The URL can be used to link to this page

Home My WebLink About0112 GOVERNOR'S WAY - Health 112 Governor's flay Barnstable F/R -�-------- A = 258 053 d c u tzBarnstable Assessing Search Results Page 1 of 2 y� IRE � 1634. timAl - Home: Departments:Assessors Division: Property Assessment Search Results 112 G®VIEIRNOIRS `SAY Owner: KOOPMAN, ELLEN H Property Sketch Legend Map/Parcel/Parcel Extension 258 /053/ }4. Mailing Address 4 ,i�IDK* Us KOOPMAN, ELLEN H f 4 is 112 GOVERNOR'S WAY S BARNSTABLE, MA.02630 2004 Assessed Values: " ,Upld -- Appraised Value Assessed Value 40f Building Value: $ 161,600 $ 161,600 Extra Features: $2,500 $2,500 Outbuildings: $0 $0 Land Value: $306,900 $306,900 Interactive Property Map: aD re uires Plug in: Totals:$471,000 $471,000 l have visited the maps before +ry P �e, . U1' Show Me The Map ' "' `. April2001 photos available Sales History: Owner: Sale Date Book/Page: Sale Price: ` KOOPMAN, ELLEN H 12/16/1996 10526/246 $ 1 KOOPMAN, PARKER M&ELLEN H 7/15/1982 3511/216 $75,000 2004 Tax Information: Tax Rates: (per$1,000 of valuation) Town Tax $3,113.31 Town Fire District Rates Other Rates 6.61 Barnstable 2.01 Land Bank 3%of Town Tax Barnstable FD Tax $946.71 C.O.M.M. 1.10 Cotuit 1.52 Land Bank Tax $93.40 Hyannis 2.03 West Barnstable 1.36 Total: $4,153.42 Due to rounding differences these values may vary http://www.town.bamstable.ma.us/tob02/Depts/AdministrativeServices/Finance/Assessing... 2/17/2004 I Barnstable Assessing Search Results Page 2 of 2 Land and Building Information Land Building Lot Size(Acres) 0.63 Year Built 1970 Appraised Value$306,900 Living Area 2444 Assessed Value $306,900 Replacement Cost$ 192,367 Depreciation 16 Building Value 161,600 Construction Details Style Colonial Interior Floors Hardwood Model Residential Interior Walls Drywall Grade Average Heat Fuel Gas Stories 2 Stories Heat Type Typical Exterior Walls Vinyl SidingWood Shingle AC Type None Roof Structure Gable/Hip Bedrooms 4 Bedrooms Roof Cover Asph/F GIs/Cmp Bathrooms 2 1/2 Bathrms Total Rooms 8 Rooms Extra Building Features Code Description Units/SO ft Appraised Value Assessed Value FPL2 Fireplace 1 $2,500 $2,500 Property Sketch Legend BAS First Floor, Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTO Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TQS Three Quarters Story(Finished) http://www.town.bamstable.ma.us/tobO2/Depts/AdministrativeServices/Finance/Assessing... 2/17/2004 s' i ._ - .. - _.�' _..^_. -`_.—_„ _ _ __. -fir_ �R.'-'•��^ f�. Ll 44 Jam_ "Am ` ' +��.. - • 1. , r _ - Jo Ail . 1 r - - ♦/ A _ .3ws� Syr ��,• r \�- �''� li f l� 1111111��/` rr a fit• � l �`�� i �_'\ • ':r"- - �. '�`� �. � ;,, � .�� i7 •��;�,i� � k 1. ti. r fA . - - ,_ - �.� ems, �� i ...� � .`� - _. �n� ��f{�r+ - •r�i j+i I'r - - � - �' y� .� ell `�`} • 1. r f'� �. -'• •.t a-1 r � L w�fr r /A r y 1■■ • .. .. _ .-. ." � -.yam i:,�.--/_� s ` • .ice'. � � - • p�r• �;�._. •ice - _ t 'i, �;•� i r•!' .�f'�•. � 1 �� .. i;.i e Ijk 46 fk INQ� ,t, I _t � .. �.1� :` ter, r`� ' t1• -�ir� �w�.r i� 4 ^1!/ :r_\ � �'1.� �•�.j IAP 7i - =_ fir. .�`' '�_ _ r. •�� ^CIAO ' - - ti� ..'_ �y�,,,. ._ _ - vf AMC NIP yr� "46= - AMW �grit _---'� a � _ • _ � -. ' 'ry'+� . . �' ��• _ _._ �( ''" '' �`� �Y �'�.,�/ � `..a` � /�. yam, _ - r VF ZN y-� - I*.� y. f : •�' A=`"kai,� 6n. ' 'J.-�y 't. '`.. �{ ?l/� •�f ��r�yf 'z .. �a i � J,'r .r1iye1f� ''1� „� ^a ".ti: �• .y,.;T": +y `,`• t_ It,w y� I' ,' �4►,1i',� \. � l /_ ., I .��.w •� "t�R �.i•i 1 f•r��;�� Y.�� •�_i IJ � �.t�l r•�, �S'hC � 'Sf'f�1�'i e � - I• i � �ih r�,Ttfif'l�' .�i►�' •�+ � " I .rr, 1�°�' �' � '1�„�� d ;°�� j `1i'�•t!� ''�' ��.