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HomeMy WebLinkAbout0064 HAMSTEAD LANE - Health 64 Hamstead Lane Barnstable A= 349-029Lf k i tl o 6 i Y � I o �k n A Y a I i I� !} o � o i 3 1 o r C6rTIM6hWealth of Massachusetts Title 5 Official Inspection Form Subsuiface Sewage Disposal System Form -Not for Voluntary Assessments F 6 64 Hamstead Ln. - Property Address , „ _ r Gail Capen Owner Owner's Name information is required for every Cummaguid MA G2637 4-4-13_ T page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any Way.Please see completeness checklist at the end of the form. Important rm, filling A ,General Information a�unliluuuu o m n the coputer, � IH OF flgSS/ `_� ,......,., yC� use only the tali 1. Inspector. key move your . = :' DAMES 'm cursor do not _ .lames D. Sears use the return. =0: $-E Q R 4 key. Name of Inspector CapewideEnterprises,LLC ��;°FRT,F��°sod Q Company Name i 5 INS? 153 Commercial St. _ �����u�Ilulltl�ut«�° Company Address Mashpee _ MA 02649 City(Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 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 maintervance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 16.340 of Title 6(310 CMR 16.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 4-8-13 ector'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. I Gins 3N3 Title 5 Official I�peclUn Form:Subsurface Sewage Disposal System•Page f of 17 Apr 09 13 11:41 p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 64 Hamstead Ln. Property Address Gail Capen Owner Owner's Name information is required for every Cummaguid MA 02637 4-4-13 page. CityFrown State Zip Code Date of Inspection B. Certification (cunt.) 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. Check the box for"yes', "no"or"not determined"(Y, N, ND)for the following statements. If"not determined,"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5irs-3f13 Title 5 Official inspectioi Four.Subsurface Sewage Disposal System Page2 of 17 Apr 091.311:42p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i1 64 Hamstead Ln. Property Address Gail Capen Owner Owner's Name information is required for every Cummaquid MA 02637 4-4-13 page. Cityllrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalarms are repaired. 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑'N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 i ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t51ns•3/13 Td.e 5Official fnspeclion Form:Subsurface Sewage Disposal System•Page 3 of 17 Apr 0913 11:42p p.4 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . / 64 Hamstead Ln. Property Address Gait Capen Owner Owner's Name information is Cumma uid MA 02637 4-4-13 required for every q page. Cityrrown State Zip Code Date of Inspection B. Certification (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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 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 lei is less than 6"below invert or available volume is less than%day flow Er�ciyj�yG' t5ins•3113 Title 5 Official Inspection Form:Subsurtace Sewage Disposal System-PRO 4 of 17 Apr 09 13 11:42p p.5 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 64 Hamstead Ln. Property Address Gail Capen Owner Owner's Name information is required for every Cummaquid MA 02637 4-4-13 page. Cityrrown State Zip Code Date of Inspection B. Certification (tong) Yes No 0 ® Required pumping more than 4 times in the last year NOTdue 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 20009pd- 10,000gpd. ❑ ® 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. For large systems,,you must indicate either"yes"or"no"to each of the following, in addition to the . questions in Section D. Yes No ❑. ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection r 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. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Apr 09 13 11:43p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form i 'e Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Hamstead Ln. Property Address Gail Capen Owner Owner's Name information is required for every Cummaquid MA 02637 4-4-13 page. Cityrrown State Zip Code Date of Inspedion C. Checklist Check if the following have been done.You must indicate'yes"or"no"as to each of the following: Yes No ❑ Z 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? ® El available 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 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 El ® approximation of distance is unacceptable)1310 CMR 15.302(5)] D. System Information J Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 15ins•3113 Ttle 5 Official Inspection Form:Subsudace Sewage Disposal System.Page 6 of 17 Apr 09 13 11:43p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Hamstead Ln. Property Address Gail Capen Owner Owner's Name information is Cumma uid MA 02637 4 4-13 required for every 4 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal tank two D Box s, one pit and a field. Number of current residents` 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ .Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2011-40,00QGaIs 2012-35,000GaI s Detail: Sump pump? ❑ Yes ® No Last date of occupancy. Present p Hate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(go) Basis of design flow(seatstpersonsfsq.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: t5ins-3113 _ TAle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 or 17 Apr 09 13 11:43p p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Hamstead Ln. Property Address Gail Capen Owner Owners Name requinform r on is Cummaguid MA 02637 4-4-13 requiredd for every page Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: NA 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/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-W13 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 8 of 17 Apr 0913 11:44p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Hamstead Ln. Property Address Gail Capen Owner Owners Marne information is required for every Cummaguid MA 02637 4-4-13 required page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank and pit na, D Box's and field 1997 permit# 97-631 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ' , Depth below grade: 28"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.): Pipeing is 4" PVC SCH 40 Septic Tank(locate on site plan): Depth below grade: 20" 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 certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast Sludge depth: 3" rsins-3/13 Title 5 OfiJal Inspection Form:Subsurface Se.vage Disposal System•Page 9 of 17 Apr 09 1.3 11:44p p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 64 Hamstead Ln. Property Address Gail Capen Owner Owner's Name information is required for every Cummaquid MA 02637 4-4-13 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 27" . 