------•----•--•--•--•••-----• Agreement: The itmdersigned agrees to install the aforedescribed Individual'.Sewage Disposal System in accordance with the provisions of TITLE p 5 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. Signed............... `- ;,. Application Approved By_ ,� -•-- eno wwino"t ............................. # ate U-14 ' Application Disapproved for tsons:'.............. -•--------•---------•-----•--•...---•-------------•--------------------•----------•--- f ..................-•-•--•---------•-••--•-•-----------------------•------•------._.....-------------------•-•--._..-•---•---•••---•-•••--••----••-•----•--•---••••••-••--•-••••...-------•--••----•--- Date Permit No. ,,.,= ==- a Issued....................................................... Date I THE COMMONWEALTH OF MASSACHUSETTS �. BOARD OF HEALTH ........ O F................... ............. r as nt tanrr �pr�t � tt#r as � THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( nr Repaired ( ) by..._ !'�q ljY1 r --"Installer-•---........-•--------••---------•.........................••- at.. f,�/ j. ,{.... ..�.�'. ! r_ .. =-fr ............................. has $ i Yn�tallc�d ffi c td�i�c '�vitr tale`provi'sion� O� I the Satan"i�ai y''o e gas described in the application for Disposal Works Construction Permit No. . dated.__... «.................. y THE ISSUANCE OF THIS CERTIFICATE SHA OT BE CONSTRUED AS A G ARANTEE THAT THE ~SYSTEM i91! L FUNCTION SATISFACTORY. �j DATE........ ? Inspector, 1=- -•--_-_- THE COMMONWEALTH-OF MASSACHUSETTS } , BOARD OFA HEALTH 6 NO.- -•-•- _....,..._. #:, , FEE..... 1� . r Dis oul Work, �onstrnrt#ion [rrntit Permission is herebyranted_ . ..� # `. to Can. uct (. for Repair/( an Indi`idtjal Sew e DIspO Syst at No. � �J'T ..-.. y[•-- :"i'l t- -e G✓� i r ?- F Stree : as sho n on the applicatioli for Disposal Works.Construction Per. 't No Dated..... .......... WBR �� of DATE-- -•-----.....................-rT•-------•--------------------------------•-• • °, FORM 1255 HOBBS &.WARREN; INC.. PUBLISHERS -