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HomeMy WebLinkAbout0093 HARRIS MEADOW LANE - Health ., b � Barnstable.8 00 t:* (� �, TOWN OF BA STABLE c,/ LOCATION / 6/L[rro dKI SEWAGE# 261Z — '�Z / VILLAGE v S lvite, ASSESSOR'S MAP&P RCEL 2 7 9 d�� INSTALLER'S NAME&PHONE NO. �D� Y/Iilf /� 14 fej"pcl� SEPTIC TANK CAPACITY ISO D LEACHING FACILITY:(type) Z tol X l 1-5 (size) 10069 NO. OF BEDROOMS OWNER ! O PERMIT DATE: ///( 7-- COMPLIANCE DATE: Separation Distance.Between the: \ Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility \ �� feet Private Water Supply Well and Leaching Facility(if any wells exist M / on site or within 200 feet of leaching facility) et Edge of Wetland and Leaching Facility(if any wetlands exist , / within 300 feet of leac g facility). N feet FURNISHED BY A ,,. vi Z CAV- 3 G A-� g C A/-wy BI,by o `S k3=Ki13= 13'f A'�=33si gy- 2Tr � bs=?,Zr , 6r : Is No.� � 96 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Applitation for ]Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 93 - rrl s /�I)Pa,� �� Owner's Name,Address and Tel:N-9. A e �f I—Ove!/ /i D� q3 Ar"Is /Rao&w�A Assessor's Map/Parcel 4 tl 4 QZ(osd SDd' 36.2 L-13 Installer Name Addres nd el. o.� �7Yi_3 Designer's Name,Address,and Tel.No C'V4- �-�le C N ,C 01 d4i I7 c✓11 Type of Building: /?4-0 ZG60 Dwelling No.of Bedrooms Lot Size U [ v sq.ft. Garbage Grinder( ) Other Type of Building (_Cr''p 0— 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 �a Type of S.A.S. Z -PQC Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by 0 t ' Board of H th. i ed m Date l0 ll Z_ r Application Approved by /j Date Application Disapproved by Date for the following reasons Permit No. Date Issued y \ f \ I I No.� � \�.� "' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2[pplication for Vsposal 6pstern Construction 3permit Application for a Permit to Construct( ) Repair ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. , ft,rl T PU G`u�f`°, Owner's Name, dress and Tel•NQ.. Assessor's,Map/Parcel 36.2 z 33 Installer's Name,Addre�,O�Tel.�1C�� �C,C Designer's Name,Address,and Tel.No. ML1� 1.15 r7 kc,4 'lope of Building: O 2 660 Dwelling No.of Bedrooms Lot Size 7 U/u-7/y sq.ft. Garbage Grinder( ) Other Type of Building R_ 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 �U Type of S.A.S. 2- Description of Soil Nature of Repairs or Alterations(Answer when applicable) /C/ Dat `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 H th.G%r'' /O / i ed n Date Application Approved by � � i Date // Application Disapproved by Date for the following reasons i Permit No. U ..-- Date Issued TH F COMMONWEALTH OF MASSACHUSETTS nU BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned �( )by " at `�{' � ���--�'1 S 1\ nr�,�}jy'i L-J\) �}'� has been const �cteaccgcewith the provisions of Title 5 and the for Disposal System Construction Permit No. ted Installer Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system all-fun`c{t�iona��ss esigned. Date h rq / a- Inspector \\ k. ----------------`---------------- - _ ---.-------------- ---------------------------------- ----------------------- No. / Fee M THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Misposal bpstrm Construction permit Permission is hereby granted to Construct nR�e.-pair( � Upgrade( V Ab don System located at 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. Provided:Construction miJnt be c mpheted within three years of the date of this permit. Date J Approved by E Barnstable Town ,of Barnstable , BOARD OF HEALTH ' '"�„ 200 Main Street, Hyannis MA 02601 O D 039. �� u QED MA'S° 2007. Office: 508-862-4644 Wayne Miller,M.D. FAX: 508-790-6304 'Paul Canniff,D.M. Junichi Sawayanagi. CERTIFIED MAIL#Attn: ltr not sent work completed on the 141 October 24, 2012' Elliot A. Lovell 93 Harris Meadow Lane Barnstable, MA 02630 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located 93 Harris Meadow Lane,Barnstable, MA was last inspected 10/4/2012, by Joseph Martins, a certified septic inspector for the state of Massachusetts. The inspection of the septic system showed that the.system"Conditionally Passes" under the guidelines of the 1995 TITLE 5(310 CMR 15.00); • Distribution-box needs to be replaced You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification: Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD-OF HEALTH Thomas McKean, R.S. CHO Agent of the Board of Health Q:\SEPTIC\conditionally passed\93 Harris Meadow Ln.,Barn..doc Health Master Detail http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=279086 Health Master Logged In As: TOWN\Flynnj Health Master Detail Monday,October 22 2012. Application Center Parcel Lookup Selection Items Reports Parcel ` Septic Perc well I Fuel Tank Parcel: 279-086 Location:93 HARRIS MEADOW LANE,BARNSTABLE Owner: ELLIOTT,A LOVELL TR Septic 1, 10/11/2012 # New Septic... Permit number: 2012-324 Permit type: I Repair Complete system: F f Issue date : 10/11/2012 ?