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 16 How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and outlet cover at 20" below grade w/outlet tee. No sign of leakage or overloading. Tank to be maint pumped after inspection. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspeafon Fonn:Subsurface Sewage Disposal System-Page 10 of 17 Apr 0913 11:44p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Systern Form- Not for Voluntary Assessments 64 Hamstead Ln. Property Address Gail Capen Owner Owner's Name information is Cumma uid MA 02637 4-4-13 required for every q page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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): 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.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins'•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Apr 09 13 11:45p p.12 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Hamstead Ln. Property Address Gail Capen Owner Owner's Name inforrnrequir dfo is Cumma uid MA 02637 4-4-13 requiredforevery q page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Two D Box's, both 16"x16", Both have two outlets. Both boxes are clean and solid. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Itins•3!'3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Apr 0913 11:45p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 64 Hamstead Ln. Property Address Gail Capen -- Owner Owners Name information is required for every Cummaguid MA 02637 4-4-13 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ' ❑ leaching chambers number: ❑ leaching galleries number. ❑ leaching trenches number, length: -- leaching fields number, dimensions: 33'x2.5'x2' ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is one old precast pit. Pit at 30" below grade w/2'water. Newer field 1997, 33'x2.5'x2'camera out. No sign of over loading or solid carry over w/vent. 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 t5ins•3113 Title 5 OPlida'Inspection Farm:Subsurface Sewage Disposal System.Page 13 of 17 Apr 09 13 11:45p p.14 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Hamstead Ln_ Property Address Gail Capen Owner Owner's Name informationis requiredairedfor every Cummaguid MA 02637 4-4-13 for page Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•3113 Title 5 official Inspection Fwm:Subsurface Sewage Disposal Syslem•Page 14 of 17 Apr 091311:46p p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Hamstead Ln. Property Address Gail Capen Owner Owner s Name information is a Cumm uid MA 02637 4-4-13 required for every q page: Cityrrown State Zip Code Date of Impection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks_ Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately j 15ins•303 Tide 5 Official Inspection Forth:subwrface savage Disposal system-Page 15of 17 Apr 09 13 11:46p p.16 Aor. S. 2013 1 : 16PM No. �j1 19 1P. 21 of 2 Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map SIM . Zoom R P d JAR if,. Fn I i 5`3 33 y 3 9y �7 o 420 F Set scale 1" = 20 Aerial Photos -? MAP DISCLAIMER f:nn...t..{.19MCARtA TnWm rd RamcoNe A�4 011 r:nhlc rccanu http://6d.203.95.236/ucims/appgeoapp/map.aspx?propertyID=349029&mappacback= 311.112011 Apr 09 13 11:46p p.17 Commonwealth of Massachusetts 4 Title 5 Official Inspection Form- a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 64 Hamstead Ln. Property Address Gail Capen Owner Owner's Name information is required for every Cummaguid MA 02637 4-4-13 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ti ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth t p cf�igh ground water: feet 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 butting propert /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 Well AM 247 at 23'Zone B =2'ADJ You must describe how you established the high ground water elevation: Lot and area high. USGH Well AIW 247 23' Zone B=2'ADJ. ADJ High G.W. at 21'. Bottom of Leaching at 5'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 151ns-ail Ti:19 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 17 Apr 09 13 11:47p p.18 y i Commonwealth of Massachusetts Title 5 Official Inspection Form F a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments k 64 Hamstead Ln. Property Address Gail Capen Owner Owners Name information is reequiredquired for every Cummaguid MA 02637 4-4-13 page. CRYrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C. D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information —Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ir.s•3113 Tile 5 Ofiicis'Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 TitleCommonwealth of Massachusetts LHEALTHDAEPT. ,. Official Inspection Form 6Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 64 Hamstead Lane Property Address �� z Gail Ca end Owner Owner's Name ° information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. , Important: When filling out A. General Information forms on the computer, use 1. Inspector: only the tab key to move your Robert Paolini cursor-do not,use the-return Name of Inspector key. Capewide Enterprises,LLC. Company Name P.O.Box 763 Company Address Centerville Ma. 02632 City/Town State Zip Code (5.08)477-8877 S14454 Telephone Number License NumberJ CD y B. Certification 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 ma htenance of on to sewage disposal systems. I am a DEP approved system inspector pursuant to Section 1.5:340 of; Title (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority F 1 d 3/10/2011 Inspe is S ildnatur Date r 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 gp'd 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. IOld t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 r' - f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: The septic system is in proper working order at the present time. 