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0098 GOVERNOR'S WAY - Health
98 GOVERNORS WAY BARNSTABLE A = 258 054 1 I06/22/2009 10:08 FAX - Ia 001/003 )C�ll VQ �Ade— TPc�,Q�, 73 v �rz) 9 �L)ee7-v\6 ft. doe pro � C . � �� 6 2, 06/22/2009 10:08 FAX Z 002/003 Massachusetts Department of Public Health NSSP Standardized Shellfish Processing Plant Inspection Form Type of Inspection ff Certification (]Pre-operational 0 Routine ❑Follow-up O SiandarditAtion Date: L l ea rName: Certification Number • L tG• r ss: �.• • �i�� [ 6ivil.•u✓ �✓� � y2�S�� 5 S I. HACCP Plan Yea No 0 Required for Certification 2. Plan Elements ✓I X Code I X Code Overall identified and Adequate NA kx'tr:, , . NA Code (a)Hazards O (e)Critical Cowrol Points K (b)Records 0 (f)Monitoring K �• (c)Critical Limits K (g)Verification Procedures O (d)Name,Address,Signed / O (h)Corrective Action if identified K and Dated 3• HACCP'&a1nIng WIN 0 No 4. Records Aeeoratd Convedve verlecation Monitoring blalatalsed(K) Plan Implementadon Action(C) Procedures Procedures(10 Own I (K) Reeords Normal Cede 3{gpedlDsdsd RIrm's Name(0) ✓! ode ✓IX Code V/X Code ✓IX Code a Receiving Sbellstock Slo _ (c Pmcessin - -_ - d) Shucked Mat Ft-orage e Other Critical Limits - -- ---• - 5. A ed Source Canbrol Failure C Irol Failure 6. Timeff store Can C :r 7. Other Critical Control Failure C x1'r^•; p.,fi�uU;er' SashatiOn stoma CUation ✓!X code !,,,;�¢, .:.,.,i/. ::•: 8. Safely of water for W=saing and ice production .02A 9. Condition and cleanlinew of food contact surfaces .02B a7yy',i;,c,•ut,, Pmvention of crow-contamination 02C ;.is•';',�:;.�:�,,w.,':?. ' 11. Maintenance of hand-wasbing,hand sanitizing,and toilet facilities .021) 12. Protection fhom adulterants .02E 13. Proper tabelin ,storage,and use of toxic compounds .02F2. 14. Control of employees with adverse health conditions .02Ci 15. Exclusion of u '{ 16. Sanitation Monitoring and Records Additional Model Ordinance Require®ents Citation of X Code 17. Plants and Grounds .03A 18. Plumbing and related facilities .03B 19. Utilities .03C 20. Insects and vermin control .031) 21. DjqMal of other waste .03E 22, Equipment construction non-food contact surfaces .03F 23. Cleaning non-food contact Surfaces .030 24, Shellfish storage and handlhi 03H 25. Heat shock .031 26. Personnel .031 27. S rvision .03K 28. Transportation Eo include only the person shipping) IX.05 K 29. Labeling and Tagging(Other than ceivin ) X.05,.06 S(K/0) 30. Shipping Documents and Ilecordil X.07 / K E_ Dealer's Slenatu Inspector's Signature [Code: Crlti C• a -K;Swan' S:Outer-01 ISSC Form 93-01(A)revised ISSC 2000 Ethctivo Data: 10/1/00 Psi* 1 of I 06/22/2009 10:08 FAX Z 003/003 I .41 DEPARTMENT OF PUBLIC HEALTH -; 212 . ,lob DIVISION OF FOOD AND DRUGS 305 SOUTH ST.,JAMAICA PLAIN,MA 02130 i (617)727-2671) i l Insraclion of ��A ylS _SS Date �ilnlc_`/Llir7lLr•fN/� Ad r s /1f des �� Owner�l5 X r I Type of Busincss l`l.�p 6>• TG M! r✓ Inspector. (*) Remarks: I _ i i ..... i r INSPECTOR r/4`�' �- / �f.� l.• ' FORM P14-F-76 Division of Fad vgr TOWN OF BAPNSTABLE LOCATION !' o G y ee IV 4)q W A`(_ SEWAGE # ('c 7 1d,�(LAGE t�7r4R �11 S4� ASSESSOR'S MAP & LOTa p INSTALLER'S NAME&PHONE NO. Jror f SEPTIC TANK CAPACITY �.S so a Gl1G✓ 3 LEACHING FACILITY (type) � Ct- (size) NO.OF BEDROOMS G BUILDER OR OWNER jj ley �� 4or PERMTTDATE: /A /� COMPLIANCE DATE: z-® /a 7Z Separation Distance Between the: Maximum.Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist wi;•un 300 feet of leaching facility)., l Furnished by _-_- s, 1 r v It 4 CIL- off, � G � 1 No. CX/©� . Fee ✓J® (.! H': THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpplicatiou. for �Bigossal 6pftem Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑ Complete System,,�ndividual Components Location Address or Lot No. Owner's Name,Address,and el.No. Assessor's Map/Parcel S Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures / Design Flow(min.required) Z174_D gpd Design flow provided el�05 S gpd Plan Date CC-( j0, 6!r Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. y9 Description of Soil Se-,e Nature of Repairs or Alterations(Answer when applicable) .. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title-5 o he Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this oard of Plealth. A-s Sig'ne e Date �Ci b '' .�-•_. Application Approved by Date 0 Application Disapproved by: Date -for itheTol reasons c Permit No. e�-�%���Q �L / Date Issued n No. ;)cola /� _ r►' �i: < Fee 1 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rppliration for Cow5tructiou Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑ Complete System, ndividual Components Location Address or Lot No. Owner's Name,Address,andrTel.No. Assessor's Map/Parcel IkST�Q Installer's Name,Address,and Tel.No. ( Designer's Name,Address and Tel.No. / " P I .� S � 1T Pv� 1 ��'1 I�Y �f c`� Irk`' C. W A.,* b Type of Building: Dwelling No.of Bedrooms '7 Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 7 7( gpd Design flow provided �' 5 gpd Plan Date OC'( /6 b Number of sheets �� Revision Date Title 1009 Size of Septic Tank ® ? �Q Type of S.A.S. _ Description of Soil ?4vw Nature of Repairs or Alterations(Answer when applicable) Date last inspected: t 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 t\e Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this oard of Nealth. Signe Date Application Approved by Date l Application Disapproved by: Date for the following reasons Permit No. L) / Date Issued l P THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-sit@ Sewage Disposal System Constructed Repaired ( ) Upgraded ( ) Abandoned( )by p Mb k1 + at PY/`E' 6 S has been constructed in accordance l with the provisions of Tittle 5 and the for Disposal System Construction Permit No. LL _Z. dated Io / 6 ' Installer a/ Designer #bedrooms Approved design flow vo gpd The issuance of this permit shall not be construed as a guarantee that the system will funcction'as des gned. Date )0 i/1 Q 1 4 1 � Inspector — --------(--------------- ---- /—/h— --.— NO. _ —4L1 I Fee / y THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE, MASSACHUSETTS Bl gponl *pgtem, Congtruction Permit Permission is hereby granted to Construct (>e-') Repair.(} ) Upgrade ( ) Abandon ( ) System located at GD!