• �, �•• `;V. � +I �.to t�1 - ii i2�;}i��O•�. i- •` %°I�nrj f-.a '' ►�.-' - '1 wa �r' �` ryl frY j1';r � :�� _ ��+�� k'"."j''"'� j• .�'. ."l \ �x�'{A ,�,; �f�f►,.,:`v .� ems.:C .� -- , 'Y � a��,, r1 / . c• .�• , ., 1. ! .. vt ,, ^�T _ ' _{ _ 40 ct F- 4, 1 Ok Ima 114 I . _ . 4 .a ,� 1) 11 i�v - �;.. �, ( e• iI� '. � e '� .6 1 �:a ��.S. - r r '-v< :i.*f# -t ;. �� 1!,`. .-^-"`"_.-•�S..Lr,st . _ - .. 4.1 FFF�� yt r_ - .t - _ t�� Y* ; _ � ��^�.y."1�+(is. � .daa.��.+f � .�: •,t3 F*� + .. - .,ti_.J.ia`� t +�►��, '-s�''�'`f'��. f�.- - r �C ay�r. '.�. i��„� d �a#�y�i-:;-�'. i�`�� -r�1!:� °:."T�4i. `� K.-��r ��Q+F�'.+4 �i � 'tom`-'-'��?}' R•_ - - �: •fig-w�b - i .1� � ..'i F � - ! C' � `• Cx. -C -r ti r Ilk `� .yam}, 1 �, ,�. a1Y-•2 Z •_ _ i i � - to � .i �sti�'..- < a �TOWN OF BARNSTABLE L(3 "s ION SEWAGE # 000 3" r7 VILLAGE -,fhS"�-rG'�� ASSESSOR'S MAP & LOT 258--e)53 INSTALLER'S NAME&PHONE NO. 134113 al r*Owd C9,,I S11, �G;t3� 9 SEPTIC TANK CAPACITY X o Q LEACHING FACILITY: (type) 3 520 c(size) 3 /2 x NO.OF BEDROOMS BUILDER OR OWNER PERMITDA'TE2�2� �d 7 COMPLIANCE DATE: V l3 03 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 within 300 feet of leaching facility) Feet Furnished by Iw � n Ink r ell � � Q 9 - No. � i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN bF BARNSTABLE., MASSACHUSETTS 0[ppYication for Migool bpztem Construction Verntit . Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Cfl&( J/7'LO'r 'S U•t,c•s,, Owner's Name,Address and Tel.No. Assessor's Map/Parcel 49r'Yd"f'ie I-e v' Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 17 .7 S )-ci#s a&pWrs c,,p . cam 0-a4 AS(F- ton aso eta 14 3 /F h$or �- Type of Building: Dwelling No.of Bedrooms�l- _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 4 U.6 gallons per day. Calculated daily flow gallons. Plan Date �� 7`/ I o3 Number of sheets Revision Date Title Size of Septic Tank SW Type of S.A.S. Description of Soil S v it s-C�s j Lc�S Nature of Repairs or Alterations(Answer when applicable) in Date last inspected: Agreement: The undersigned agrees to en e e construction an ntenance of the afore described on-site sewage disposal system in accordance with the ovbeisio of ' le 5 of the Envir in de and not to place the system in operation until a Certifi- cate of Compliance e 's y this Board of ea e Date Application Approved by ® Date , ILZMQ Application Disapproved for the followin easons Permit Nc ' Date Issued THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A , m / � IL DATA Fee / THE COMMONWEALTH''OF MASSACHUSETTS—. Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE} MASSACHUSETTS! ZIpprication for MigpontbpMem Congtruction Permit Application for a Permit to Construct( '. )Repair( - )Upgrade( )Abandon( ) ❑Complete System 0 Individual Components Location Address or Lot No. I , (�C L, -.- t, { c. •✓, Owner's Name,Address and Tel.No. ' Assessor's Map/Parcel �`� ''�/-1 6 / I Loci „''►y,,,, Installer's Name,Address,and Tel.No. �+ ` Designer's Name,,Address and Tel.No. -7 7 5 c7f 20C y G`C ris� _ C� 5�0 �r� �r/' / 7 ��"C1 �� v �� C 1 G �lJ ��i[/' //`7 C 1 Type of Building v Dwelling No.of Bedrooms U Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures t , F Design Flow t4 ti gallons per day.Calculated daily flow gallons. Plan Date S / Number of sheets Revision Date Title !