� Complete date : 10/12/2012 ' r Septic tank size: Type/Size of SAS: Installer: I Martin,John,John Martin,Inc _, Card on file: F I/A service type: Select service Innovative/Alternative Technology type: I Select IA type Variance date :F << Abandon complete date :F _1_2 Abandon permit number:F Repair deadline date : Repair notification date : Keyword: Comments: 4 BR-D-BOX ONLY {sl Delete Septic I I I _Inspection 10/02/2012 I New Inspection... I Number Inspection Date Inspector Result r 7496 10/02/2012 Martins,Joseph M.,ACCU SEPCHECK - CP(Conditional pass) Received Date Comments { 10/16/2012 �1- i Delete Inspection Save Septic Changes Return to Lookup 1�4 http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=279086 10/22/2012 - -- ---- . � � �� � ���-�e ' �� I � r , � � � --- -- � _ _ _ .._ J Q� -�- C:mrnon-�ve ith of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Hans Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lane Owner Owner's Name information is Barnstable MA 02630 10/aJ2012 required for every page. CityJrown 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 A. General Information filling forms on the computer, use only the tab 1• Inspector key to move your cursor-do not use the return Name of Inspector key. Accu Sepcheck Company Name tM-Me r l S. Dennis, MA 02660 Company Address t S Cityfrown State Zip Code - So9-.3,g� 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 maintenanceof•on site' sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: � ❑ Passes [B�Conditionally-Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority li o 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. rdle 5 O6dW Inspection rortre subsuftce sewage Disposal system•Page 1.of 17 t5ins•11110 d � I Commonvl�afth`of Massachusetts Title 5 Official Inspection. Form subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Hans Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lane Owner Owners Name information is Barnstable MA 02630 10/;,/2012 required for every State Zip Code Date of Inspection page. Cityfrown B. Certification (cons.) 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): 6407LIt, d'a&e&Io( -q ib'-ca, t5ins•11110 Title 5 Official inspection Form Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of M'assachUsetts OIL Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Haris Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lane Owner owner's Name information is Barnstable MA 02630 10/242012 required for every page City/Town State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water le a distribution box due to broken or obstructed pipe(s)or due to a broken,settled even 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 ElN N . FIND(Explain below). ❑ distribution box is veled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to bro r obstructed pipe(s).The system will pass inspection if(with approval of the Board of ): ❑ broken pipe(s)are replaced ❑ ❑ 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 ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ms-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachuisetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Haris Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Hams Meadow Lane Owner Owners Name information is Barnstable MA 02630 10/2,/2012 required for every page. Cityfrown State Zip Code L7ate of Inspection B. Certification (cunt.) 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 withi eet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is 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 wa analysis, performed at a DEP certified laboratory,for'fecal coliform bacteria indicates abse and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provid 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. , t. 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 El or liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in.cesspool is less than 6°below invert or available volume is less than %day flow t5ins•11110 Title 5 OtfictW InspeLton Form Subsurface Sewage Disposal System•Page 4 of 17 _ e Commonv"lth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Haris Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris,Meadow Lane Owner Owner's Name information is Barnstable MA 02630 10/2./2012 required for every State Zip Code Date of Inspection page- Cityfrown B. Certification (cunt.) Yes No El obstructed pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: - ❑ Any portion of the SAS, cesspool or privy is below high ground water elevation, ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ � Any portion of a cesspool or privy is within 50 feet of a private water supply well. El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This. system passes if the well water analysis, performed at a DEP certified laboratory,for 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 s facility with at<'" design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is wit ' 400 feet of a surface drinking water supply ❑ ❑ the syste is within 200 feet of a tributary to a surface drinking water supply ❑ a th stem is located in a nitrogen sensitive area(Interim Wellhead Protection ea—IWPA)or a mapped Zone II of a public water supply well If you have a ered"yes"to any question in Section E the system is considered a significant threat, or answer "yes" in Section D above the large system has failed. The owner or operator of any large Sys te onsidered a significant threat under Section E or failed under Section D shall upgrade the em in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. tsins•11f10 Title 5 Official Inspection Form Subsurface Sewage Disposal system•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary AssmmefltS 93 Hans Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lane Owner Owner's Name information is required for every Barnstable MA 02630 104/2012 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 ❑ Lam" 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) )�,r 4.s b�rff '❑ 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,OG( g 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. 