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ^M 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if (with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N FIND (Explain below): 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 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 1/2 day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOTdue 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is Cummi uid Ma. 02637 3/10/2011 required for q every page. City/Town State Zip Code Date of Inspection C. Checklist 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 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: ❑ ® 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is q required for Cummi uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 3/10/2011 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: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name. information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Measured Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2811 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line. 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the leach trench vents. Septic Tank(locate on site plan): Depth below grade: 18 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 certificate) ❑ Yes ❑ No Dimensions: 1000 gallon 411 Sludge depth: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments °M 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" 3" Scum thickness Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 11" How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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): 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.): " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert No 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.): System has two D-Boxes.Replaced and relocated first box.Both boxes are Ievel.Both have two outlet Iaterals.No evidence of Ieakage.No evidence of solids carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is required for Cummiq uid Ma. 02637 3/10/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 2/33'x2'x2.5' ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Sandy soil.No signs of hydraulic failure.Leaching pit water level was 3' below invert.Leaching trenches were dry. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 64 Hamstead Lane M Property Address Gail Capen Owner Owner's Name information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Map {4 j Page 1 of 2 Town of Barnstable Geographic Information System Parcel Viewer F Custom Map Abutters Map Size zoom out fl E E E I E D®In yK b , Fr� r+, 9 - 3 9 q 37 y 11�1 Io5 a pi y" x 000 .I I, I rRIu � °'h gin, hn<i�'• a. ' �,. � �" . l .. ir h 9 P v a t'. LL fal'i lwpg t, '. 2 Feet one„ gl� l � v �Ial�Ihi ,:t Set Scale 1" = 20 1 I Aerial Photos ', I MAP DISCLAIMER ('.nn—inht 9f)nF_901f1 Tn%Ain of Rnrnetnhin RAA All rinhte rocnni. I� http://66.203.95.236/arcims/appgeoapp/map.aspK?propertyID=349029&mapparback= 3/11/2011 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 10 64 Hamstead Lane Property Address Gail Capen Owner Owner's Name information is required for Cummiq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: Bottom of Leaching 55' feet 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: As-Built EJ Checked with local excavators installers - attach documentation ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: USED:USGS Observation Well Data.USED:Technical Bulletin 92-0001 plate #2 annual ranges of groundwater elevations. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 64 Hamstead Lane M Property Address Gail Capen Owner Owner's Name information is required for Cummlq uid Ma. 02637 3/10/2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION WeAns-TC-Ri) L44i SEWAGE# VILLAGE ASSESSOR'S MAP.&PARCEL 3N4 ©'tq INSTALLER'S NAME&PHONE No. .tnsee'J."r G B it e-- SEPTIC TANK CAPACITY i 0®© J rn L LEACHING FACILITY. (type) L P. P,,A VeAA&14 ) (size) NO.OF BEDROOMS OWNER PERMIT DATE: 3 It COMPLIANCE DATE: ' to Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 5 j Feet Private Water Supply Well and Leaching Facility(If any wells exist orr 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 LApzw,'Je &-)bk-rPgi"e> LCC i 5 33 No. 6L4,57 Fee THE COMMONWEALTH OF MASSACHUSETTS Enfered in computer: . PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppliLation for Disposal 6pstrm Construction 3permlt Application for a Permit to Construct( ) Repair(() Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location A dress or L No. 6,4 4Afn Sre-% A L4,r.e, Owner's Name,Address,and Tel.No.�+�; L C Assessor's ap/Par ed 1 S �°l Installer's tName,Address,and Tel.NoC4,.`,6_ �1LS Designer's Name,Address,and Tel.No. �5 LoMN�cf4i/y� sq 1 Type of Building:Dwelling No.of Bedrooms Lot Size 6 91 4 sq.ft. Garbage,Grinder( ) Other Type of Building ;\A o rc No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) _ 591n,66 ce_ ce 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 Certificate of Compliance has been issued by this Board of He Signed C Date " Application Approved by 1Y . Date Application Disapproved by Date for the following reasons Permit No. (t ' Date Issued ��� No. ��-�_J� Fee I DO _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION = TOWN OF BARNSTABL°E,,MASSACHUSETTS, - Yes .I ', 4pritation forilDisposai *pstern Construction Permit Application for a Permit to Construct( ) Repair(K) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components i Location Address or L t No. �� I-�A�►1 Sc 2A (�� Owner's Name,Address,and Tel.No.