� Size of Septic Tank f dV Type of S.A.S. Description of Soil S T= S f+ / L f �_ Nature of Repairs or Alterations(Answer when applicable) I"- �q Y Date last inspected: "~ Agreement: i The undersigned agrees to ensu a he construction and ntenance of the afore described on-site sewage disposal system in accordance with the provisio of Ti/le 5 of the Envir ye, to de and not to place the system in operation until a Certifi- cate of Compliance l bee 'ssued'by this Board of ea�h. a Date Ale Application Approved by Date Application Disapproved for the followinV easons R Permit No.6m, ' Date Issued r i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS certtftcate-of Compliance THIS IS TO CERTIFY, that the On-site,_Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by 1-7// 5 rc at I CUP r)-(% /)/—( has be . constructed in Accordance with the provisions of Title 5 and the for System Construction Permit No '"'3 dated t t{1C.3 . r Installer Designer The issuance of his permit shall not be construed as a guarantee that the system/�' ti01r,/ e`signe . Date I( 3 3 Inspector !/ - � / .. •� vim.._ --------------------------------------- No. la-20 Fee THE COMMONWEALTH OF MASSACHUSETTS'` PUBLIC HEALTH DIVISION - BARNSTABLE: MASSACHUSETTS '1111igpogar *pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade(� )Abandon( ) System located at ' G Cy��`' r r ✓M �.�`r; S f g �, / "( 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:Constr��ctffio m/us�t bg completed within three years of the date of t i ermitl.�/� c Date:____T/ "T Approved by ,?� I TOWN OF BARNSTABLE LOCATION _ SEWAGE # 3" � VILLAGE fns�'� � ASSESSOR'S MAP & LOT 25$-053 INSTALLER'S NAME&PHONE NO. 1341 k3 a r* � S'L 3 cog SEPTIC TANK CAPACITY LEACHING FACILITY: (type) AGO L.�12��p-�t(size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DA1P-- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Tabte 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 df Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet j Furnished by i i - F 1 F7 7;rr� s i FAILED INSPECTION DATE : 615103 PROPERTY ADDRESS: 112 Goveznoaz Day -- -L3a2nhta��e, t7a.3h------- %EIVED _--02630------ ----------- - JUN 2 0 2003 TOW,iOFdARNSiABLE HEALTH DEPT. On the above date, I inspected the septic system at the above a ress• This system conslsts of the following: 1. 2- 1000 ga eion /?2ecaht Ceach.ing 12.ith. Pith ate in he2.ieh. Based on my inspection, I certify the following conditions: MAP �� 2. 7hih .ih not a t.it2e �-L)e he/7t.iC �syhtem. PARCEL i ® � 3. 7h.ih -ih a hewage hyhtem. LOT 14- 4.' The hewage- hyhtem .ih in hydnau.2ic laieu2e. 5." R new he/2t is hyhtem needh to ge .inhtai-eed. SIGNATUR / Name : _ J_- P__Macomber_Jr ___-- Company :, gat t _P�_M.s ggo�pr 8_ Son, Inc . address :__ _ _QLP-11SeLYLLLP., _22-632- 0066 Pnone : 508- 775_ 3338 -------- THIS CERTIFICATION GOES NOT CONSTITUTE A GUARANTY OR WARRANTY IOSEPH P. MACOMBER & SON, INC. Tanks Cesspools Leachtletds Pumped & Installed Town Sewer Connections P.0 Box 66 Centerville, MA 02632.0066 275.3338 775.6412 z -\ COMMONWEALTH OF MASSACHUSETTS r ExECVTNE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 .OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 112 C7oveano2.6 Uau NrjAA- Owner's Name: en oo� an Owner's Address: Same Date of Inspection: 615103 Name of Inspector: (please print)1o.eeah /). Nacom&ea a2. Company Name:,7. P. Nacomgea & Son inc. Mailing Address0ox 66 Can v ' , Na.6z. 02632 Telephone Number: ___5OR-775_ 3 3 3R CERTIFICATION STATEMENT I certify that 1 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: /� Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner.shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1'12 gove2no z.3 0ay, a2n.6 a e, Owner:E-Uen Koo�ma2 Date of Inspection: 615103 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: fib 1 1ve not found any information which indicates that any of the failure.crit�er11'a described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not'evaluated are:indicated�6elow. Comments: �l m .iz in ht1d1tauiic a i.2u2e. k new `,4.. t(. �.ive .6e7Q4.ig c✓iAinm nondA in 0O .! .SfrI�Ced ti i � B. System Conditionally Passes: /l)L) 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. A&Lyj'he 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. 