2 � 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: L/ Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): t55urs•11110 Tdle 5 Official Inspection Form:Subsurtace Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Officinal Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary ASS2SSn12t1tS 93 Haris Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lane Owner Owners Name information is Banstable MA 02630 10/ /2012 required for every page City/Town State Zip Code Date of Inspection Do System information Description: j�y� q �l � � �t✓� Number of current residents: Does residence have a garbage grinder? Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes E]--*/No Laundry system inspected? 4; /4--El Yes ❑ No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Detail: �10c) Sump pump? ❑ Yes No o 1Z L Last date of occupancy. Date Commercial/Industrial Flow Conditions: Type of Establishment:- Design flow(based on 310 CMR 15203): Gal r day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? . ❑ Yes ❑ No Industrial waste holding t present? ❑ Yes ❑ No Non-sanitary a discharged to the Title 5 system? ❑ Yes ❑ No r meter readings, if available: t5ins-/1/10 Title s Official Uspedon Form Subsurface Sewage 01sp=al system-Page 7 of 17 ' Commonwealth of Ma Ssachusetts Title 5 Official Inspection Form j Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Haris Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lane Owner Owner's Name 1. information is Barnstable MA 02630 10/2./2o12 required for every page city/Town State Zip Code Date of Inspection D. System Information (cunt.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information. Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: Septic tank,distribution box,soil absorption system El 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 1/A system by system operator under contract ❑ Tight tank Attach'a copy of the DEP approval. ❑ Other(describe): t5ins•11110 TNe 5 Official fnsped ion Forth:S tsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Haris Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lane Owner owner's Name information is Barnstable MA 02630 10/2./2012 required for every page City/rown 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: feet Material of construction: Acast iron X40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): O 1C /U a L-eg45 Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain) I If tank is metal, list age: years Is age confirmed by a Certificate of Compliance_?(attach a cofppy of certificate) ❑ Yes ❑ No Dimensions: I" 2 y ! 7 Sludge depth: 12 �' V t5ins•11/to Title s omcial lemon r-om subsurface sehmge Disposal System•Page 9 at 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments 93 Haris Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lade Owner Owners Name information.is Barnstable MA 02630, 10/2-/2012 required for every State Tip Code Date of Inspection page Cityfrown D. System Information (cunt.) Septic Tank(cunt.) Distance from top of sludge to bottom of outlet tee or.baffle. 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): • C / auto L evi' l .q r p.1 He?—i, hex r R 1eq L/ Grease Trap(locate on site plan): Depth below grade: feet Material of construction: El concrete Elmetal ❑fiberglass yethylene ❑other(explain): Dimensions: Scum thickness Distance from top of s to top of outlet tee or baffle Distance fro ttom of scum to bottom of outlet tee or baffle Date of ast pumping: Date t5ins•1111U Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 f Commonwealth of Massachusetts t gTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments wy 93 Hans Meadow Lane Barnstable M Property Address Lovell Elliot 93 Harris Meadow Lane Owner Owners Name information is Barnstable MA 02630 10/j/2012 required for every page. EWI own 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 m be pumped at time of inspection)(locate on site plan): Depth below grade: Material of constru on: ❑concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain): Di/ensions: Capacity: gallons Design Flow. gallons per day Alarm present: ❑ Y ❑ No Alarm level: Alarm in working order. El Yes ❑ No Date of last pumping: Date Comments(condition of alarXanoat itches, etc.): ;_Ia�ch copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11110 Title 5 Off=W lispection Form:Subswface Sewage Disposal System•Page 11 of 17 4 Commonwealth of Massachusetts' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Haris Meadow Lane Barnstable MA ; Property Address Lovell Elliot 93 Harris Meadow Lane Owner Owner's Name reformation is required for every Barnstable' MA 02630' 10/�/2012 ' page. Cfty(rown State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate'on site plan): Depth of liquid level above outlet invert 14 vex 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.): 4 ild Q rt'd /t? -P W-V fo 6z gcg(q�e - G OVU !