/�'/t.�SE'_ S A�i. •Lt �/�/ and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this rniit. Date Approved by Town of Barnstable Regulatory Services . . °" Thomas F. Geiler,Director + B"NSrABLE. 9�A a S. Public Health Division rFnrn�.�A Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:. 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: Sewage Permit#,- _4/49Assessor's Map\Parcel Designer: S1—Z-rsoAl 171,91j R.S. Installer: -Z R /-/o/Z./A/ Address: . 28 ,aA-i> Address: 75' SA_(t On /o ./6 - O4o &1A) _was issued a permit to install a (date) (installer) septic system at 98 W4Y . 9r4aos based on a design drawn by (address) dated / (designer) t/ I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Stripout (if required) was inspected and the soils were found satisfactory. r r I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Stripout (if requiredw inspected and the soils were found satisfactory. .rt ,Ur;q t�•':}� �ASsq �y (I staller's Signature) �; HALL � No.527 PVAL (Designells Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH IDIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:\Septic\Designer Certification Form Rev 03-09-06.doc � 1 t"INO_R-- 'A/ Y `� PAVEMENT '°' 95.00 26 �I' '• is'yt 5 8' FT, c�+I Exl sa 13 ' h STING c�. 7° . Cp4e.: S''� DWELLING �Seli= close / - .� OT 15 SeC . Ltt/ `i I E 24,200 SQ.FT. f p / r DECK xIS ZO QARgGG "NOTE'=40 MIL WATERPROOF 'slob" MATERIAL Fn-1 e oJf O®o/LS '� 13 o c tests Ole$ 5 PROPOSED CA r TRENC CH 12.831x 33.So' 62' 185, ` OF WAY 0'WIDE -�10.00 69, 47 ... RIG �e>ro►owAtilcg PooL 41.25 CENTERLINE OF RAILROAD 1 . e PLAN RE•F,— PLAN BOOK 214 PAGE 77 t 3l � N y , . Town of Barnstable P# Depat�uent of Re I ^tor Services • Public Healf Division :Derr. , g ro .say a 200 Maio Stra4.Hyannis MA 02601 ' Date Sch /pip ID Fee P �. eitlled Tams , roil 5u>rtabM&.Assessmen for ewage, mposal Performed By. STtTSgAs �' I�,/AGL- /Z S, 'Witnessed By: ;S OCATION&.�}►Flv� T EVORMATION ovation Address' 98 ✓���/p> 'W!� ma's Ifta a t Y �✓7 h� Asa s Zr t�A Assessor's Map/PgrerJ: 8/Ob i 1 Engineers Name NEW CONSTR ,U ON RBPAQt I ; TelephoaeM �lp3�o 7 Land Use � 1�aL slopes(i) Surface Siones rJe.✓�i- ` Distaaca from: ()pea Water Body.� _R Passible Wee Area 2--R Drlakiag Water Well?.44A=,it 1)ralaage Way /0e) tt Property JU Oil ,,-n Jt od R SKETCH:(gtnet same,dimensions of hat,mact locations or test inks a:pert tan.locate wadaa&is p m*hdty to boles) G, r r e. /S. Go Cvs tq'�1 GI `pry 1. ei 4� �i,� t�tl►�'s ZQ,2oo?a GhI r OF WAY Phi i p B:Arms.Esto'te�' TRusrEEs OF THE NEW YoRK, NE . yavE/v /aaTf-�,�zc> Paroat material(godlogle) � i Depth to Bedroek Depth to Groundwater: Standing Water is Hole:' A brJ a Weeping hom Pit Estimated Seasonal40gh Groundwater T HIGH WAT k D�TE MN TION FOR SEMOAL HER n.1A �' I Method Used Depth 0Wxved standingin obs.tole+ Depth to tall mottles: Depth toiweeping from side otobs.hole: ln. Oroundvvrrot 11�Wtttteat —UvolD h, Index Well# Reading Dahl Index WeO:kvCl ..�g •� •d h " . ' PERCOLATION.;TESx Observation s I;, Hole N Depth of Pere Inmo at 6" ,..e._� Slant PFC_M t 11mo.0 t • w 9aI/�f Rate Min./Inch (Y" _` Site Suitability AssO mwl: Sits Passed_.�_ Site Failed; Additional Taatierg Needed Original: Public HepUit Division Observadod Hole Data To Be Completed on Back ***If percola ''on test is to be conducted within 10o,of wetland,-you must fint,M fy the -.11--..-•^+t,,.,lrllvkion at least one(1)we&prior to beginning. Wi, n,from , Y soil Horizon suil I*CxIute Soil color Soil i uroer SWAMPS.) (USDA) (Mumelo Mottling (Swc re,Stones,Boulders. DEEP OBSERVATION HOLE LOG. Hole# Dept,dim, soil HO&M Sol"Tatore Soli Dolor Soil Other Surfm(110 (USDA) (Muaaell) Mottling (Structine.Stones,Boulders. -------------- r , . 7/47 DEEP OBSERVATION HOLE LOG Hole# Depth soli Hod>oort Solt 7MIwe soil color soil Other surfiee(ia.) (USDA) (Mansell) Mottling (Structure.Stones,BouMers. Tell VEEP OBSERVATION HOLE LOG Hole# Depth fm Soil Horizon soil'tleatture 'Soil tbbr soil other • (Munseln Mottling (Structu%Stones.Boulders. snrtitoe(in.) (USDA) Inood RA 1 iu4aret a te Mks 1�v Above SOB 1earo fl l both No__._ Yea Withia IN yew otrndary NO— Yea Wild 100yeitrf oodboundary No--- Yes of a- •,�0 + , a � � . t•,aat fo feet of naturally occurring Pervious mtiterial exist in all areas observed throughout the Does at I tom? �_ e pod tlte`aoil absorption ays bill marortaI? If not.what-is the depth df naturally occurring p ry tld ssed the soil evaluator exaetination approved by the I certify that on. —(date)I have passed consistent with I)epsrtment of environmental i'roteCdon and that the above analysis was pert'ormcd by me the required tm it e experience described in 310 CNIIt 15.017. _ Date Z 7, a OQ 6 Si Q 4Bt't1G1PBRCFM, M•DoC 4 Commonwealth of Massachusetts Title S Official Inspection Fora Not for Voluntary Assessments ` '`` rd4 i 4 EL E Subsurface Sewage Disposal System Form a'[r'. .jti�� ., Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 611512000. Inspection forms may not be altered in any way A. Certification Important: When filling P rtY out 1. Property Information: forms on the ' computer,use 98 Governor's Way Barnstable Front system only the tab key Property Address to move your David Hinckley cursor-do not use the return Owner's Name key. 98 Govemor's Way Owner's Address Barnstable MA 02630 Cityrrown State Zip Code May 20, 2005 ,an Date of Inspection: Date v 2. Inspector: Michael Kellett Name of Inspector Aardvark Environmental Inspections Company Name P.O. Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority June 1, 2005 Inspect6rYSignaturer Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. "***This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 , Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (coat.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: ® 1 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 need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y, N, ND)in the❑for the following statements. If`not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: t5insp.doc•11/2004 Title 5 Official Inspection Dorm:Subsurface Sewage Disposal System- i Page 2 of 16 Commonwealth of Massachusetts Title S Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (font.) 98 Govenor's Way Property Address Barnstable MA 02630 CitylTown State Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection B) System Conditionally Passes(cont.): ❑ 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: El 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 t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cunt.