'kmetal 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: 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: 4/2) 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 112 Gove/tno2.3 (day a/tn-6 e, Owner:Uien Kool?man Date of Inspection: 615103 C. Further Evaluation is Required by the Board of Health: ,M) 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 envirorunent. 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 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. /Q The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. M The system has a septic tank and SAS and the SAS is less than 100 feet but 50 ff�t 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: 7hiz -.z a -sewage zyz.tem. 7he zyh.tem conziztz o/ .two .c-r— ---� n .�e2.cez. e ewaye zy.s em .c-6 to UUU yae2on qy ,zaaH c i ua`7) new tttTe 7tDe zel2 .cc :6y,6 em - need-6 to ke inztaZZed. 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM: PART A CERTIFICATION(continued) Property Address: 1 12 goveanoa,s Gl¢rj Owner: FP.Pon Knnnmrin Date of Inspection: 615 Z(M 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 __4)7tC Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or � / cesspool _C__ Liquid depth in cesspool is less than 6"below invert or available volume is less than %day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped y 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. fit_//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. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303.therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no/ Y the system is within 400 feet of a surface drinking water supply /the system is within 200 feet of a tributary.to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 I" Page 5 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART $ CHECKLIST Property Address: 1 1 Z C/ovenno2e blamer. l3a2n.61_ag2e, Na.6.6 Owner: (E.Q.Qen KoQl2man Date of Inspection: 615103 Check if the following have been done. You most 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 o k _ 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,4uding the SAS, located on site ? Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions, depth of liquid,depth of sludge and depth of scum ? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no / Existing information. For example,a plan at the Board of Health. — Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)(310 CMR 15.302(3)(b)) 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 112 Goveltno2,3 (Jay a2n.e a e, Owner: E.P 2en o o/2marz Date of Inspection: 615103 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):-I/- Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): X yo Number of current residents: Z Does residence have a garbage grinder(yes or no): VO is laundry on a separate sewage system-(yes or no):T [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no):,Vb Water meter readings, if available(last 2 years usage(gpd)): 2002- 18 9, 000 gai.eon,=5 17. 6 1 gl"D Sump pump(yes or no): 2003= 95, 000 ga.PPon.6=260. 