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HomeMy WebLinkAbout0115 KEVENEY LANE - Health 11.5 KEVENEY LN. CUMMAQUID A-351-059 a d t II l I', �1 E A I •• Commonwealth of Massachusetts 351- o6 ` - Title 5 Official Inspection Form E Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYN ON M & HILLARY B 4a Owner Owner's Name ' information is Barnstable Cumma uid Ma 02630 140/16/20 required for every q 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 forms A. Inspector Information on the computer, use only the tab Michael DiBuono key to move your Name of Inspector cursor-do not DiBuono Sewer And Drain use the return Company Name key. 35 Content Lnto a „y Company Address Cotuit Ma 02635 City/Town State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification , I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑. Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. a Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 c Commonwealth of Massachusetts p Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,.� 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARY B Y Owner Owner's Name informrequired is Barnstable Cumma uid Ma 02630 10/16/20 required for every 4 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3,,or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR.15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is functioning as designed with no signs of failure. I 2 System Co nditionally o ditionally Passes: ❑ One or more system components as described in the"'Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ .N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form{Subsurface Sewage Disposal System•Page 2 of 18 c Commonwealth of Massachusetts b Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every q page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑. N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipes) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of.Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every q page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: I , ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply., ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: i 4) System Failure Criteria Applicable to All Systems: You must indicate .'Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection form R 4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARYB Owner Owner's Name information is Barnstable Cumma uidM1 Ma 02630 10/16/20 required for every q " page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No } ❑ R Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Q ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® _ ` ` Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: . ❑ ® Any portion of the 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 water supply 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 2000 gpd- ❑, ® 10,000 gpd. , 0 ® 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. • r 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section C.4. F Yes. No ` ❑ the system is within 400feet of a surface drinking water supply u ❑ the system is within 200 feet of a tributary»to a surface drinking water supply El4 ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well t5insp.doc+rev.7/26618 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Peg 5 of 18 f Commonwealth of Massachusetts Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every q page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The'system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for aU inspections: Yes No I ❑ ® 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 backup? ® ❑ 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)] t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARY B ; Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every q page. CirylTown r State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ❑ No Does residence have a water treatment unit? ❑ Yes ® No If yes,'discharges to: Is laundry on a separate sewage system? (Include laundry system in ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? Yes - No Last date of occupancy: Date t5insp.doc•rev.7/26/2018 ; Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every q page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No if yes, discharges to: Industrial waste holding tank present? - ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes.❑ No Water meter readings, if available: c Last date of occupancy/user Date - Other(describe below): 3. Pumping Records: Source of information: Not provided Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every G page. City/Town State Zip Code Date of Inspection D. System Information (cont.) , 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 11/20/97 Were sewage odors detected when arriving at the site? ❑ Yes ❑' No 5. Building Sewer(locate on site plan): 1.5 Depth below grade: 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.): , System is vented at the roof line t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 r c Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 62630 10/16/20 required for every q page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness Distance from top of scum to top of outlet tee or baffle 4" Distance from bottom of scum to bottom of outlet tee or baffle 30" How were dimensions determined? Tape Measure/Data On File 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 should be pumped if not done in the last 3 years I ` t5insp.doc-rev..7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments•' 115 Keveney Lane Property Address `r JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16%20 required for every q page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet ^ . Material of constructions ❑ concrete ❑ metal TI fiberglass ❑ polyethylene• other(explain): t' Dimensions: Scum thickness k Distance from top of scum to top of outlet tee or baffle Distance from bottom'of scum to bottom•of outlet tee or baffle Date of last pumping: Date' Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc): 8. . Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: N` Material of construction: ..,a. ❑concrete '. ❑ metal n,fiberglass '❑ polyethylene °" ❑ other(explain): .r Dimensions: Capacity: gallons ' Design Flow; gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•gage 11 of 18' Commonwealth of Massachusetts ry 1. Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every q page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): " 1 *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Level and at normal level 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 KeveneY Lane Property Address JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every q page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc): *If pumps'or alarms are not in working order, system is a conditional pass.. 11. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 Infultrators ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: N ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5ins .doc•rev.7/26/2018 Title 5 Official Ins ection Form:Subsurface Sewage Disposal System•Page 13 of 16 P P 9 � Y 8 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 115 Keveney Lane Property.Address JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every q page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): No ponding or break out .i 4 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration . Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes . ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 6 K t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARY B ' Owner Owner's Name information is Barnstable Cumma uid z Ma 02630 10/16/20 required for every G page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): r - t t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form L' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every G page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately s . t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 115 Keveney Lane M ' Property Address JACKSON, LYNDON M & HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every q page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 10+ 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: 11/20/97 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ` y ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database.