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 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, 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: t5insp.doc•11i2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (coat.) 98 Governor's Way Property Address Barnstable MA 02630 Cityrrown State ZipCode David Hinkley May 20,2005 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® 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 ❑ ® 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 RIOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] Yes No ❑ ® The system fails. 1 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. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments w Subsurface Sewage Disposal System Form A. Certification (cunt.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town State - Zip Code David Hinckley May 20, 2005 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either`yee or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5insp.doc•11/2004 The 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 1.6 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 98 GOvemoes Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection Check if the following have been done.You must indicate"yes'or'no'as to each of the following: YES NO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS,located'on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles orrtees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)] t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 I Commonwealth of Massachusetts Y Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form H C. System information 98 Governors Way Property Address Barnstable MA 02630 City/Town state Zip Code David Hinckley May 20, 2005 Owner's Name Date of Inspections Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Number of current residents: 2 Does residence have a rinder? garbage 9 Yes Z No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(fast 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (coat.) 98 Governor's Way Property Address Barnstable MA 02630 Cityrrown State Zip Code David Hinckley May 20, 2005 Owner's Name Date of Inspection General Information PumpingRecords: ' Source of information: Was system pumped as part of the inspection? ❑. Yes ® 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/Aiternative 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 (f known) and source of information: 8/01/98 3/1/94 for new pit Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 I _ r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form N C. System Information (cunt.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town state Zip Code David Hinckley May 20, 2005 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 49 inches feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 40 inches feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of [� Yes El No certificate) Dimensions: 1000 gal Sludge depth: 3 inches Distance from top of sludge to bottom of outlet tee or baffle 29 inches Scum thickness 2 inches Distance from top of scum to top of outlet tee or baffle 5 inches Distance from bottom of scum to bottom of outlet tee or baffle 16 inches How were dimensions determined? measured t5insp.doc•11/2004 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 10 of 16 Commonwealth of Massachusetts Tine 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 98 Governor's Way Property Address Barnstable MA 02630 Cityrrown State Zip Code David Hinckley May 20, 2005 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensio ns: 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.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 J I Commonwealth of Massachusetts UWTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System information (font.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day 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): Distribution Box(f present must be opened) (locate on site plan):- Depth of liquid level above outlet invert even 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 box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 1 Commonwealth of Massachusetts Title 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4 C. System Information (cunt.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20, 2005 Owner's Name Date of Inspection Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): ` If SAS not located, explain why: Type: ® leaching pits number: 2 � ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovative/attemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): This system has 2 6'x6'precast pits surrounded by stone. The new pit had 2.5 feet of liquid. t5insp.doc•1.1/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 98 Governor's Way Property Address Barnstable MA 02630 CityrFown State Zip Code David Hinckley May 20, 2005 Owner's Name Date of Inspection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Farm wo Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 98 Governor's Way Property Address Barnstable MA 02630 cityrrown State Zip Code ' David Hinckley May 20,2005 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply,enters the building_ - I 1 1 t „ t vT i t5insp.doc•11t2004 Title 5 Official,Inspection Form:-Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (coat.) 98 Governors Way Property Address Bamsable MA 02630 City/Town State Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record. If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: USGS maps show an elevation of over 25 feet You must describe how you established the high ground water elevation: t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System• . Page 16 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form �� � ���� ,�NS .. Not for Voluntary Assessments A LE Subsurface Sewage Disposal System Form ,Inc 91fill 17 9: 54 Inspection