28 gPD Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: �14 Design flow(based on 310 CMR 15.203):_ eW —gpd $asis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): tQ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):� Water meter readings, if available: WX Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: "rj-w � S Was system pumped as part of th inspection(yes or no):_ If yes, volume pumped: 0 gallons--How was quantity pumped determined? �t Reason for pumping: TYPE OF SYSTEM ,: 1b 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) tid Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) y6 Tight tank ,L6 Attach a copy of the DEP approval Other(describe): Ap ro imate aoe of all omponents,date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no):"-(4 6 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 7 12 Gove/cno/c.6 Uay L3a2n�ta�2e, Na.6.3, . Owner: E P—ven Ko o pman Date of Inspection: 05103 i BUILDING SEWER(locate on site plan) Late 4" Pvc Pi/2e & Depth below grade: Materials of construction: cast iron A±40 PVC A/'other(explain): Distance from private water supply well or suction line: /O Comments (on condition of joints, venting,evidence of leakage,etc.): lo-nt.3 a/?Rea/c tight- No evidence o/ .leakage. The 3y,3tem i,6 vented thorough the houze vents. SEPTIC TANK: (locate on site plan) Depth below grade: A)/f Material of construction✓f/ concrete&metal,1?4fiberglass4gpolyethylene' N other(explami ) If tank is metal list age:� Is age confirmed by a Certificate of Compliance(yes or no):___Qi (attach a copy of certificate) Dimensions: A//9 Sludge depth: AIA Distance from top of sludge to bottom of outlet tee or baffle: _ Scum thickness:_ '0A Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Wd Comments(on pumping recommendations, inlet and outlet tee or baffle'condition, structural integrity, liquid levels as related to outlet invert, evidence of.leakage,etc.): SeRtic tank i.6 not R2eheni— GREASE TRAP+JAMlocate on site plan) Depth below grade:A�4 Material of construction.0A concrete 4�4 meta l VAfiberglasU)4 polyethyleneI)X other (explain): Azo Dimensions: 4114 Scum thickness: Distance from top of scum to top of outlet tee or baffle: AIZ4 Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: A W Comments(on pumping recommendations,.inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): M 7 Page 8 of 1 I OFFICIAL INSPE`— FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE ,`— AGE DISPOSAL SYSTEM INSPECTION FORM PART C 7EM INFORMATION(continued) Property Address: 112 Gove2nolzz Clay a/Fn 31 a9Pe., 7'��s. Owner: EPie-n o�R_ Date of inspection: 3 TIGHT or HOLDING TANKj(j4j)�& :ark must be pumped at time of inspect ion)(locate on site plan) Depth below grade:_1 Material of construction: c. ::. '/4� 4A metal fiberglass (L�polyethylene�other(explain): i Dimensions:_ k 1 Capaciry: JAI Design Flow: TA -__ /day Alarm present(yes or no):_,AM Alarm level:-AJA Alarm i:, order(yes or no): Date of last pumping: —A Comments(condition of alarm c:.. ,A itches, etc.): 74gh.i- o2 hoid-.ny fank,6 ate not /?2e.6ent DISTRIBUTION BOXJ t ..: : must be opened)(locate on site plan) Depth of liquid level above outi:: Comments(note if box is level --uuon to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): [7�.�ticzPution Pox--. no �2eeenf. PUMP CHAMBER4jW0—(lo plan) Pumps in working order(yes or :.:: 10 Alarms in working order(yes o: :. "(1/9 Comments(note condition of p..... jer, condition of pumps and appurtenances, etc.): O4 /72e.62n f 8 r Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:112 Goveano2.3 Clay Baan.s a e, a.6.6. Owner: E.P.Pen K6o/2rnan Date of Inspection: 6/5/0 3 , G SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,fexcavation not required) 2- 1000 gaP.Pon /2,zeca.st .Peach.ing p.itz. l:it•5 ate .in zea.ie.s. If SAS not