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HomeMy WebLinkAbout0075 GOVERNOR'S WAY - Health 75 Governor's Way, Barnstable A = 258 -061 k f - — Commonwealth of Massachusetts �. Title 5 Official Inspection Form X Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ' ; 75 Governors Way "ems v +ll` Property Address Maeve Field " -r•3 Owner Owner's Name information is required for every Barnstable Ma 02630 3-5-19 page. City/Town State Zip Code Date of Inspection jt Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. - 374 Route 130 Company Address Sandwich Ma 02563 City own State Zip Code rim (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ■❑ Passes 2. ❑ Conditionally'Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails :.uenmN verse M&en HiQry Brett Hickey �:m.�Hw.o.�.m. ,��. ...�� 3-5-19 %�'��Oz1e:48t9 N.OB HVt:36-051p Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts ,/p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes:, ❑■ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: The system was in working order at the time of inspection. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 f Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ""y F 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7126=18 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 c� Commonwealth of Massachusetts p Title 5 Official Inspection Form I a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ O Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts ,0 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow ❑ a Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ M Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ X Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ E Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis. and chain of custody must be attached to this form.] ❑ El The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ E] The system fails. I have determined that one or more of the above failure . criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form r� i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for aH inspections: Yes No El ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ El Were any of the system components pumped out in the previous two weeks? El ❑ Has the system received normal flows in the previous two week period? ❑ a Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ❑ R Was the facility or dwelling inspected for signs of sewage back up? El El Was the site inspected for signs of break out? X Were all system components, excluding the SAS, located on site? ❑ ❑ Y P 9 El ❑ 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? ❑ a Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: El ❑ Existing information. For example, a plan at the Board of Health. ❑ El Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 I Commonwealth of Massachusetts �. ,P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 3 Number of bedrooms(design): Number of bedrooms(actual): 3 330/gpd DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Description: 1 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes Q No If yes, discharges to: 4 Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonaluse? _ ❑ Yes [g No Water meter readings, if available(last 2 years usage(gpd)): See below Detail: 2018- 13,000gallons 2017- 15,000gallons Sump pump? ❑ Yes M No Last date of occupancy: currentDate t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 L 10-1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: NA Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner- last pumped 3 years ago Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts IV I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ❑N No 5. Building Sewer(locate on site plan): 2'6" Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Distance from private water supply well or suction]ine: Town waterfeet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 c� Commonwealth of Massachusetts p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way V Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 11611 Depth below grade: feet Material of construction: ❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years i Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1 Dimensions: 500gallons 4r� Sludge depth: 3211 Distance from top of sludge to bottom of outlet tee or baffle 1 of Scum thickness 691 Distance from top of scum to top of outlet tee or baffle 1511 Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection . Form I�l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: NAfeet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments u 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): o„ Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes No* Alarms in working order: ❑ Yes No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: Elleaching pits number: (2) 6'X6' ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Ofridal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form <I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching was in passing condition. Both pits were 1/4 full. First pit was stained to the top and the second pit was stained 1/2 up from the bottom. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): NA Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code. Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts ip Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way V Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: 0 hand-sketch in the area below ❑ drawing attached separately 6 7;ri U100MOT LB.XC,1�tt�t,G 2iT4,<3►�!,HEL3RC?�Ji['.t .. w;„ ,�. ,,.-P1l1'1/,!1'I'8 W�stt.�. R'�►�t..�':[7Bi:.I+� `W'e'b.2"8�`.:-: ]fii7kZc,1�.7►8� 41R +CJ W"NBIt._ .: �;"- '1�_"-"'7' l«��..,. L`ZAA,T P'BIt 'C �iil.T� xi.t�>��'"LIA1hIL^E�I�S ]F��► .�.+-: ,. �'�"` .� U'ARI1S, 8 r f t5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is required for every Barnstable Ma 02630 3-5-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: Check Slope 0 Surface water Check cellar 11 Shallow wells Estimated depth to high ground water: No GW @ 156"feet Please indicate all methods used to determine the high ground water elevation: 0 Obtained from system design plans on record If checked, date of design plan reviewed: 5-23-85Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: A plan on file with the Board of Health was used. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form eP- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 75 Governors Way Property Address Maeve Field Owner Owner's Name information is Barnstable Ma 02630 3-5-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 0■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked ❑■ C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6(Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 ' I . CO HL MNIONWEALTH OF N ASSACSETTS ,,fly EXECUTIVE OFFICE OF ENVIRONMENT, j _) DEPARTMENT OF ENVIRONMENT h ROTE TION ONE WINTER STREET. BOSTON. NIA O'_IOS 1 ,- 92-^"PECE'VE0 1997 WILLIAM F.WELD TOWNOFBARNS>gglE � TRUDY COS Governor H�LTH ncpT Secretan ARGEO PAUL CELLUCCI N~ DAVID B.STRUELS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO ORly1.� I 1'�� Commissioner . PART A CERTIFICATION Gpu��N®RS • Property Address: '75 CeOJrV,Zi`1G 3 Llcl:a+tr ��}} jg, Address of Owner: Date of Inspection: —77/Z_�5/q (If different) Name of Inspector: ,ppLLpii.-L ✓ir;tZ I am a DEP approved system inspector pursuant to Section 15.340,of Title 5 (310 CMR 15.000) Company Name: —M-&0T;Z oclAin -m—S Mailing Address: —ZO,X, Telephone Number: ;tea-_­-�6Z 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: _asses Conditionally Passes Needs Further Evaluation B�• the Local .Approving Authority fails , •/ Inspector's Signature / Date: The System Inspector shall submit a copy of his inspection report to the Approving Authority within thirty (30) days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: A] SYSTEM PASSES: 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: BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement,or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http://www.magnet.state.ma.us/dep at j Printed on Recyded Paper c� SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: --- -Z , ct^� 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 levelled or replaced -0�- The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction.is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT 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 I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that . the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation.not valid). 3) OTHER s (revised 04/25/97) Page 2 of 10 F SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: -T1%1-1 Date of Inspection: —� ( -Z DJ SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: 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 Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution boa 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 1/2 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 pomon of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Anv 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. r EJ LARGE SYSTEM FAILS: 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 god or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone 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. (raviaad 04/25/97) Page 3 of 10 l_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST - Property Address: ��G�'p �� �✓�� Owner: Date of Inspection: Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X _ As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. All system components, e the Soil Absorption System, have been located on the site. i uCi.�7 s�c J The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffies 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: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)J (zeviaed 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 60L1�� Owner: Date of Inspection: ) FLOW CONDITIONS RESIDENTIAL: Design Flow: Q.p.d./bedroom for S.A.S. Number of bedrooms:— Number of current residents: 'Z-.