results must be submitted on this form or on the official Tile 5 Inspection Form dated 611512000. inspection forms may not be altered in any way. A. Certification ._.._.. Important:When filling out forms on 1. Property Information: the computer,use only the tab key to 98 Governor's Way Barnstable REAR SYSTEM move your cursor- Property Address do not use the David Hinckley return key. Owner's Name 98 Governor's Way Owner's Address Barnstable MA 02630 CitylFown State Zip Code Date of Inspection: May 20, 2005 Date 2. Inspector. Michael Kellett Name of Inspector Aardvark Environmental Inspections Company Name P.O. Box 896 Company Address East Dennis MA 02641 Cityrrown State Zip Code 508-385-7608 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority June 1, 2005 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•11/2004 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 4 1' Commonwealth of Massachusetts Title 5 Official inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined (Y,N, ND)in the❑for the following statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: t5insp.doc•11,12004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form y yy0 A. Certification (cont.) 98 Governor's Way Property Address Barnstable MA 02630 CitylTown State Zip Code David Hinckley May 20, 2005 Owner's Name Date of Inspection B) System Conditionally Passes(cont.): ❑ 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 ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: ❑ 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 ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form. Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20, 2005 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health(coat.): 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, 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts f UTitle 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cunt.) 98 Governor's Way Property Address Barnstable MA 02630 Cityrrown state ZipCode David Hinckley May 20,2005 Owner's Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® 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 '/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: El ® Any portion of the SAS,cesspool or privy is below high ground water elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must YesEl 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. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cunt.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20, 2005 _. Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yeses or'no"to each of the following,in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply If you have answered "yes'to any question in Section E the system is considered a significant threat, or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 98 Govemor's Way Property Address Barnstable MA 02630 City/Town state Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection Check if the following have been done.You must indicate'yes"or"no'as to each of the following: YESNO ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® 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(3)(b)j t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts U Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form � C. System Information 98 Governors Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20, 2005 Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms 4 Number of 4 (design): bedrooms DESIGN flow based on 310 CMR 15.203(for example: 110 440 gpd x#of bedrooms) i Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] El Yes ® No Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 f - Commonwealth of Massachusetts Title 5 Official Inspection Fora Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 98 Governors Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes 0 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/Altemative 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 (f known) and source of information: 8/01/98 per BOH Were sewage odors detected when arriving at the site? ❑ Yes 0 No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 .4 Commonwealth of Massachusetts Title 5 Official Inspection Fora Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cons) 98 Governor's Way Property Address Barstable MA ' 02630 City/Town state Zip Code a David Hinckley May 26, 2005 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 21 inches feet Material of construction: ❑ cast iron ®40 ❑ other PVC (explain): Distance from private water supply well or suction _ a line: feet Comments(on condition of joints,venting,evidence of leakage,etc.) Septic Tank(locate on site plan): t Depth below grade: - 12 inches feet Material of construction: ® concrete � fi❑berglas' p❑olyethylen ❑ other(explain) If tank is metal, list age.. - years . Is'age confirmed by a Certificate of.Compliance?(attach a - ❑ copy of certificate) El Yes No ` Dimensions: 1500 gallons Sludge depth: 3 inches _ Distance from top of sludge to bottom of outlet tee"or 29 inches baffle Scum thickness 2 inches Distance from top of scum to top of outlet tee or ` 6 inches baffle Distance from bottom of scum to-bottom of outlet tee 15.inches or baffle How were dimensions determined? measured t5insp:doc-•11/2004 Title 5 Official Inspection form:Subsurface Sewage Disposal System Page 10 of.16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form UE-1 C. System Information (cont.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town State Zip Code DAvid Hinckley May 20, 2005 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ ❑ ❑ El metal fiberglas polyethyl 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.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ ❑ E metal Fiberglas polyethyf El other(explain): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Tine 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (coot.) 98 Govemor's Way Property Address Barnstable MA 02630 City/Town state Zip Code Daid Hinckley May 20,2005 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working ❑ Yes❑ No order. Date of last pumping: Date Comments(condition of alarm and float switches,etc.): Distribution Box(if present must be opened) 0ocate on site plan): Depth of liquid level above outlet invert even 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 box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order ❑ Yes ❑ No Alarms in working order: ❑ .Yes ❑'No t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Tine 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cant.