(!A.,L C 4 Assessor's4K1ap/IAcel Q a S,AtiMe Installer's Name,Address,and Tel.No Kr�✓ )LS Designer's Name,Address,and Tel.No. u Type of Building: Dwelling No.of Bedrooms Lot Size (0 Z�; f:sq.ft. Garbage Grinder( ) Otlier Type of Building n No.of Persons Showers( ) Cafeteria( ) i Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. , " Description of Soil Nature of Repairs or Alterations(Answer when applicable) P &�e_ 5V4,6& ' p �yC Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in 1 . accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Hea • . Signed Date ' (0 Application Approved by L ff" Date I � Application Disapproved by Date j for the following reasons Permit No. Date Issued —JD THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance i THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by at '6-W has been constructed in accordance 1 . , 7 with the provisions of Title 5 and the for Pisposal System Construction Permit No.2 0//-0 dated /J1 -// i Installer r Designer n #bedrooms Approved design flow /,l r' gpd .The issuance of this prit hall.not be construed as a guarantee that the system will no n, design . Date Inspector ,✓+` ' No. �3 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION—BARNSTABLE,MASSACHUSETTS Misposai *pstrm Construction Permit Permission is hereby granted to Construct( ) Repair(�/) Upgrade( ) Abandon( ) System located at '.✓kt i and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. i Provided:Construction must be completed within three years of the date of this permit. C Date Approved by JL�(\,Y ►\ ��. (?'ice Commonwealth of Massachusetts VV Executive Office of Environi ental airs Dept. of Environmental Pr-otecti EtVED M� S PIN .John Grad One winter Street,Boston,Ma. 0210:8i 2 1997 D. . Title V Septic h><spector 70WN a"' P.O. Box 2119 ij q p=O S, HrAtr►fo� Teaticket,MA 02536 WILLIAM F.WELD Aa (508) 564-6813 Governor u ARGEO PAUL CELLUCCI Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 64 Hamstead Lane Cummaquid Heights Address of Owner: . Date of Inspection:8120/97 (If different) Name of Inspector:John Graci Velleco:Box 204 Cummaquid Heights Ma.02637 1 am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes This inspection is based on criteria defined in Title V Conditional Pa e5 code 310 CMR 15.303.My findings are of how the system is performing at the time of the inspection.My inspection does _ NeedsFu er aluation By the Local Approving Authority not Imply any warranty or guarantee of the longevity of the X Fails septic system and any of its components useful life. i Inspector's Signature: Date: 8124197 r The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: Check A, B,C, or D: A] SYSTEM PASSES: _I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion, of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If "not determined", explain why not.. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection-,or the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/27197). One Winter Street 9 Boston,Massachusetts 02108 • FAX(617)556-1049 9 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 84 Hamstead Lane Cummaquid Heights Owner: Velleco:Box 204 Cummaquid Heights Ma.02637 Date of Inspection:8/20/97 _ Sew,aae backup or.breakout.or hiah.static water level observed.in.the distrihution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced _The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 feet to a surface of water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for col•Iform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: _ I have determined.that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No —X-- Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded of clogged cesspool. SAS is in hydraulic failure. (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 64 Hamstead Lane Cummaquid Heights Owner: Velleco:Box 204 Cummaquid Heights Ma.02637 Date of Inspection:8/20/97 D] SYSTEM FAILS(continued) Yes No X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped x Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. —X• Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _C Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No X the system is within 400 feet of a surface drinking water supply x the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04127/97) I - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 64 Hamstead Lane Cummaquid Heights Owner: Velleco:Box 204 Cummaquid Heights Me.02637 Date of inspection:8/20/97 Check if the following have been done:You must indicate either"Yes" or"No"as to each of the following: — Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined. Note if they are not available with N/A: X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. " X The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected — — for condition of baffles or tees,material of construction,dimensions, depth.of liquid, depth of sludge, depth of scum. X The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. x — Existing information. Ex. Plan at B.O.H. Determined in the field('If any failure criteria related to Part C is at issue,approximation of distance is X unacceptable)115.302(3)(b)j + (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Add ress: 64 Hamstead Lane Cummaquid Heights P Y Owner: Velleco:Box 204 Cummaquid Heights Ma.02637 Date of Inspection:820/97 FLOW CONDITIONS RESIDENTIAL: d./bedroom for S.A.S. Design flow: 330 g.p Number of bedrooms: 3 Number of current residents: 2 Garbage grinder(yes or no): Yes Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No last two 2 year usage d Water meter readings,if available:(as ( )Y 9 (gP ): Sump Pump(yes or no): No Last date of occupancy: n1a COMM ERCIAUINDUSTRIAL: Type of establishment: n/a Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present: (yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n/a Last date of occupancy: nle OTHER: (Describe) n/a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System was last pumped 1 month&ago by Robinson Tank only System pumped as part of inspection:(yes or no)No If yes,volume pumped: 0 gallons Reason for pumping: nla TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy ' Shared system(yes or no) (if yes,attach previous inspection records,if any) I/A Technology etc. Copy of up to date contract? J Other: APPROXIMATE AGE of all components,date installed(if known)and source information: 13 years Sewage odors detected when arriving at the site:(yes or no) No (revised 0427/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 Hamstead Lane Cummaquid Heights Owner: Velleco:Box 204 Cummaquid Heights Mo.02637 Date of Inspection:8/20/97 SEPTIC TANK: X (locate on site plan) Depth below grade: 2'4' Material of construction:X concreate_metal_FRP_Polyethylene_other(explain) If tank is metal, list age . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L B'6'H 5'7'W 4'10' Sludge depth:0 Distance from top of sludge to bottom of outlet tee or baffle: 0 Scum thickness:0 Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: 0 How dimensions were determined: Measured r Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: We Material of construction: _concrete_metal_FRP_Polyethylene—other(explain) Dimensions: We Scum thickness:n/a Distance from top of scum to top of outlet tee or baffle:We Distance from bottom of scum to bottom of outlet tee or baffle: No Date of last pumping,/, Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) n/a BUILDING SEWER: (Locate on site plan) Depth below grade: 3' Material of construction:_cast iron X 40 PVC_other(explain) Distance from private water supply well or suction line?o- Diameter: 4* l�/amrnents: (conditions of joints,venting, evidence of leakage,etc.) (revised 04/27/97) t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 64 Hamstead Lane Cummaquid Heights Owner: Velleco:Box 204 Cummaquid Heights Me.02637 Date of Inspection:8/20/97 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: We Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: n1a Capacity: nla gallons Design flow: We gallons/day Alarm level:_nta Alarm In working order?_Yes_No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) We DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box etc.) We PUMP CHAMBER: (locate on site plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) nla (revised 04127/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 64 Hamstead Lane Cummaquid Heights Owner: Velleco:Box 204 Cummaquid Heights Me.02637 Date of Inspection:8/20/97 SOIL ABSORPTION SYSTEM (SAS):X (locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present,explain: n/e Type: leaching pits,number: 1,000 Gallon leach pit leaching chambers,number:n/a leaching galleries, number: nla leaching trenches,number,length: n/a leaching fields, number,dimensions:n/a overflow cesspool,number:n/a Alternate system: n/a Name of Technology:_n/a Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.) The leach pit is past the effective depth of leaching The sas is in hydraulic failure. CESSPOOLS:_ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: nia Dimensions of cesspool: n/a Materials of construction: n/a Indication of groundwater: n/a inflow(cesspool must be.pumped as part of inspection) n/a Comments:(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.) nla PRIVY:_ (locate on site plan) Materials of construction: nra Dimensions: n/a Depth of solids: We Comments:(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) n/a (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 64 Hamsteed Lane Cummaquid Heights Velleco:Box 204 Cummaquid Heights Ma.02637 620/97 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) b44 MA AC �ot II V'c F� (revised 04/27/97) page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 64 Hamstead Lane Cummaquid Heights Velleco:Box 204 Cummaquid Heights Ma.0207 8/20/97 Depth of groundwater 12, Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (MUST be completed) USGS Maps and Charts f . w (raised 04/27197) rage 10 of 10 6 T TOWN OF BARNSTABLE . 0 LC?C .TION A 2± SEWAGE # - VILLAGE e/ ASSESSOR'S MAP& LOT3 " CO 9 INSTALLER'S NAME&PHONE NO. ]Ma 1?f0`LJ SEPTIC TANK CAPACITY cZI LEACHING FACILITY: (type) L L a"AJCIV:S (size) a4- 3.3yC NO.OF BEDROOMS :3 BUILDER OR OWNER - C 6 PERMITDATE: f0 -3 I 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) Cd Bt® Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leac ing�ty) 1VON-e— Feet Furnished by A A C , 57 RS P I� 2_33 x �` �" �k Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Miopogar 6potem Construction permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components boon Address or Lot o. 4 o Owner's N��ess and Tel.No. As essor's Map/Parcel — 2 Lit' l6/ Cs�lacP� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. S ig M00 a.zGv Type of Building: Dwelling No.of Bedrooms Lot Size V2 ArA"sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 7 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1600 Type of S.A.S. Description of Soil Nature of Repai or Alterations Answer when applicable) 3 X ;�L•a� 2 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 f Tit 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issu d by i oard ea f� Signed A Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued w No. K/ z Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS application for Df5pool *pg;tem Cowaructfon permit Application for a Permit to Construct( )Repair(�Upgrade( ')Abandon( ) El Complete System 1:1 Individual Components Ron Address or Lo o._ o Ow�is N� ress and Tel.No. M or's ap/Pazcet .�� (/ r Installer's`Name,Address,and Tel.No. Designer's Name,Address and Tel.No. S ,2G TO Type of Building: Dwelling- No.of Bedrooms Lot Size q.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 3(_3 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title 4e �. Size of Septic Tank /U0Co 04X Type of S.A.S. Description of Soil Natureof Repai or Alterations Answer when applicable) ft�fGlC d�-` 33 X ;'+� Date last inspected: Agreement: The undersigned agrees to &ethn,enstruction and maintenance of the afore described on-site sewage disposal system in accordance with the provisionsf the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issuoard al Signedie--- Date Al �� Application Approved by m Date Application Disapproved for the following reasons 7 t� Permit No. Date Issued --------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( ) Repaired (;. Upgraded( ) Abandoned( )by Aowmo at ha b constructed in accordance with the provasiotM of Title 5 and the for Disposal System Construction Permit No. "' �Jjdated Installer . c lole,�Z� Designer The issuance of this permit shall not be construed as a guarantee that the sys will s 'o as designed'. Date /U ' 3 1' `7 Inspector ———————————-——————————————————————————— No. Y7 Fee (� — THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Df 5po.5ar *pztem Congtructfon Permit Permission is hereby gr tte Con tract( Repai K)U rade( )Abandon( ) System located at (17 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:Constructio /must be om/ ted within three years of the date of th'�/ermit. /J 0 A Date: i Approved byi' �T.l...