-S Garbage g,i.der (yes or no):-b—/O Laundry connected to system (yes or no): y6� Seasonal use (yes or no):—,—\/C) Water meter readings, if available (last two (2) year usage (gpd): Sump Pump (ves or no): /1!y Last date of occupancy: A11A COMMERCI AUINDUSTRIAL: Type of establishment: /✓�� Design flow: ¢allonsiday Grease trap present: (yes or nol_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitan, waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last pate of o cupancy OTHER: (Describe' Last date of occuoanc-vi GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) --/O If yes, volume pumped: f allons 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? w Other APP.tOXIMATE AGE of all components, date installed (if known) and source of information:/6 7 Sewage odors detected when arriving�at the site: (yes or no) (revised 04/25/97) Page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: —7,5 G OII�i2 s (b Owner: 0AP Date of Inspection: BUILDING SEWER: (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: (locate on site plan) r� Depth below grade: I Z Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No Dimensions: %Z X 6.1 X �s Sludge depth: •Z" i n Distance from top of sludge to bottom of outlet tee or baffle: ' 3 Scum thickness: C> Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: f� How dimensions were determined: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity�evlidence of leakage, etc.) G iV .J A--)D "7— K ST2 GREASE TRAP:/x (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.) I (revised 04/25/97) Page 6 of 10 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 7/z,al a 7 TIGHT OR HOLDING TANK: •Tank must be pumped prior to, or at time, of inspection.) (locate on site plan) % Depth below grade: Material of construction: _concrete metal _Fiberglass _Polyethylene _other(explain) Dimensions: Capacir�-: gallons Design flow: gallons/da\ Alarm level: Alarm in working order _Yes; _ No Date of previous pumping: Comments: (condition of inlet tee. condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) �t Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or•Qut of box, etc.) A 0 I72..z+ '4/v�ll ,� ' ,d! �' 1 Aa PUMP CHAMBER: (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.) (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: -7/z_*-97 , SOIL ABSORPTION SYSTEM (SAS): (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._ 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.) d ,cam i C— CESSPOOLS: (locate on site an) 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: a (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on,site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,,condition of vegetation, etc.) (revised 04/25/97) Page 8 of 10 r • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 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) as �1 /f^ 0 � ... ti 7/ / 5:UU . t (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: 4 Depth to Groundwater 12 f 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 I Check pumping records Check local excavators, installers Use USGS Data Describe in your own words ho\•. you established the High Groundwater Elevation. (Must be completed) �eloUD C c d� t z:lne� !SF--;�;'vC i LO ev`f ` 1��—>a tL R 17 2j t�;+J Cam- Levi, (raviaed 04/25/97) Page 10 of 10 TOWN OF BARNSTABLE Q/ III LOCATION /Urnm SEWAGE VILLAGE 7 /7 J `A S OR'S MAP & LOTZ�X 'S NAME & PHONE NO INSTALLER _ SEPTIC TANK CAPACITY LEACHING FACILITY:(type) P—/ (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER I . DATE PERMIT ISSUED: '' 0�" DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Q-6� I oca ptrcti(a' Ocb "� 5 _OCATION MAP , .+ � ,.wit i.y '�,�Pc1VKY. � y�ri.� ✓ WL.'U ��.,�....,r:.'Gwwgia.,,_ ,.;�.: .. ,:. "..•! NV 1 _ t gti' v , tj O Aq r >o rt3 ool o � 8 Z a �� Vr o ,, —----------_ -- t_ HUB E (')R JSGS P"061ABLE WATER TABLE EL = G' Gr;OJND WATER TABLE( / j EL : _ so L i E S i� DAT E OF SOIL FS r --�--- Wi T NESSED o`' _ Lrr:�,a_?_2_---- - ,`' PF--pro AT iON P",' E rf_MIN / INCf{ --&ISERVATION HOLE 2 L / ELEVATION [-ELEVATION = A tic i I ��iiC 1,r-•' f'i�Jf � j .•J �n.�G � ~•� z V0 L • TO i , I I M.1N. FRONT SETBACK MIN. REAR SETBACK '0 MIN. SIDE SETBACK ?LICANT HORITY. APPROVED BOARD OF HEALTH I DATE AGENT PROJECT LOCATION I (moo✓c-z/l/o N_S �/ y APPLICANT i SCALE' �� __ �G DR. BY: DATE Uf �Q.P,S JOB NO .- 77_ p,APPD. BY' REV. i (h I \1k (,!CHARD a "� EARAI A/c DRAWING rw Nc . liflil rQ, REG. LAND o"URVEEYORS- REG. SAN/TAR14NS .35 ROUTE 1.34 -- UNIT 2 N0. SOUTH QENNI S , MASS. OF r No........ n.� FEB..�. ..�f................ Q f1Q THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE r.plirarth for Diripwial lVarlt-q Towitrurtivit ramit Application is hereby made for a Permit to Construct ( ) or Repair (�an Individual Sewage Disposal System - n�n -----. ... ---------- ---.......-------_- ------------••--- .. `I�oc�t' Address � o. Lot No. ........ .____ ....... ... ......._.- ---'-- -- ----- --^------ ------------ - ----------- ------ ----- I Ile-- --- - - ---- -- ------ .- - Installer Addr s UType of Building 1] Size Lot............................Sq. feet �..� Dwelling—No. of Bedrooms...........'_f______________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------_---- No. of persons---------------------------- Showers ( ) - Cafeteria ( ) QOther fixtures ------------------------------------------------------ ............................�.r W Design Flow........................................ .gallons per person p day. Total �.9 flow...... 7��..._........._..__._...gallons. WSeptic Tank—Liquid capacityl �� gallons Length................ Width.....✓........ Diameter................ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................--- Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter............-------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- --------------------•-----------------------------------------... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 ----------------------------------•.........----------------•-...:..------------•--•--------• -..-.------- •.... •...... .......... -.... ...... .... .......... - 0 Description of Soil................................................................................................. ----------------------•---....--------•---------------.....•-•-•...... x ------- -..... W --------------------------------------------------------------------------------------------------------------- --- --- -------- x Nat r of Re�air or Alterati s—Answer when li b1e.IS �� � �� �� /� � ..5 � IF ��a 'v an ( -. /?------------------------------------------------------•....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned furth agrees not to place the system in operation until a Certificate of Complian s d he � c Signed ......:......... . _..... ... ............................. .. ........ . .. ... .....�3...-1 14..1... ...... Dare Application Approved By ...:..::::. :............... -------- .... .......................... .. ..................... " Date Application Disapproved for the following reasons: .................... .......... ...... ................................................................ ........................ .................................................. . ......... ..................................---------�" ..�. .................-- Permit No. ��................. ---------------------- �'`� Issued ....... ...... ...... Dare ------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTHI TOWN OF BARNSTABLE C ertifirate of Complianre THIS IS TO CERTIFY Th t th Ind' ,i�du�all ewage Disposal System constructed ( ) or Repaired by ....................... ........................ AWA— ..t )�'K ------- --- ...... - .... at --------- ......... ..............--- .....W. has been installed in accordance with the provisions of TI' .E 5 of The State Environmental Code as dpssribe in the application for Disposal Works Construction Permit No. ..... dated .r�--l...,,..._'�.. .. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT CONSTRUED AS A GUARANTEE THAT T SYSTEM WILL FUNCTION SATISFACTORY. DATE...... ............... Inspector -- .........._.._................._.....................__..................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH —� .3 r i TOWN OF BARNSTABLE I Alipfiration for Diri uiuf Worbi Toutitrnr#iun Vanfit Application is hereby made for a Permit to Construct ( ) or Repair f an Individual Sewage Disposal System at '(owe .....-----------•- Loc IG611 lddrrss V E/� fi I Ll/.:.off L. t f J�f/ r or Lot No. .... _ Lr�W OCncr __0 ( Arcs- S ....................................... r r Installer Addre's Type of Building Size Lot............................Sq. feet �. Dwelling— No. of Bedrooms........... ---------------------.--------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) d Other fixtures ......................... -------------------- ---------- W Design Flow............................................gallons per person per day. Total daily flow...... �C�_---_..-__...._.-__.--_._gallons. WSeptic Tank—Liquid capacity iS+;gallons Length..... ...... h _.. Widt ... -------. Diameter. ...-.-----.-_ Depth................ x Disposal Trench—'No. .................... Width.................... .Total Length.................... Total leaching area...._...............sq. ft. 3 Seepage Pit No..................... Diameter......-.------------ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' •-••------••--------•-------•••••-•-...--••-•-•••.................•---...-----------........._...---......................................................... 0 Description of Soil........................................................................................................................._.............................................. W •---•--------------- ------------------......-----•-----------•---------------------------------------..... U Repairs or Alterations—Answer when applicablelo ....... 0C . ! L.I Nature of 1/ I................C. ---�`J�(�.�__ ��� -----UJ�-fin-- l j dl C,i (C /f 1/... ------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the Y P P � - '/..y .............° - -'-'of heaPih. Cam.-- g system in operation until a Certificate o om lance __ Si ned .:.............. ..a/eet- s er .:. .... .....� .`. t�. 1... - ~� ApplicationApproved By ........... .......................... .......................................... ... ......!���. .......� Application Disapp-oved for the following reasonr: . .. .......................... .............................:............................................................ i/ Dare Permit No. .... s .......... - .... ...... (71 Issued ..................................................�7............ Dace ------------------------------------------------------------------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tertift.Cate of (gDtttyliartCP THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired Di by ............................................................................_..1...... ------------ In r Ilcr / I1! l has been Installed In accordance with,the ......_ ----- ---------- --------------.................. . .................................. . • the provisions of TI'l�.E 5 of The`State Environmental Code as describe _in_ the application for 1isposal Works Construction Permit No. f ..�.._.GS..... ........._. dated .`�-�1.._�.".........�, THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................._...................................... -------------_------.............--- Inspector .............................................--------------..................................... ' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No..1 -�� FEE._ `U -Difyinaf Workii Tianotrudian amit Permission is hereby granted-----__-" �_f__A --------------------- to Construct ( ) or Repair ,( ') a• _Individual Sewage Disposal/system at No........................................................... �• �•�d� ---•-•- ------ ----- street as shown on the application for Disposal Works Construction Permit Dated----�f7. ..............—------ ----:� f Board of Health DATE..----- ........................... .......................... FORM 36508 HOODS 6 WARREN,INC.,PUBLISHERS G �u� 6A 4J C' TOWN OF BARNSTABLE LOCATION Clorgm SEWAGE VILLAGE ky, eomJ S SOR S MAP & LOT Q� INSTALLER'S NAME & PHONE NO SEPTIC TANK CAPACITY j R LEACHING FACILITY:(type) �� (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 8� 3C N� 0 No.._./. ......Q_ Flls.......... � .��..... APPROM THE COMMONWEALTH OF MASSACHUSETTS r BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Di-aipuittl Work.6 Tonstrnr#inn rami# Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: ............-------------- •---....._..._ . --------------•.........• ----`-------- -- ---------------------------•-•---------••----------- Loc \ddre s or Lot No. Owner � Address aCF .15' '-G`••� �........................ ............................................... Installer Address Type of Building Size Lot............................Sq. feet ,. 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 Length---------------- Width-----.---------- Diameter_- ------------ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No----_--_----------- Diameter-------------....... Depth below inlet-------------------- Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY-------- ..........--..................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth'to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •--••---•-------------------------------•--------••----•-------------------•-•-•---------._........•......................................................... 0 Description of Soil........................................................................................................................................................................ x U .......................................................-------------•---------•---------..........--•-------------------------------------------------------------.---••-•--------.....-•-------------- w --------------------------------------------------------------------------------------------------------------------------------------------------------------------- - ------------- -------- V Nature of Repairs or Alterations—Answer when applicable.______.�.� ._ C' c _. ..............�..._.. & ...... ..-........ Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed ----------------------------------------------------------------------------------------------- ......................................... Dace Application Approved BY --------- ----- - - - --- 7 �_� te Application Disapproved for the following reasons: ------------------------------------------------------------------------------------------------------------------------------------ .... -------------------------------------------------------------------------------------------------------------_ - ------------------------------------......--------------------------- ------------ ------------------------ Dace Permit No. ----- --���- r.&---------------- ------ Issued ..................................................... . ............................ ............... Dace qq rr dd No... Fics..........l. ..... THE COMMONWEALTH OF MASSACHUSETTS /7 BOARD OF HEALTH /5� L/ TOWN OF BARNSTABL V "` ,��r�lirtttit�lt fur �i��n�ttl �urlt,� C�ttn��rnr#iun �rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at: `�5 .�.�s:�o�"� ..........................ct. •-•-- -• .....`=�'�=�-------------------------------------------------- .......................................................- C�-� - Localiq \ddress or Lot No. --- Owner Address . v2. ......_.'.`_q_ ��-- ......................... ........................ ......•---- Installer Address d Type o Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons--.-------_--_-_-_-.-..-.-- Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------.-------------------------------- ------------------------------------------------------------- WDesign 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 ( ) Percolation Test Results Performed by--------------------- .................