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching number: 3 chambers leaching ❑ galleries number: ❑ leaching number, trenches length: ❑ leaching fields number, dimensions: overflow cesspool number. ❑ innovative/aftemative system Type/name of Comments(note condition of soil,signs of hydraulic failure, lever of ponding,damp soil, condition of vegetation, etc.): This System has three 500 gallon infiltrators surrounded by 3 feet of stone.They had 1 inch of liquid with no sign of ponding orfailure. t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 i Commonwealth of Massachusetts Title 5 Official Inspection Fora Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 98 Governor's Way Property Address Barnstable MA 02630 Cityrrown State Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cunt.) 98 Governor's Way Property Address Barnstable MA 02630 Cityfrown State Zip Code David Hinckley May 20,2005 Owner's Name Date of Inspection Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. l c t5insp.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 r ' c Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (coat.) 98 Governor's Way Property Address Barnstable MA 02630 City/Town State Zip Code David Hinckley May 20, 2005 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: USGS maps show an elevation of over 25 feet You must describe how you established the high ground water elevation: t5insp.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 16 of 16 . 57e s No. Fee iA—" '— —OL THE COMMONWEALTH OF MASSACHUSETTS entered in comer:puti Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for ]0i.5po.5a1 *pgtem Construction Vertu Application for a Permit to Construct(�epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Cnn & _%V- �, t Type of Building: Dwelling No.of Bedrooms Lot Size ay i s .ft. Garbage Grinder Other Type of Building St No. of PersonT 3 Showers(j ) Cafeteria K) Other Fixtures �� Design Flow 3 gallons per day. Calculated daily flow er gallons. Plan Date 6 q,8- Number of sheets 3=2� Revision Date Title _A_ve_ - Size of Septic Tank (I 3-vo - 9�' Type of S.A.S. 3 5a00 lzm 1✓ Description of Soil Se" Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu by this Board Health. Signed�� ? Date 4 13 1 Application Approved by sz� Date i- Application Disapproved for the following easons Permit No. Date Issued No._� ;t! Fee ritered in com uter: THE COMMONWEALTH OF MASSACHUSETTS p- Yes PUBLIC HEALTH DIVISION --TOWN OF BARNSTABLEs:�MAS.SACHUSETTS 01pprtcatton for Mioogar *rwm Congmructton Vermtt Application for a Permit to Construct(✓S Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Locaattioon Address or Lot No. Owner's Name,Address and Tel.No. (�ypVQrhAc> W0.y �t�yG� Assessor's Map/Parcel / Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 3s Ram Type of Building: Dwelling No. of Bedrooms Lot Size ay 1 _,� s�.ft. Garbage Grinder Other 'Type of Building Si n4�. Z�ti No.of Persons�l;d�' 3 Showers�X) Cafeteria(k ) Other Fixtures / Design Flow g � gallons per day. Calculated daily flow 3� gallons. Plan Date 6 Fl Number of sheets Revision Date Title <ec— S� 1✓ Size of Septic Tank (1 5-V0 21 K Type of S.A.S. 3 SdG Kay(ksK we w Description of Soil �, S''�`� Q�� -q,my .L Nature of Repairs,or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue,4 by this Board ealth.' Signed Date 24131 If Application Approved by Date 2 -/3 - 75' ci Application Disapproved for the following easons r' 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(V) Repaired( ) Upgraded( ) Abandoned( )by ca"'s-r- at 4� �'uve��e►�S too S1�L_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. lad dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date 3 Inspector - --------------------------------------- NO. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS tgogaY pgtem .Congtructton Vermtt Permission is hereby granted to Construct( v'�RepairC� Upgrade t)Abandon(�`) System located at 9 a G',Ove-.r and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Con ruction ` us a completed three years of the date of th"e -t Date: Approved byi `' °G! -0 J yY , �( ►4 $ t�rtQ,�E�, GA T-0V- c ErZTt CtY ?L r% Pc.AAJ �y SEE ATT�kLHL-D Q�-AN PL&N REF'ERENGE� goo►c ar y , P�`-�E 77 EXISI S -" CwE��r►.rd -- � - <g 'PEeG a T osex LOT I S FS stir GA- -A �N R RV R,R PLOT PL_ t14 OF LAND IN E)A► 2 N 15 A P{-EPL&IZED FOiZ JOHN D,syID HINGIKL E-r C-�e-tt�xc> = 33Z'� 6,PP p630 x2� i= AGO tLSC- l J-Z�O C��c. ►.�Tii►.w�,�C.. F�i ELfl - 7A = 446, s I1sc sop aALLckl L C—:,4,cA-+I-,X& GNp.M a rZ e07- Dwt S F 5 �L4. 1�►2E� iv co k. A,S 5 1 rn ark 2\A,L. p6btt STAAAtC PETER SULLIVAN NO.297M y CIVIL C-1, 26= z eO M I ow oc�a2►►s i�4 SiS'/�� G�`•' G-.C-00#aC.7\,IJA�rE2 Map �ti i i• E4 REFERENCE r BOOK Zl y PGc,E 77 Co Ex41 ISTINC� T� LOT 15 00 r F. I I-�ER�?�� GE4�T�F`� TFJL�T TNE ' GWE�LIN'C� SFJOWI`i HE2EOr�i IS LOCA1'Ep 4 IT,. EX! STS' Cry T"HE Ole <j PIC - ur e y PLOT ,,'PL.aN OF'r L4NIC5 .IN 54izN PREPdIZEL� r. JOHN 'Dd1/IpV, `I"IfNCVLE.µ s CAL_E . . TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE wr��� 6-C`"" ASSESSOR'S MAP & LOT - INSTALLER'S NAME PHONE NO. 4tC:e-c=4 gzv�,j 9T' SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATER BUILDER O :3 W DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: '3I� 11y VARIANCE GRANTED: Yes No 140 S e V� /a . O ems, r 60)3OQF LOC �►fT" ON SEWAGE PERMIT NO. �. � Z-O V-I`k L A G E INSTA LLER'S AME i ADDRESS L BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 2!_ � w � /� r. � _ }'T � � � A . J_�. .�� .. w i �� ��. � �� _ . . ` _ � +. ,� � ��Z c� nl � No.gL.".3 900 _� -� Fes$ .................... THE COMMONWEALTH OF MASSACHUSETTS BOARDRP H .....................OF...............................�:... Appliration for Dispnsal Workii Tomitrurtiun ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at �� a 7 ....6, Z4��r vocation-A ress or Lot No. -----�T... ............. """'�J! .._...._..... .........----•-............