� cry l f r J ' I0/9197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated :/y-- ��_ 7 ,concerning the property located at Co meets all of the following criteria: There are no wetlands located within 100 feet of the proposed leaching-facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will u!2 be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) S B)Observed Groundwater Table Elevation(according to Health Division well map) DATE: o - 3(77 SIGNED: LICENSED SEPTI LYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert � - 33sc2 x zC Z—. -� Tic TOWN OF BARNSTABLE LOC`:ATIOI �v /► S-E SEWAGE # VILLAGE c/ ASSESSOR'S MAP & LOT.' s Q INSTALLER'S NAME&PHONE N0. SEPTIC TANK CAPACITY l y 52 ilk"RING FACILITY: (type) L l k t ql w (size) .2- 33 K 2 u Ilk- NO.OF BEDROOMS 3 Bt kbER OR OWNER ���Ge' ZS FERMTTDATE: /0 -31- COMPLIANCE DATE: Separation Distance Between the: M0jin Adjusted Groundwater Table and Bottom of Leaching Facility �-�t Feet Priv4te Water Supply Well and Leaching Facility (If any wells exist :::on;site or within 200 feet of leaching facility) 7r., Cd K/ Feet Edge:of Wetland and Leaching Facility(If any wetlands exist -within 300 feet o leaching facility .� y4/Il Feet Furnished by . A A - c = S7 g of U C (q tr3G 33 x D.k a.S SZ i 1 e,4 c4 T2 ely-I-< T L"�CLI,TIOt�1 ` �,� 1 SEWOC�,E PER 1.10. �iwS`T LL R•S 1JLNAE ADDR-E,�S ',Z �UILD R 5 Q O,AAE bADDRESS Dt►tt PERNAIT 155UE® : --43 I I�T�E. '"G0 M P L I &Iv C E I SS U�E.D : �d:r 4r F� ' t A FEic........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............OF Allpfiration for Uhiposal Workii Tomitrurtion Frrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal System at: . .....................................16.1.................................................. Location-Address or Lot No. ..... .. ..... . .................. ........................• '�d­d'r,es's------­---------------*---—-------------- .......... ....... ................................................................................................. .......... ................. ............... Installer Address Type of Building Size Lot....6....../ r................Sq. feet U Dwelling—No. of Bedrooms__________ .............................Expansion Attic Garbage Grinder 04 Other—Type of Building ............................ No. of persons............................ Showers Cafeteria Otherfixtures ....................................................................................................................................................... Design Flow............5�5......................gallons per person per day. Total daily flow............3 ..®_.__._._____.._.._gallons. gallons. 1:4 Septic Tank—Liquid capacity./ flons Length... ...... Width......It....... Diameter________________ Depth___-:.._..._. Disposal Trench—No..................... Width....._.__._.._..._.. Total Length_.____...___._..____ Total leaching area-----_-_--------sq. f t. > Seepage Pit No........ ....... Diameter­/.Ok5... Depth below inlet___._ Total leaching area504t./.-.,jqr4t.6-P,L>, Z Other Distribution box Dosing tank ..... ............Percolation Test Results Performed by.4A2��... ...W4— Test Pit No. I.__*40'......minutesperinch Depth of Test Pit... Depth to ground water�Y-'7' ----------------rZ, Test Pit No. 2_­3......minutesper inch Depth of Test Pit... Depth to ground water.��e�?A 7&?Ze7> 04 ................................................4........................................................................................................... 0 Description of Soil-------------------! �......... ........................................................................................................... U ..........................................................................................................................................71............................................................ ............­­....................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable----- .......................................................................................... .............................................................................................................................................................I.,........................................ Agreement: The undersigned agrees to install the aforedescribed, Individual Sewage Disposal System in accordance with the provisions of TL I TL 1Zj 5 of the State Sanitary The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha ..board of health. Si ........... ............................ ........... ............. ----- ---------- ApplicationApproved By . ...... ...... ... .. .................... ...................................... -------- Date Application Disapproved f o'I following reasons:............................................................................................................. ............................... ........................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date ------------------------------------------------ �_ �I NO. r. :.v FEs... �, .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ .N...............OF...........�.: ) '>ti1 '9""f L- Z.................... Appliration for Diipo,ittl Workii Tonfitrnrtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ... : b...'4A- 4...r�"D.P/��a ......2 - --------------------------------------1L-I-................................................. or {+' Location-Address ................................................... .................................Lot ... Owner Address W Installer Address d Type of Building Size Lot....o--/T__�'`�2G?__Sq. feet U Dwelling—No. of Bedrooms___...__._*................................Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ______-_..•___-•------_--_.- No. of persons............................ Showers ( ) — Cafeteria ( ) n" Other fixtures .--•-••........ ••-••---•-•---•-...•-• • . . W 0.....................gallons per person per day. Total daily flow._._.....___3'_.��.0..........__...___gallons. Design Flow_..._._..._� WSeptic Tank—Liquid capacity_/t�.Q_4kalIons Length-_te.!..... Width--___4-._'.... Diameter................ Depth...4!...... ,y Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area;_...................sq. ft. Seepage Pit No--------I............ Diameter..!!?t_,5._'. Depth below inlet..... ._ ....... Total leaching area5,Z4$-,./._sq_f4.6*P, Z Other Distribution box ( Dosing tank ( ) '-' Percolation Test Results Performed by-L P Aq. q' _.1�? 4r -± .....1: -�._ Date.... .......... a minutes er inch Depth of Test Pit-- . '0 Depth to ground waterr�Z-..._e,tV .. Test Pit No.-I•.�.�"'..._._ P P �/='�'"�----•• P f= Test Pit No. 2____ ......minutes per inch Depth of Test Pit.../('R":::-.Depth to ground water.0-001".7 2.es> O Description of Soil...................,►"`_. ......... ..._...._ A 1 Nature of Repairs or Alterativ3ns irnao h b�� _.•.__ --------••----------------------------------------•-----•-••-•-- ---------------------------------------------------•----._...-----------•--.....----•-.....------...-•--•-......-----------•....------------•--•-----------------------------•••--••......------•----•-- a.• Agreement: , . �... . . The undersigned agrees to install the aforedescribed Individual'Sewage Disposal System in accordance with the provisions of i ITLE 5 of the State Sanitary Y94o— The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha e board of health. Si .......:. : :....... Dat Applicati PPr: _ ...--•-• ----••.:.....:..............:... Lr,_..._l,d'..... Date Application Disapproved for following reasons-..............................:`................----------.............-.....................i................... , . Date PermitNo.................=..................................•--- Issued._..._..-•--------••----...---•--... ....... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...................................................................................... (Irrtif iratr of Toutplittnre T I� TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by...... 1J- ..._•--•---_... ....... ......... ---- ......... -•--•-----------------........................... Installe at..... 4.!/ �8c + x .... fr' ----------- ••... .-- has been installed in accordance with' ie provisions of TI F 5 )f4�h St e Sanitary Code s ff i d in the application for Disposal Works Const uction Permit No.... .. ......... ....... dated_.�� .. .>. <'d" . ............... - -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO STRUED AS A G ARA�TEE THAT THE SYSTEM WILL FUNCTION SATISF CT RY DATE ... = Inspector...............W--------------•------------------•-----_--••------•-•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...........................................OF...................................................................................... N .................. FEE... ............. Map Workii (9unotrttrtion rrmit Perm ss' hereby granted i - --------------------------------------------------.....................___-..... to Const "�1/or e it n ege sposal System Street �. as shown on the application for Dispos Works Constructio P. ' µ ..................... Dated.......................................... /_^ �� % Board of Health DATE..................... ....... •- - .................................. ! FORM. 1255 A. M. SULKIN, INC., BOSTON PV Fee— BOARD OF HEALTH TOWN OF BARNSTABLE Application-forlVerr Con5truction3permit Appli ation is hereby made for a permit to Construct (Alter ( ), or Repair ( )an individual Well at: Location — ddress� / Assessors Map and Parcel +'= �=! t - —_ 1<�l.e�4! �S✓ -----------------—-------- — -- — Owner A—ddress v In aller — Driller -- Address -- _ Type of Building t; Dwelling Other - Type of Building--- ' fT ------- No. of Persons------------------------------------ Type of Well— - --`---- `—�-- — —-------- — Capacity- -- - -— — ------- — - Purpose of Well---- - ---- ,/- �`j --------- / Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation unt' a Certificate of Compliance has been issued by the Board of Health. ! A Signed date Application Approved By ------------------------------ ---- date Application Disapproved for the following reasons:-----------------------------------------------=-------- _--_ _ — --_---__-- --------------_ date — — Issued--- - —-- Permit No.--____-----------____-- _ --- -- date BOARD OF HEALTH TOWN OF -BARNSTABLE Certificate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed Altered ( ), or Repaired ( ) '--- ------- --------------------------------------------------------------------------—-------------------------------- bY- - - Installer at- -- - — ---- ------------—-----------------------__----- ---—-- -has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. LO1-,-=27—Dated--------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE ------------ Inspector— Noj- -=-- -- Fee---a ------ BOARD OF HEALTH TOWN OF BARNSTABLE Appfitation for lVell Con5truct ion Permit Application is hereby made for a permit to Construct ( , Alter ( ), or Repair ( )an individual Well at: LocatioVL ddresi' J T - assessors Map and Parcel 9� t = = a /�- __ Owner - Address�''"`�' k -- -!- ------------------------_-----_- Ins ]ler_ Driller ) ! Address Type of Building Dwelling- - d - Other - Type of Building---- s-15-4------- No. of Persons--------------------------------------- Type of Well_-Zj-__- _ /---------- Capacity------------------------------------ - Purpose of Well----ta---Y� ---- , Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate of Compliance has been issued by the Board of Health. n Signed =.vJ �— - r date �— Application Approved By-v -- - ---- - ----------------------------------- _____ _-- date Application Disapproved for the following reasons:----------------------------------------------------------------________ — ---- --------------------------------------------------------------------------------------------------------------------- — date Permit No.