/V 45 'Pump Chamber(locate on site plan): Pumps in working order ' s° ❑ No Alarms in working order. ❑ Yes ❑. No Comments(note condition of pump chamber dition of pumps and appurtenances, etc.): e.r Soil Absorption System(SAS)(locate on site plan, excavation notre a _ If SAS not located,explain why: . t5ins•11110 Tile 5 Of6dat I spectlon Forte:Subiatace Sewage Disposal System•Page 12 of 17 - �� Commonwealth of Massach setts Title 3 Official Inspection Form, Subsurface Sewage Disposal Syslzm Form-Not for Voluntary Assessments 93 Haris Me dow Lane' , Barnstable MA Property address Lovell Elliot 93 1Iafris Meadow Lang Owner ' Owner's Name . information is Barnstable MA 02630 10/ -f2012 required for every page. cltyrrown State Zip Code- Date of Inspection t D. System Information Cont.) _ Type: / L&I-a leaching pits . number: Z l� t� .t Ej leaching chambers number. ❑ leaching galleries number ❑ leaching trenches number, length: ~ ❑ Teaching fields . number,dimensions: : s' ❑ overflow cesspool f. 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.): 6md eTv ot6'ot S Ides Glen^ No S - 57-0rve-- 1. .1 c Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth-top of liquid to inlet invert t- Depth of solids layer = , Depth of scum layer Dimensions of cess ' Materials ' construction 4 1 cation of groundwater inflow El Yes ❑ No 15ins•11110 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal Sysl)em Form-Not for Voluntary Assessments 93 Haris Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lane Owner Owner's Name information is Barnstable MA 02630 10/X/2012 required for every State Zip Code Date of Inspection page Citylrowrl D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): s o Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failur , evel of ponding, condition of vegetation,- etc.): r t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Haris Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lane � i Owner owners Marne Barnstable MA 02630 * 10/1-/2012 information is !, required for every State Zip Code Date of Inspection page:. aijf-Town D. System Information (coat.) 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 and-sketch in the area below ❑ drawing attached separately inJ l . i / Q ` C A- - � 3 0 = ..� q1_ IS 2 ff-Za low- A3=aSs g3 i3� A� =335*; $�- 22�- t5ins•11/10 Tittle 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments: 93 Haris Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lane Owner Owner's Name information is Barnstable , MA 02630 10/ Z/2012 required for every Citylfown State Zip Code Date of Inspection page. D. System Information (coot.) Site Exam: Check Slope 2'surface water [heck cellar hallow wells Estimated depth to high 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(abutting property/observation hole within 150 feet of SAS) [✓r Checked with local Board of Health-explain: ,e�?vRh.,L- ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: ; e- c oQd� y Cen����t You must describe how you established the high ground water elevation: /f S. L .P✓Z b to TO Pa /L1 I'P �ssc'Sso�r ) z _ Gll.a�l e wP �STr r T !J a. 5- 3 • C CCU vd a)cak Can - a„ Before filing this Inspection Report, please ee Report Completeness Checklist on next page. t5ins•11/1-3 T&6�cW Inspecton Form Subsurface Sftage Disposal System Page 16 of 17.r. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Haris Meadow Lane Barnstable MA Property Address Lovell Elliot 93 Harris Meadow Lane Owner Owner's Name information is Bamstable MA 02630 10/2./2012 required for 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 UKsystem Information—Estimated depth to high groundwater ketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 WS No.................... F��../���................... �� MONWEALTH OF MASSACHUSETTS BOARD O?,ff HEALTH Appliratiuu -fur Bid ugtt1 Worko Tontitrurtion Vrruift Application is hereby`made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sys em at: .................. AfZ�� ------ r��&ow l- AA-f - ----t�C�✓� .ft' ..1. -------...f�._�1 :_� CC+ Loc io Address or Lot No. --- _ � X____ 1 f S:1-_............. -------- �.y ltr�... = a _.. ��/ /9a �.../.. Address...........................:. + Viler Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling 1 No. of Bedrooms._.__.___._.. -------------- Attic ( ) Garbage Grinder ) Ga, Other—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ________________ ___•-•-__----. . _ W Design Flow... .... ..........................gallons per person per day. Total daily flow....._.....®....__.............---gallons. 9 Septic Tank Liquid capacitvd�®--gallons Length---------------- Width................ Diameter_-.---_-..-_--_ Depth...--.--_-.----- xDisposal Trench—eN�o..................... Width-------------------- Total Length--_-_____-__._--_--- Total leaching area----.--.__-_...___-_sq. ft. Seepage Pit No...... ---------- Diameter... . ®'?.... Depth below inlet.................... Total leaching area_--.._---.-.---_-sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ® `- � � 7 z?F 76 M ~' Percolation Test Results Performed by_ 6.... 1 �/ .. ................................. Date..------------------------------------- a Test Pit No. 1............._.minutes per inch Depth o Test Pit-------------------- Depth to ground water.----------------------- (1 Test Pit No. 2----------------minutes per inch Depth of Test Pit.