•.................. ..._ Owner Address a .........--•-•----.... 2.. .................... ...... Installer G' Address � Z �® Type of Building Size ... feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `k Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures ............................ . W Design Flow............ .....................gallons per person per day. Total daily flow......................... = ...........galls. W Septic Tank—Liquid capacit} 6 agallons Length---- ....... Width..... /..... Diameter................ Depth..... x Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area....................sq.. ft. 3 Seepage Pit No......../......... Diameter..... 0,57f Depth below inlet... :-.Qt..... Total leaching area..Z ��'_sq. ft.d�- Z Other Distribution box ( Of' Dosing tank aPercolation Test Result Performed by.:GQ. ... ____ Z. ..... Date..... ,4 Test Pit No. 1<.--_•.2_...minutes per inch Depth of Test Pit...l.5.M. _. Depth to ground wa er—Va-e..-..... 44 Test Pit No. 2..'IZ .minutes per inch Depth of Test Pit___` 2_ Depth to ground water---------- ............. a+ -------••-------------------------------•--------------..................................................................................................... U Description of Soil........•-5.— ---•-•- ............................................ ------------------- ----------------------------------------------------------------------------- -•-•-•---•---------------------------•---------.-----•--------------------••---- --•------------ W UNature of Repairs or Alterations—Answer when applicable.___............................................................................................ ---------------------------------•-•-----•---••-•-------•--•--------•------._...-------•----•--•-••----•-----...----------------•---•------------------•-•-------•--•---------------------------••••---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of.Compliance has been ' d b the board of l lth. _.... Application Approved By............. ------- ---- ------------------------------------------------------------------- -a/ e --• •----Date--•----------- Application Disapproved for ollo ng reasons-............................................................................................................... Date PermitNo......................................................... Issued_....................................................... Date NO----------------------- ,:THE COMMONWEALTH OF MASSACHUSETTS BOARD� '� .................................................. ...... _0 ...... .............................. Appliration for Disposal. Works Tonstrurtion Prrmit Application is hereby made for a Permit to Construct (4,, or Repair Repair an Individual Sewage Disposal System at: 0.......... /Z ....... .................................... ........... Location- s or Lot No. .. ........ .......................................................................................... Owner Address ;4 --------------------------------- .................................................................................................. Installer Address Size Lot...... — ..G?�,;aSq. feet Type of Building 7 11Z Dwelling—No. of Bedrooms......--....—Z.........................Expansion Attic Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of.persons............................ Showers Cafeteria ( ) Othe7fixtures ........................................................................................................................................................ Design Flow............;? ----_--------------gallons per person per day. Total daily flow........... ...........gallons. Septic Tank—Liquid capacity r�4?0gallons Length....52!,_ Width..... ..... Diameter---------------- Depth..._ Disposal Trench—No. .................... Width.....__......_...... Total Length.....................Total leaching area....................sq. f t. Seepage Pit No......../......... Diameter...../0. Depth below inlet.... Total leaching area...Z.S. �.sq. ft. Z Other Distribution box Dosing tank 2 .. ... e ....Percolation Test Results Performed by._.(.- .... ..... . ... . .... Date...... ........... Test Pit No. ....minutes per inch Depth of Test Depth to ground warer.�V= .. Test Pit No. 2- ��—_.I.minutes per inch Depth of Test Pit..__ Depth to ground water.......,..'............. ............................................................................................................................................................ 0 Description of Soil........ ..........�S �4 .............................................. U ......................................................................................................................................................................................................... --------------------------------------------------------------------7;.............I.................................................................................................................... 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 TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Ce:-tificate of Compliance has bee ued.,by the board of health. ign ............... .......;Dae Application Approved By............ . ...... ......................................................................... 41---------------------- Date Application Disapproved e owing reasons:.............................................................................................................. ........................................................................................................................................................................................................ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD? OF .....................0 .......... ......................................... ,7�r, THIS-IS TO CERTIFY, TpMh(e IndivAiJual Sewage Disposal System constructed) or Repaired .......................... ................................ nst at............................................. ................................ ............................................................ ............................ has been installed in acc9fda.Ace with the provisions oVjTLF_ ' L-The State Sanitary ode �...