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water----.................... GZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--.................... a ••--•••-••------------------••--•---•-•-••......-•---------••---•••---------•-•-•--•..........--••-•......................................................... 0 Description of Soil........................................................................................................................................................................ x V W ---------------------------------------------------------------------------------------------------------------------------------------------------------�--,---�--.-.. . U Nature of Repairs or Alterations—Answer when applicable.-.----_( vc- _c�.- .............� `.L_4..........� ........ .. •---•--•---------------•----•--••••-•--•••--•••-•-••-•--•--•-••••••••-----------•--•-•-•-•-•--••---••---•••-------- ----------•--••----------••••-...-----------•---••-•------•---•------...•-•••- Agreement: .�` L 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 board of health. Signed ---------------------------------------------------------------------- ------------------- ..................................------ Dare Application Approved By ------_.... . ... a� - r Dce Application Disapproved for the following reasons- ------------- ------ -------------------------------------------------------------------------------------------------------------- ------------------------------------------------------------------------------------ ----------------------------------------------------------------------------------------- Dare Permit No. f` ....... ........................... Issued .......................... Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CQer#ifiratL> of C11ontylialare THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repairedby ( ) ------------------------- ------------------.--------------- ------- �� Insr.Jlcr at --------------------------- . �s,� ✓YL ...... . ' ... . -- - ..... has been installed in accordance with the provisiV s of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..........` -..._6............ dated ---------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION VSFAC ORY. DATE...... r ` ' .,. c- .. .~. _..... .. Inspector ------ - ............�`�...Ga�� A. --------- --------------------------------------------------------------� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ropngttl Workii (/T�unntrinn rrnttt Permission is hereby granted------ --------- -- .....r� ................................................;-------•---•--....---••--••---...... to Construct ( ) or Repair an Individ�ewage Disposal System 0 at No................. t • •. t l truction -------------------------------•-----------....................••...... street C / as shown on the application for Disposal Works Permit No. - :57-_ Dated........................................... --•----•-•------•---...-•----•-----------------------------------------------------------•••--•----•--•-- Board of Health DATE................................................................................ FORM 36508 HOBBS&WARREN,INC..PUBLISHERS McKean, Thomas From: McKean, Thomas on behalf of Health Sent: Wednesday, March 06, 2019 10:44 AM To: 'Amanda Kundel' Subject: RE: 75 Governor's Way Barnstable - 3 bed septic? Hello, I reviewed the records on file, including the 1997 septic system inspection report which reports three bedrooms, engineered plans which shows a three bedroom home; zone of contribution maps, and assessors records which reports three bedrooms. The system was upgraded in 1994 likely due to a failed leaching pit; but there is no recording of the rationale. Three bedrooms would be approvable for this location, yes. P.S. Future expansion may be possible.because this site is not located within a GP, WP,Zone II, nor within any Saltwater Estuary Protection District. From: Amanda Kundel [mailto:akundel(&kinlingrover.com] Sent: Tuesday, March 05, 2019 8:21 PM To: Health Subject: 75 Governor's Way Barnstable - 3 bedseptic? Hi. I was checking into this property today and noticed that the permit on file did not list a bedroom#that it was designed for. Hoping you can clarify please. Thank you, Amanda Swift Kundel Kinlin Grover Real Estate P.O. Box 156 3221 Main Street Barnstable, MA 02630 508-360-7364 Mobile 508-362-9001 Fax Licensed in Massachusetts Broker#009521133 1 I.oLr tb tp° j f 24 Tt t �, V4.59e•="S .sync T6 . .4 a.c j t . MATTHIAS 6."A I ,; 10 SOAC ` m .sa.a • O .� Q 10 4 t pp ; a n [ OC .alas U La. < SIAC '`3 i •�+ it II 6A So' i 9e Je 10 t a 103 3 l :b CA j 40 i ti �E 56 so 15 34 28-t �— ` _ c o a7A6 .aa .►a— Ac .S9AC. "Go ec ° i ii u Cr i 41 17 IIIp 1.65 AC. � Z� a t I;./ I 1 II 11 70 O` 151 01 1 e.c Z8-Z 1 I i q 77 m 1.OOAC O - S6 32 R o 29 g Q z r� " 4e.C. - 30-3 lo° sz t•C./O UpLANC Il 60 _ .03 r'bN0 as At I.L9 AC Tacq� N �g a ¢ o . y o r k: 38-I sl �t 1.42AC- .+au 31 > i O -cl. rt^�gGµO 44 I �t LL f 1 A1� I t ' a ! .saac a5 78© pp — is e r Moa.�vrr vee° 1t,tr rl•LS j! i l REV. 3Y AWS I l970 j #• 3a'Z a ORIGINAL ISSUE 1968 1 I.4'3 -� 9a 239 259'290