located explain why: Located See Rage 10 Type ,/ leaching pits,number: leaching chambers,number: Aleaching galleries,number: C> leaching trenches,number, length: 6 .L leaching fields,number,dimensions: 0 overflow cesspool,number: -01- n innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): /,nna2y Arinr/, LorO� MF7lIM/7 S N:7 dnih n4 v .Pear&1ag / ,fA rime .in by 2riLA.P.in �o,i.Puny. ldaAyie I.1nyvn 1A 2" QDQnw fhv a A- S'nLPA rite dam/2. Vegetation .i.3 noamai. A new 7.it Pe Zive .3e/2t.ic .5ybtem zhouid ge .inata.iied. CESSPOOLS+Cf�yy�(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: 401 Materials of construction: Aby Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): C P AA n n n P A n n o n n f n n o A o n t , PRIVYAdLXx locate on site plan) Materials of construction: Dimensions: AJA Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): paiyy 1.5 no#_ P/-v_,sn.n.t. I 9 f Page 10 of 1 I OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properry Address: 112 gove zno.,z.6 Clay L3a2neta�2e, Na.e.e. Owoer.Ei.Pen Kool2man Date of lospectioD: 615103 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 publie.tiwater supply enters the building. Z zS.r�r- c s <N a.1 r,�s-1 a b Le w��•cr r;4 40,j v. riI � e � ' 10 L . f r Page 1 I of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL, SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 112 GoveIcno2.3 Clay l3a2n�str<�2e, Na.3-6. Owoer:Eiien Koopman ' Date of Inspection: 6/5/03 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate (check) all methods used to determine the high ground water elevation: ND_Obtained from system design plans on record- If checked,date of design plan reviewed: NR yE-Observed site(abutting property/observation hole within ISO feet of SAS) NCL__Checked with local Board of Health-explain: 414 yam-Checked with local excavators, installers-(attach documentation) y Accessed USGS database-explain:. ht.6? //.town, 9aznbta&.Pe. ma. u.6. You must describe how you established the high ground water elevation: U,6ed: Gahae.tu & MiUe2 (Iodei, 12116194 Gaound wate2 e2eva.t.ion,s agove .6ea PeveP. 11zed: USES: L,6ed: IZS.qS:TenAn!rn9 aijPF¢fln 92_nnn— Z PO 12 12 Annuai aangez o y2oun wa#.elt e.Peva'.t.ion. �grzuua2u 1992 I up orn Leaching Pit :cct Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is A0 feet. I1 y.•nnnr+.—n•r�-+-r-arnrnr•nee.r.r�.na�.rmmn�+•+e+nrt+.e*mnn nrn-ri re�+er.� .�-�r��_, _. r_..,F 1 TOWN OF Bu2R,6tue-ie- WARD OF HEALTH 1 •.•.t..,_r••,_••,-_•"r_SU[1SURFACF SEWAG-F DISPOSAL SYSTEM IN�9PFCTION FORM - PART D .�CEIZ'1�(FICAT[UNr� ' -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 112 goveltno2,3 Glau Ba zn.stag.Pe, Pla,3,3. ASSESSORS MAP, DLOCK AND PARCEL # 258-053 OWNER' s NAME EP.Pen Koollmun PART D - CERTIFICATION [ NAME OF INSPECTOR _ Jozeph P. MaeomPea aa. COMPANY NAME P. Nacomge2 & Son Inc:"* COMPANY ADDRESS Box 66 Centeltviiie, MaSS. 02632 Street Town or City State ZIP COMPANY TELEPHONE (508 775 - 3338 FAX ( 508 1 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is P true , accurate , and om let p e as of the time of -inspection . The ins e p ction was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : Systeci PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public liealLh or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILEllI * i The inspection wilicii I have con ircted has found that the system fails to protect the ptiblic health and the environment in accordance with Title 5 , 3.10 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Insector Signature Date p .