- - -- -- —--- -- ----- Issued------------------------ -— --- — -- date i BOARD OF HEALTH TOWN OF BARNSTABLE C ertif irate ®f Compliance THIS IS TO CERTIFY, That the Individual Well Constructed (�,.�, Altered ( ), or Repaired ( ) by---- '---- r-- --- Installer r at--- ---;r- — ------—-- ----—-has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. Dated--- ----- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE-------------------------------------------------------------------------------------- Inspector--------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Very Con5tructiouPermit No. -� -=� --- Fee---�- �'�'---- Permission is hereby granted--------- OZA -------u-z;_Ju------------------ to Construct (�,a; Alter ( ); or Repair ( ) an Individ i Well at: No. - -_ �'�' � -��- -------------------77 1�, *— v - -- - -- ---— — - Street as shown on the application for a Well Construction Permit No.--------—-- -- --- —----— --- - -- - Dated---__-------------- __--------------- Board of Health DATE —- - -- ---------------------- -- m, -2411DIA. CONCRETE MANHOLE IF, CONCRETE RETA/N/NGWALLSARE SHOWN ON THIS PL AN,THEYSHALL CONE/RMATIONOFCONSTRUCTION INACCORDANCEWITHTH/SPLANISREQU/RED. FRAME AND COVER BROUGHT BE CONSTRUCTED WATERT/GHT,WITHOUT WEEPHOLES OR OTHER PERVIOUS 7_HIS0c_RCF IgLL BENOT/FIED PRIOR TOBACKF/LL OFTHESYSTEMFOROUR&SPECT101V TO FINISH GRADE IS REOU/RED 18"D/A.ACCESS MANHOLE CONSTRUCT/ON -WOULD THE RESERVE AREA BEBUIL TIN ThEFUTURE,IT �- FINISH GRADE MAYREQU/RE THE EXTENS/CaV OF THESE RETAINING WALLS. M III 1/ t i i i i lu II II III 1 n i ul II � 90 11/lllllll I111 I�Ilil ! 111 1 I1 Illt itl - `I 21,1/B 11 TO 4"UNPERFORATED UUPEPRFOEATED N Z //2" j P/PEASHEu"STOP J72LlOUlD LEVEL � II - O _ OOio' 3 314` TO/-//2" 4 Sched.40 -. 'd 2 PVC.P/PE11— _ __G�C1 O O O WASHED STOVE I oaSg8O8000= 4 VC 6 P _ �io SAN. 4„PW Op 000000=� TEE d 8, O„ SAN E �O =:00000 0 0 0 0 _ :0000 0 0 0 0 0 ::000000000 - - - : OPCOC•OCO _� TANK /S 4`l0,"W/DE NZA OUTLETS ' IOOO REQUIRED 12 0" GALLON SEPTIC rAN/< ---I DISTRIBUTION For proper performance,septic tank should be (� BOX GROUND WATER TABL E inspected annually and Wen the total depth of �1 [� T-/1�� scum 8 so/ids exceeds //3 the liquid Depth of SEEPS-1GE/-// H/Y® LINER �0 the twik, the tank should be pumped. /O/ PROF/LE A// topsoil, subsoil and itpoervious moteriaS if any,must be �— excavated 8 removed glow bbe leaching area and to a 061 20 it - 2 ' OF 3/4"70 /-//2`1 distance of 0 feet from all sides of the /eochirg area. WASHED 57LY✓E� Excavate down to 6"below the surface of the natural' , 4 /8" permeable soil. Back fill as required with clean coarse sand '' UNPERRIR4TE0 ACCESS and gravel,fre6 from fines,clay,organic matter and 1 ®t i - -- too PIPE '.MANVLE large boulders. L+ ! _ QQ.Q i REGULATION 2.17 OF TITLE 5 -- �` 39/-- �R,A)' �J I l P/T 1 . . \ / REQUIRED 38' 99 /0 0 SEEPAGE PIT 6 D/A. L INER w16 0, CONC. LINER Lot l l 7 "�'"�•- '- a- / r � 6' deep (267 s.f.l SEE GE PIT AND L/NER 1000 gallon l o�. PROP. TJ' ! I Lot 115 SEPTIC TANK DWELLING N '' / / wl - - PLAN t Ioo.S% _ -98 Note The desgn of this system does not permit the use of garbage c+�+ VNI disposal units. c DESIG11 No , 01::ELEVATION SCHEDULEELEVATIONpermanent structures shall be cansiructed over the reserve area. / TOP OF FOUNDATION 102.00 LEACH/NG ARE4 OES/GN ANALYSIS L=2 .84 FINISHED BASEMENT FLOOR 9 4. 50 UP 12 RECU/RED FIN/SHED GARAGE FLOOR , I01 — 100x40 ED17 - 9x44 Qee 99x4/ of a � — - - -----. X99 PAVElfENr SEWER /NI/ERTAT FOUNDAT/ON - 98. 00 BEDROOMS AT,110_.,GPD18R= - -33Q GPD f t00x42FON /fix 90 99x 49 �x98 50% FOR GARBAGEGR/NDER = GPD f.' ��°° _._ l00x48 99,�60r a' "'. 99x 13a�,-- . „' gex 72 ROAD SE6f/ER INVERT INTO SEPT/C TANK 97. 50 DESIGN: 330 GPD TOTAL EFFLUENT "` -- _ SEWER//VVERTOUT OF SEPTIC TANK 9730 ' �Q� SEWER INVERTINTO D/STR/BUT/ON BOX DESIGN PERC. RATE 2 MIN/INCH g9� BOT SEWER INVERT OUT OF DISTRIBUTION BOX TOM. AREA = 78. 5 SF x 1. 00 = 78.5 GPD S/DEWALL AREA = 188.5 S.F. x 2.50 = 471 GPD SEWER INVERT AT SEEPAGE P/TS 95.50 TOTAL LEACHING ARE4 267 SF W/CAPAC/TY OF 545►GPD S.M. -- Noil in U.P. 13 ELEVATION OF GROUND WATER TABLE not enc. 85. 5 e0ev 10000 assumed SOIL EXAMINATION REPORT EXAMINATION TAKEN BY AL PEARSON A.,PE ON 6//0/9 83 AND WI TNESSED BY JOHN JA COBI BOARD OF HEALTH AGENT TEST PIT NO. — I TEST P/T NO TEST PIT NO.. TEST PIT NO. TEST PIT NO. GROUAID SURFACE EL. /00.0 GROUND SURFACE EL. GROUND SURFACEEL. GROUND SURFACE EL GROUND SURFACE EL O 0 _— 0 0 0 I Loom 8 Subsoil U Permit NP 2030 Fine Silty 2 2 2 REMA RKS 2 REM LEGEND THE SAN/TARP D/S POSAL FAC ILITY.Y H S AL L BE CO NSTRUCTED UCTED/N ACCORDAN CE W/TH THE Sand 49 LOT HAS NOT BEEN STAKED. EX157-IIVG CONTOURS /00 _-l00 REQUIREMENTS OF TITLE= OF THE STATEENVIR NME 0 NTAL CODEANONO VARIAT/CAbS 4 Clay — 4 4 — 4 TYPE OF HOUSE., CAPE PROPOSED CON76URS IOC --- FROM THIS DESIGN SHALL BEALLOWED W1 THOUT PRIOR APPRWAL OF THIS OFFICE. 4.5 4 DUE TO SOIL COA,C/Tl'ONS,WATER TABLEELEVATION AND ACCEPTABLE MAMSPIAL FOUND EXISTING ELEVATION IOOXOO ASSESSORS PLAN N0. CAN VARY AND MUST BE VERIFIED PRIOR rO THE TIME OF CONSTRUCT/ON. PROPOSED ELEVAT/ON /00 E — 6 6 - 6 6 PLOT NO. LOT NO. 116 F/N/SHEDSTJRFACEGRADEFLOW +-- ZONING CLASSIF/CAT10N.• CUSTOM CARPE/Y TRY TEST P/T LOCAT/ON Sand 8 8 8 I CERRFYTHATTHESEWAGED/SR0SAL FACIL/TY SHOWN HEAL-ON HAS BEEN 2 PAUL l/1P d fVE. GAR®CKTON, MASS.. DESIGNED IN A CC 01?D4 NCE WITH REGULATIONS OF THE LOCAL BOARD /o %EALTH/ANO TITLEWOFTHE STATEENVG?CNMENTAL CODE. , /o — Grovel /o /0 OFH SEPT 2, 1983 "'mpg SANMARY"" DISPOSAL SYSMM DATE PROFESSIONAL ENGINEER - Lot ll6 /2 — 12 /2 /2 12 Long Pond Rood E DESIGNED BY. A.F. B. p /4 no water enc. /4 DRAWN BY G. F R. Mars ton ills Barnstable, Moss. /4 s /4 /4 CHECKED BY A.A.P,/J.B.W. x ; 17 - N� MS, /l1/C. o APPROVED BY.•A A.P.//B w HAYWARD BOYAlM W/L L/A PERC. TEST PERC. TEST PERC. TEST PERC. TEST PERC TEST DATE• SEPT.-1, 1983 ENGINEERS SURVEYORS �, TAKEN AT_45-6 FEET TAKEN AT FEET TAKEN AT FEET TAKEN AT FEE-T TAKEN AT SHEET FEET SCALE. ! 40 RATE //NCH RATE_ M/N//NCH RATE_ Mir✓.//NCH RATE= M/N-//NCH RATE_ MIN//NCH fib REVISIONS:/.19128183 /4O SCHOOL CHOOL S l" BROCK rONs IWASS / OF low NMI 7 BR040WAY rAUNrON , MASS. U Oz SDP 784