__..._................. escribed in the "Jr. e application for Disposal Works Construction Permit A._—_............................. dat . .. ... ... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................................... . ... ................. Inspector...... &:-- --------------------------- ------------- THE COMMONWEALTH OF MASSACHUSETTS B D CLF H ..................... No......................... Fa .......... ... ....................... Disposal No , s �tolrttftion "prrutit Permission iskreby granted ...... ... ..... ........................ ........ ---------- to Constru or air Individual SeW- isposal- I e atNo....... ... ...d ..................................... ............ -----Si_r`ce;.........�V.vy ..................... ......... ..... as shown on the application for Disposal Works Construction Permit No........... _ ated................................V.......... ................................................................ Board of Health ..... -------- DATE................ 7// ?_ .................. ---------------- FORIM 1255 HOBBS & WARREN. INC., PUBLISHERS No.............•-•.IMPROVED Barnstable Conservation Departr*f4L4 COMMONWEALTH OF MASSACHUSETTS I q BOARD OF HEALTH Signed DateTOWN OF BARNSTABLE Alip iratiou for Uhrip ial Works Tomitrurtiott Vrrutit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: ...W o rt S c•.................................. ................................................................................................. L tion-Address or Lot N ��cVL-V� Ste` .•�- ................... l j WC1L .....-•................................... Owner Address W Ft\C�Cti 5�' _��.....-_�.��....... ....... 8--•------- � ------..L-4__..._... tt!c+J Installer Address UType 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 --------------------- d -------------------------------------------- ----•-----------------------------------•------------- 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 ( ) Percolation Test Results Performed by........ -•-----------••--•--•-•---------•------•-••---•-•---•------------ Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit----_.-__--____-_-_ Depth to ground water------------------------ (T Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P. --------•-------------------------------------------------•-------------------•---•--•-•------•---........................................................ O Description of Soil.... = ..........Q-- --------------------- Z— --- V ...................................•---•----...--•--••--•-•.....•----••--•••---•----------••---•-----•----•..........----•-•.....-----------•....•--...--••---•--•------•••---•-•---••--........--••-••-- W U Nature of Repairs or Alterations—Answer when applicable...__......... --' , k ----•-.... ' ............................................................... S:TIw► -•----..... 4s f 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 Com liance has been issued by the board of health. Signed .... +t,-- - ... - .......4l --------:------ Application Approved BY ...�. `.............. .................... ........ ........... 3.. --- Date..�.�..- Application Disapproved for the following reasons- ------------------------------------- .--------------------------------------------------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------------- qDate PermitNo. --------- 1-1----7t .............................. Issued ------------------------------------------------------------------ Date 78 No................_....... ! FRI& ��'.�...._ .. a ,P THE COMMONWEALTH OF MASSACHUSETTS V_ BOARD OF. HEALTH TOWN OF BARNSTABLE .XvOratioit for Dijapomi Work,6 Tongtrurtion Vrrmi# Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal Systemiit: i < `• ( i '8 j �ov�awo rL s �,� ,��•. .......- ..... ------------------------ ............................................. .... etion-Address or Lot N . -----' ��� W�... v `i -------------------------•-----------•-•-------------- �aJ Owner Address c�c� eo -. � eacrz�, � � 4 ........................... --- ------------------------ -•••---•-----------••----•-••-•-.._..-------- ... ----------------•---- ,a � Installer Address Type of Building Size Lot............................Sq. feet P—P Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons------------------------- Showers ( ) — Cafeteria ( ) Otherfixtures ---------------------------------------------------------------------------------------- ----------•--•--------------•--•-----•---•--•--..__....------ 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 ( ) Percolation Test Results Performed by.........................................................................• Date......................................- a Test Pit No. 1________________minutes per inch Depth of Test Pit------------------__ Depth to ground water......................_ f%4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 ------------------------------------•-------------- ----•-•---•------••••----------•--......--••---...._...---------------------.._..•-----.....-----•_----- DDescription of Soil : ?-.__.______.S_.5�_____________________Z-- x ---------------------------------------•-----------------------•----...------------•--• V .....---•-•-•------•-...••---------•••-•••-----•-----•--••-•-•••---••-•----•-•----•----•--._....••-•-•••-----•-------•---•-•--------------------- W x --•----------------------- ------•----------------------------------------...---•--------------•---•----•---------------•-•-----.._.._..-------•---•---------•-•---•••--....---•--•-----•--••••----••--- U Nature of Repairs or Alterations—Answer when applicable----- _ .":.- �'CJ 6-6 ----------------------------- ............................................ �ST ..._.__.. tiy.► S�.seT! -- Sys 7?!rr 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 c--- � --- 3 D4are ----- J 3 gAPPlication Approved BY - - �.....--... Date Application Disapproved for the following reasons- --- ------------------------------------------------------- --- ------------------------- .-.......-- ... ... ................ .................................... .. ....... ..................... - ...-.. --- -- ............--........