-_-__-________-__-- Depth to ground water--.--.---__----.-.--_._- G ------------f------ - y Description of Soil -----C?-`-------- _ .�•r� - c _._ c.� - - - W VNature of Repairs or Alterations—Answer when applicable_--------------------------------------------------------------------------------------------- -------------------- --------------------------------------------------•-•--•---••----------------•------•----•-•-•-•----------•-••------•--------•--------------------------------------------------- Agreement: The undersigned agrees to install the-aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has d y h rd of health. Signed J ...... _.1... _._. Application Approved B --- - Date Application Disapproved for the following reasons:-------•--------•-••------------ --•--------•--..........-•--•---------------._._...........-----------•..... .....................•....••--...-••------•------•...---•••------------••-----------------•-•---------•-.-----.----.---------------•-------------------------•--•----------------•-----.---------------- Date PermitNo......................................................... Issued........................................................ Date l _ a No,,... ----------•---•y FEE... ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD Of HEALTH 1.._ .l`l h........-.OF......... .. ..u.✓.4 I.................... Apphration -fur 43i�ipuutt1 Works Towstrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: t� _ .�r'? • fir' �I ?r-I i S7 w /�•L P I:.a��f"�/r S /�'4!S.%�" ''�. _.......r_ ._..... 3 ` Location-Address - ,... /`_ or Lot No. .L� (� ......../mil.................... j=- �T_ �)_.._.L !�,�?_�_ti_ /li y o��'�" .C�J t } Address --------..........................................----............. •. t.. Installer Address Q Type of Buildinj Size Lot............................Sq. feet U 41 Dwelling—No. of Bedrooms-------------- _---------------------------Expansion Attic ( ) Garbage Grinder (� ) A4 Other—Type of Building __-------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ...................................................... �' '�� W Design Flow___ ___5- _________________________gallons per person per day. Total daily flow_.._..._.._...__:___..._______.___-_-__..__-gal lons. 04 Septic Tank Liquid capacity_4i o_gallons Length---------------- Width----- Diameter-----.---------- Depth---------------- W Disposal Trench—No..................... Width-------------------- Total Length-------------------- Total leaching area--------------.-----sq. ft. x Seepage Pit No------a.......... Diameter..._ .._ Depth below inlet------________-_-_- Total leaching area______--________-sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ego- /2�1A - 7 ` / cl- 76 Percolation Test Results Performed by----` _.r?-/•`s.................................. Date--------------------------------------.. a Test Pit No. 1................minutes per inch Depth of "Pest Pit.................... Depth to ground water-----------------...---- (-Ir, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water__-._..__--_______.... 0 Description f Soil *�--2-- �-- J / .Y - L �-� J. V --•---•-- ...._t U r I ` "==-" -•.-... �'.f•!a! -�. 0 r� W UNature of Repairs or Alterations—Answer when applicable..--------------------------------------------------------------------------- .................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been-issued by he board of health. Signed.. - - Application Approved By___________ __ ---E�'_....._--'-__ /-- Cl/ . Date Date Application Disapproved for the following reasons:.------------------------------------------------------------------ ............................................ --•---••-•--•--------------•-----------------•----------••-•.----------------------------------.-- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ;.............G.�' ?...........oF......... ..t !f ................................................... wkrrtifirtr of f"umii�tnrr ,•- THIS IS TCERZ .FY The Individual Sewage Disposal System constructed ( ) or Repaired ( ) f A , j at... =/,-" e '�'2it!1 •-• cr./JcJ � i �_ ..__I_l.�t. rrf; ......- ------ .--- ----••-•- ------ -- has been installed in accordance with the provisions of Article XQ The State Sanitary Code as described in the application for Disposal Works Construction Permit No ___________of3 ___________ dated ... ........................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ,r .......................... Inspector. THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH ..... .1-'L ......OF........... .. �.................l --� J s...... /f� No. FEE •................. - �i��u�tt1 urk,� �uu�#rurtiugt �rrutit Permissionis hereby granted.............................................................................................................................................. to Consttr`uc`t'( or ( � an/Wdividual Sewage Disposal System �l J ,/ at N o�'/''....................................................") �'fiL�i/ Al f G"(!v-�-cl,�. ."1��/c-{; r s 1 c/�t e,�:, i .� l.t � ,/��y '7- - w- '----------------- - Street as shown on the application for Disposal Works Construction Permifr No------- ...... Dated__----;_� - Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. 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