__� _ _ •-'ma's=� ne copy of this certification must be provided to the OWNER, the BUYER I ( where applicable ) and the 130ARD OF HEALTH. * If the inspection FAILED, the owner or"'operator shall upgrade - the within one year of the date of the inspection, unless allowed orrequiredm otherwise as provided in 3.10 ChJR 15 . 306 . partd .doc IL Town of Barnstable P# OF1144E Tp� Department of Regulatory Services s i Public Health Division Date � gpBNSYABI.E, r . v sb 9 `0� 200 Main Street,Hyannis MA 02601 ' �pjEO MP't& Date Scheduled �/Z//o-3 ` Time �/ A'l Fee Pd. (C Soil Suitability Assessment for Sewage Disposal Witnessed B Performed By: 0� �A ! L�-'Q Y Y•4 Y kl 4 = Y Y '. bMIN AA IN amin '� �'�r. �wners�.. Location Address Owner's Name p/ Q , Address T � - _ Assessor's Map/Parcel: 5 g_6 Engineer's Name NEW CONSTRUCTION REPAIR Telephone# °�� Z � `CIP�S' Land Use j�iOD�7?;-t Slopes(%) O Surface Stones y Distances from: Open Water Body�ft Possible Wet Areaft Drinking Water Well �ft a _ Drainage Way35 ft Property Line -3 o ft Other ft SKETCH:(Street name,dimens ons of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) q -� S ,Ll J Parent material(geologic) �l l I Depth to Bedrock /v Depth to Groundwater: Standing Water in Hole: Weeping from Pit Face �Q U- Tvu�.9NG l Estimated Seasonal High Groundwater �/ yR �� 37 I f , L� j �, A x :,r 65 , -)IS ��il�l/ 157' LK� /d d ••/� Method Used r /Fw1 A t' ✓�� v Depth Obs rved standing in obs.hole: in. Depth to soil mottles: �n' UN Depth to weeping from side of obs.hole: in. Groundwater Adjus meat ft• 2 6� Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level a, ', Al"". Observation Time at 9 Hole# " Depth of Perc IJB�` fo d Time at 6" 2O�t Start Pre-soak Time® f�. Time(9"-6") --3---� e End Pre-soak f 0- 5, J i Z'"/,,)RateMinJlnch / �/ Additional Testing �0 Site Suitability Assessment: Site Passed Site Failed: g Needed )/N Original: Public Health Division Observation Hole Data To Be Completed on Back Q:HEALTH/WP/PERCFORM 6p min' �p,ir fi Ili'B!1'',V" iakF4,t- yykkx ,9 # °+ In Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel Ld f ��'yr'v z_ ho erne jy6Aji- 2��3� �/ r✓ r $ /C� 616 �Id ��'hQSj�r9itJCl /Ia Gtl i3 �/ A::.� k:..kp:::�::::.::r:::!:ml�"uiii'Cid � k:.:._..ails t•.' t 5!r!ns i 4 S Yk N ,], .;�3ts�aaW 7%;? C .��_...:.O ............. Depth from Soil Horizon Soil Texture Soil Color Soilter Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel x,,i:.• .:e''::. .:"C�.k... x ixNi!%;j::,iiiK'1){F�...;i,�.. ;i�^:��.. 9�- u a,�`,;n:; 'V :.0 '� r �ss:.;,craw I ..L.,.' : n ew : zr.. . w t.�.y R.�•m�:.... Depth from Soil Horizon Soil Texture Soil Color . Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency,%Gravel Depth from Soil Horizon Soil Texture Soil Color I Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulders. Consistency,%Gravel Flood Insurance Rate Map: Above 500 year flood boundary No Yes Within 500 year boundary No— Yes Within 100 year flood boundary No— Yes Depthtof Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? ' W If not,what is the depth of naturally occurring pervious material? Certification. 2 I certify that on Not). `W3 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the requiredLtIamit&expertise and ex erience described in 310 CMR 15.017. Signature Date � 2J/ -�3 Q:HEALTH/WP/PERCFORM JOB NO. B03-05 N/F NOTES Koopman.dwg 4(,n r 3 CATER 1. LOCUS IS A.M. 258, PARCEL 53.rHOMEOWNER INSTALLED 3" PIPE DRAINS 2. ELEVATIONS SHOWN ARE TOWN GIS ±0.5'.PUDDLE IN STREET TO LOW SPOT 25' 3. LOCUS IS IN FLOOD ZONE C ON FIRM DATED JULY 2, 1992.EAST OF PROPOSED LEACH AREA. 4. ALL PIPES TO BE 4" SCH 40, AND PITCHED AT 1/4" PER FOOT. (UNLESS NOTED)N 