-... ---------------------------------------- Da" PermitNo. .............. ..." ................................ Issued ------------------------------------------------------- Date ------------------------------------- ------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of (1:11-amlatialare THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaire ('�) by ------- --- ---------- aw 5�:-------_----------------------------------------------- taller Ins \ at . ......- C��J E-�� OSLS-----------_ ---.n� l�-`1------------- -------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in . the application for Disposal Works Construction Permit No- - --------- --...L/..-_-. -F dated ---------------_---------._.-----------..--- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE C NSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. , DATE.____.� ter-•. ?1'�el...................._..._.. ----- Inspector ....-... � r� ✓L?--.-....- ------------------------------------------------- --------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 5° TOWN OF BARNSTABLE Na-.--_y:.3..._ FEE--'-.•- 2.... �i��r,a��t1 ork� �un�tr�r#ion rrmi� Permission is hereby granted........�` 'c�1`-4 c ---------------------------------------------------•-----...------•--•----.......------ to Construct ( ) or Repair<(� an Individu l Sewage Disposal System atNo.....9_8.....( 9'1 LNQ S--------• "`a -------- ------------------•-•---------------------------------------------------.._._......... Street �� (� PP P � Construction Permit Dated........................................... No.,.__,__"__.__.._.__ as shown on the application for Disposal Works Co � ................................ ---------------------------------------- Bbard of Health DATE............. -'_1__--:........1**__--•-•--------------------------- FORM 36508 HOBBS B WARREN,INC.,PUBLISHERS -. . TOWN O/h/B STABLE N� SEWAGE# tON aZi4WE �� � •� 'e AS SSO 'S MAP & LOT ' 0� INSTALLER'S NAME&PHONE NO. Q SEPTIC TANK CAPACLTY LEACHING FACILITY: (type) 19& (size) 4. NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leachi%facility)� Feet Furnished by e Y� LlX :Y tr uj 2 y Z ,gas �y5 J v J 58.72 N Q TOP OF FOUNDATION N '" _ ROUTE 6A CONCREic COVERS 2.66 4"CAST IRON 9 ""'_ - -- - FIN. 58.50 , �S O OR SCHEDULE 40 4"SCHEDULE 40 P.V.C. (ONLY) ' LEACHING TRENCH ( )REQ. 2' P.VL.PIPE MIN. � 9 MIN. " '.. PIPE•-MIN. i 8"- 12" WASHED 36 MAX. PITCH 1/4'PER.FT " 24 TO / / S ED STONE i • ' EXISTING PITCH 1/4 PER,FT. BE LEVESL � - - �= • •:• �___ � 2" EL.55.51 W ,C7{C3;CM'ci '(y.',.pl'd;tom'L►X� i 8,",EL.55.34 }' Q b6 GAS BAFFLE-� Cj C7:t=1'cl`I-iC7% �C] -C3,b: 4 .54.34 - 0 3 ;•• EL.....:....... SEPTIC TANK INVERT 6" 0 E tNVr�T Ch ';Lt�t �:t7�'p' t5�ta-'t3 �_ 24„E .•; 55.46 .E E55.09 , L .... ,:. INVERT55 71 ,,1500 GAL.. INVERT DIST, - -- EL.52.33 �� Y EL......:....... 55.26 INVERT ,. „ E--•••••• ••• BOX 54.49. Precast 500GaI.Leach 3/4 -1V?- -1 S EL.... (3 ) REO. RAILR •,; 6"CRUSHED STONE EXIST _ Chamber WASHED STONE NONE QAD 14 8' 26' - . I H- 10 25,6„ ENCOUNTERED LOCUS MAP SCALE 1"= 500 FT. 33,6„ ., PROFI LE OF ' •'''' P-_11441 GROUND WAT=R TABLE ASSESSORS MAP 258 SEWAGE DISPOSAL SYSTEM TYPICAL CROSS SECTION PARCEL 54 SOIL LOG" No SCALE LEACHING TRENCHDATE .9/26/06.. TIME . j0:00 AM NO Sr---:*A' TEST HOLE I TEST HOLE 2 ELEV. 60.00 ELEV. 9.5Q. ... DESIGN DATA _....W_.- 1/8'=1�2" SAND LOAM F!U't=ER CC °='ROOhtS 4 9-":A;N. wISTIED -36"MAX. 6�� A L.59 50 6� EL.59.0 T 570NE 2,„ - `N\ SANDY LOAM TOTAL ESTIMATED FLOW ... 44Q . ... GALLONS/DAY �"-•' ' -t g -_ B !� IOYR 5/8 -.�- B 429. 80 R ;tom-p;c3: a z \ BOTTOM LEACHING AREA ............. SO.r►./TRENCii44 EL.56.34 EL.55.84 18 5.32 ,;�t�tom;tom; ; 24 ` PERC. SIDE LEACHING AREA . . . . .... . .... . SQ.FT./TRENCH MEDIUM GARBAGE DISPOSAL .. . . . . ..(50% AREA INCREASE) C SAND '--'' C TOTAL LEACHING AREA ' , IO YR 7 4 PERCOLATION RATE'. . . 4 M I N 65„�_6 5 . . ... ... PER.INCH 12110„ ERN - LEACHING AREA PER PERCOLATION RAT-c 455.19SG.F�. � - 150" ... GROUND 'N,TErR —1,2LE T ? ED � ' O R t S _EL. 47.50 EL.47.00 APPROVE) .. . . . . . . . . . . . .. BOA?D OF HEALT':I , _— - - - --- - -- - _ WAY 98 OF �1 PAVEMENT_ _```'NO . ...waTER -cNcoU^:TERED — — — — DATE ..... .. .. ... . AGENT o� INSPECTOR WITNESSED BY . 95.0 ' DONALD DESMARAIS,RS BOARD OF HEALTH STETSON HALL RS ENGINEER EDWARD E. KELLEY, RPLS LOT 14 Lu X � w 4j I a; � ~� 58' Cb 0), 98 h S? EXISTING WELLING S9 4- L SITE 8' SEWAGE PLAN IN BARNSTABLE s 0T 15 fVIA . e DEC ' EXIS � ,•; � 200 SQ.FT. � K i T►NG FOR s9 , p �gRAGE "NOTE-40 MIL WATERPROOF G 5 12, EXIS 2 f Slab " MATERIAL LES L I E S VA LERI E HEM M I LA °�\ ` ,�_ SEPTICI V OCTOBER 10 , 2006 EXISTS — NK r3oo , ., test holes ��:5, 61' SCALE AS NOTED , EDWARD E . KELLEY �—� LEASH NG �� r 6/ ' _ ' _ TRENCH 1 $. ° o PRpPO _ A REG. PROF. LAND SURVEYOR — — — I- SED LE CH PLAN SCALE I"= 20' CUMMAQUID , MA . _ 1 —' EXIST 5 �� TRENCH 12 83� 62' — •—. 185.52 7 _ -• -�;60X - - ��-- ' 7•' X 33•5p' ..-- ,.rc- LEGEND — EXISTING GRADE 61 ,' � — 61 RIGHT OF WAY 10' WIDE 10.00 69. 47 1 PROPOSED GRADE 58.......... ....58' SHED 41 . 25 ILI OF , HJ EfDWARDy J:� r KEE. LLEYNo. , 'M a. CENTERLINE OF RAILROAD �+ QfI;ISTER� t L 0 rFVAttU�' NOTE ELEVATIONS BASED ON ASSUME DATUM PLAN REF. — PLAN BOOK 214 PAGE 77 . 4 f 7 r - i 7-0 64 4 c`+ F � = 6 ' -54 ,5z rt x�strn 9 9rouna� Pro f'r /e — A , —o — o--o --o -- Pr000seol c�rour-7ol Pr o f, /e NO2/z. SCALE : / _ /o G T /�/ (/ E ,2T SC 9LE /"_ /O' S C H E D. 4 c- ' V C. 0 AE --- F L O,.AJ T f r ? ., EQu�� To oT/G � rrr,nirr,vrr� %¢� Per- foot �2 0 washed/ Stone T9nJK� t o/sT B O x cc dla 6" sump ° o . CLI I �.3 i / 000 GAL.._SE PT/C TANk /of 3/4 5 wa hed stone •. ° . . 53.E of /4 2 �.�� G� SCALE: ., - / , o.. LEAC: 14 P/ T �a 9 '',�x -r'�►' X' /!�' �,,� - - S / G /L/ —__— TE- S 7 H O L E- L.. O G �O \e �/,y G- f3 2- C-)�2 0 o M H n u s E O y T E i / - T 5 T B Y: D/�/ /it/c= � I \ )"::E e C- B A T E n�/N. /N C H &-V Al r<E c_/`� G/FIF- F� ow ,GATE ' ZQ GALS.�oHy Fczrr/sfa.�/e Bd f flea /f%; cod. �� I SEPT/ C- 7-.9A.//< �20 x / S = 53C . y U TE5T f�OL E # 1 TEST HOL 6- '#Z �•0 — 0 -7- /5 ^ � �4 20o s.7` �F OEPTN u Co• 0 5a.r7d meal/ rr/ 2'o 4A-1 e 4`/ /�;y,e o/ w 16 Sarrcl 1--LL-1 S.F <�S --Q/=- GAGS/GAy / CTjrXE'�j ✓^ �\ ` R . 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