5. MUNICIPAL WATER IS AVAILABLE. LOTS WITHIN 100' ARE ON TOWN WATER.N <:_ 44 j 6. COMPONENTS TO BE AASHTO H-10, UNLESS NOTED. N/F S'' 98 pg.O W 7. INLET TEE TO PROJECT DOWN 13", OUTLET TEE DOWN 14". a 8. IF TWO OR MORE LINES, WATER TEST D-BOX FOR EQUAL FLOW SCHEID D-BOX EXIT PIPES TO BE LEVEL FOR FIRST TWO FEET. NOT TO 9. DEPTH OF COMPONENTS NOT TO EXCEED 3', OR VENTING MUST BE PROVIDED. / IN, BUILD UP COVERS TO WITHIN 1' OF GRADE. MORTAR CHIMNEYS IN PLACE. SCALE ONE COVER OF TANK TO BE WITHIN 6" OF GRADE. LOCATION MAP 508 10. STONE TO BE DOUBLE WASHED 3/4 TO 1 1/2" WITH 2" MIN. 1/8 TO 1/2" PEA STONE ON TOP. 11. IF UNSUITABLE SOILS, OR SOILS DIFFERING FROM THE SOIL LOG ARE FOUND, 4 CONTACT THE BOARD OF HEALTH, OR R.J. CADILLAC. \ TH 1 / 12. IF AN OVERDIG IS CALLED FOR BELOW, FILL MATERIAL FOR 5' AROUND AND UNDER LEACHING TEST HOLE 1 ACCORDING TO PUMPER RECORDS THIS IS AN IS TO BE CLEAN GRANULAR SAND MEETING SPECIFICATIONS OF 310 CMR 15.255(3). OLD 1000 GALLON TANK. TANK APPEARS 5l 50 7 13. PUMP AND FILL ANY EXISTING CESSPOOLS. REMOVE ANY CLOGGED SOIL, BLOCK, AND STONE IN TO BE PARTLY UNDER DECK. COVER SHOWN sL� 5�,�, � O LEACH AREA, AND DISPOSE OF AS DIRECTED BY HEALTH AGENT. DEPTH (inches) ELEV.(feet)ayer 10yr 3/2 0 50.8 AT END COULD BEE CENTER OF TANK. - / 14. ALL CONSTRUCTION TO MEET TITLE 5 AND LOCAL REGULATIONS. A l loamy sand TEST HOLE DATE: May 21, 2003 12" 4 51 , NO GRADE CHANGES PERFORMED BY: Ron Cadillac, Soil Evaluator ARE PROPOSED 50 525184 WITNESSED BY: Sam White, Inspector B layer 10yr 5/8 5-�- Cv -�`V rn 2 c� PERC RATE: <2'-00"/inch (C layer) sandy loam / LC) 53.65± SOIL SURVEY(1993): Barn.-Plym-Nantucket Complex 32" cV EL J Top Found. GEOLOGIC MAP(1986): Sandwich moraine deposits 48.1 �z j ; v� 11,_A a� C layer 10yr 6/6 \ pR1 �� V Invert 49.66E "a Use Gas Baffle 3 DRY WELLS 60 loamy med. sand \ Invert 48.00 2 �\`)� Proposed o b a _ _ _ _ 48.6=Top Conc. 7 S-1/4"/ft 48.3=Top Peastone 0 Z \ ,e) N ting I 00 I. \ W 1 I- - - - - -- -- 24" 135" no water 39.6 0 U7 \\ \ Invert 48.17 Invert 47.80 45.8 O Cy' \\ 6 Stone or Compact Proposed Proposed 6.2' Bottom N Z \\ I I I N I 9' I 72 ,� \ I I rn I 9' Bottom TH1=39.6 W \ DESIGN DATA Cv , S 52.8 � _ NF n BEDROOMS: 4 / 4,0 2 4' 2 _.:.::: - GARBAGE GRINDER: No LEACH AREA RICE REQUIRED CAPACITY: 440 GPD x 52.5 ,_ EXISTING SEPTIC TANK: 1000 GAL. USE 3-500 GALLON DRY WELLS WITH 65� = BOTTOM LEACHING AREA: 435.5 SF APPROXIMATELY 4' OF STONE ALL AROUND TO MAKE A 33 1/2' X 13' x [(33.5' X 13')] X 2' DEEP LEACH AREA. CP 54.9 SIDE LEACHING AREA: 186 SF N -, - 53on [2(13'+ 33.5') X 2' DEEP)] �" - --- DESIGN CAPACITY: 459 GPD 56 56 56.0 [(435.5 SF + 186 SF) X .74 GPD/SF] - LOT 14 3 E(2 H MARK--TOP OF SPIKE SET i� GROUND= 53.00 GIS± 0.5' 0) OFF FRONT CORNER.3C-r OFF REAR CORNER) N 9 BENCH MARK--S.W. CORNER OF q�h N CONC. BULKHEAD=53.63 GIS± 0.5' ,`4q. rye 5 SITE PLAN FOR THIS PLAN IS A VALID COPY ONLY IF IT BEARS ELLEN H . KOOPMAN AN ORIGINAL RED STAMP AND SIGNATURE. N/F Ass HINCKLEY �jHOFrvj,4 a OFr1. LOT 14, 112 GOVERNOR'S WAY, BARNSTABLE, MA IC LEGEND 8° 90. �NALD )NALD <n WS MAY 219 2003 SCALE. 1 "=20' TH 1 TEST HOLE LOCATION, NUMBER C'AD A W/ WATER LINE MARKINGS F- OVERHEAD ELECTRIC WIRES (IF SHOWN) S 1 - -- GAS LINE MARKINGS SIN rA� .. RONALD J. CADILLAC, PLS, RS x &7 EXISTING & PROPOSED ELEVATIONS ('X' MARKS POINT) I �j PROFESSIONAL LAND SURVEYOR & REGISTERED SANITARIAN ,, -6_` EXISTING CONTOUR P.O. BOX 258 e- PROPOSED CONTOUR U WEST YARMOUTH, MA 02673 UTILITY POLE (IF SHOWN) ® EXISTING DRAINAGE CATCH BASIN HEALTH AGENT APPROVAL DATE (508) 775-9700 STONEWALL (NOT ALL SHOWN) PAGE 1 OF 1 C 2003 BY R.J. CADILLAC