-explain: You must describe how you established the high ground water elevation: r; Test hole data on plan M Before filing this Inspection Report, please see Report Completeness Checklist on next page. , f t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 . Assessing As-Built Cards https://town.bamstable.ma.us/Departments/Assessing/Property_Valu... TOWN OF BARNSTABLE ./ o LOCATION SEWAGE x 7-6 7a VII.LAGE �qy� ASSESSOR'S MAP&LOT ZE -_6a'9 INSTALLER'S NAME&PHONE NO. .Qcrr�oilj SEPTIC TANK CAPACITY/EO�d Gu LEACHING FACXXrY:(type) yf:CA*/orp (size) //'X 3�75'pf,2 I NO.OF BEDROO BUILDER OR PERMiTDATE: I COMPLIANCE DATE: Separation Distance Between the-, Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S f Feet Private Water Supply Wep and Leaching Facility (If any wells exist / Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by r i ,Jill, 3 - I � I 1 of 1 10/19/2020, 11:55 AM Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 115 Keveney Lane Property Address JACKSON, LYNDON M& HILLARY B Owner Owner's Name information is Barnstable Cumma uid Ma 02630 10/16/20 required for every Q page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector Information: Complete all fields in this section. ❑ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked El C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ❑ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached , r For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included , } t5insp.doc.-rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 r t� 36/ -o5U Commonwealth of Massachusetts Title 5 ® ICIaI Inspection Form Subsurface Sewage Disposal System Form -Not for Vol f die kle Voluntary Assessments M lND Property Address Al-ie IM Owner Owner's Name ® �G► /v/GT✓� information is r� required for every. / //� //•�� City/T u{/�16MG'e page• own iStN/ t/ 7 _ State Zip Code Date/fln s ction Inspection results must be submitted on this form. Inspection forms ma no way Please see completeness checklist at the end of the form, - y t be altered in any Important:When filling out forms A. General Information the computer, use 6/# /29 9y use only the tab key to move your 1 Inspector. cursor- not r/ use the return key. Name of Inspector L-c Company Name n do /aCompany Address � AsTr��N'I City/Town —Jac n® State Zip Code Telephone Numbberr / © �40 ?'2 License Number � 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 maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Inspector Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original 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. t5ins.doc•rev.&16 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1wa�VS Commonwealth of Massachusetts Title 5 Official Ins Subsurface Sewage Disposal S Inspection �®1'1°1'� ` System Form -Not for Voluntary Assessments GM I Property Address �e 61 Owner information is Owner's Name required for every t A Im page City/Town I�Q e 114 State Zip Code Date of I r o �o �°sei'bifiCBtion (cont.) pec n Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System sses: 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 crita not evaluated are indicated below. eri 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 El N ❑ ND (Explain below): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 COMMonwealth of Massachusetts ` i Title 5 Official Inspection F Subsurface Sewage Disposal System Form -Not for VoluntaryAsssees'sments `M 11 S /r-eyeoe Property Address Owner lam 110rC information is Owner's Name required for every cat MCI CS Q w4 � �/S fit- q tc� page. City/Town N L? State Zip Code Date f Ins ection Bo Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health pumps/alarms are repaired. approval if 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 ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i _ C®mmonwrealth of Massachusetts Title 5 Official Inspection - Subsurface Sewage Disposal System F ®r� r Voluntary Assessments Property Address ke ve Pie L Owner Owner's Name e f�rQ information is � e required for every — u / � page. Clty/Town �IMq�H 1 1 % � bll State Zip Code Date of spec on � Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if an 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 E pill,— 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 . ❑ p s than 6"below invert or available volume i than /2 day flow s less t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 COMMonw/ealth of Massachusetts Title 5 Official Inspection Fm Subsurface Sewage Disposal System Form -Not for VoluntaryAss ments Property Address I es e - L Owner /QlQ information is Owner's Name % required for every page. LAW/I own d d= B. ��t'tlflcaft9®� State Zip Code Date o Ins ection ® (cont.) Yes No ❑ Required pumping more than 4 times in the last year RIOT due obstructed pipes . Number to clogged or ( ) ber of times pumped. ❑ Any portion of the SAS, cesspool or privyis below low 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. ❑ ICJ Any portion of a cesspool or privy is within a Zone 1 of a Publi c c well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ElAny 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 2000 d- 10,000gpd. gp ❑ 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Tile 5 Official al Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessmen ts e Property Address L Owner information is Owner's Name required for every A4` page. f �O C. Checklist State Zip Code Dat of In pection Check if the following have been done. You must indicate "yes"or"no"as to each of the following: ;e�o ❑ �Pumping information was provided by the owner, occupant, or Board of Health re any of the system Components p nents pumped out in the previous two weeks? ❑ s 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): --L-" t5ins.doc•rev.6/16 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 _ - Commonwealth of Massachusetts Title 5 Official Inspection F®Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o� /i/S M k'eveq Property Address Owner dress ll0/6ri information is owner's Name required for every CQ IMF"q A- page• City/Town tJ'� / i✓O�-t0®J � � �� ®o Sy ten- inf®rMation rate Zip Code Date of spection Description: / � /�� /S� 101 Number of current residents:, Does residence have a garbage grinder? �/ Is laundry on a separate sewagey s stem? El stem? L7 No information in this report.) (Include laundry system inspection �� ❑ Yes R? No Laundry system inspected? ❑ Yes No Seasonal use? Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: 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?- El 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address �cleple Owner Owner's Name //0 Q information is required for every �Z( 0.) &��,.. � f page. Clry/Town / �T State Zip Code Date of spe ion Do System Information Last date of occupancy/use: Other(describe below): General Information Pumping Records: Source of information: `� i 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 S em: 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.doc-rev.6/16 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 8 of 17 COMMonwealth of Massachusetts W Title 5 Official Ins pecti®n ®r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l rcve�e Pr l/S operty Address Owner Owner's Name information is required for every page. City/Town State o pon ipC® SystemloB � filot Approximate age of all components, date installed (i know /•�_ � )' nd source of information Were sewage odors detected when arriving at the site? DR-go,�.! ElYes Building Sewer(locate on site plan): Depth below grade: feet Material of constructi;4'0--P El cast iron VC ❑ other(explain): Distance from private water supply well or suction line: /® ' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet Materi construction: concrete ❑ metal ❑fiberglass 9 ❑ polyethylene El other(explain) If tank is metal, list age:. years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes. 6 ❑ No Dimensions: X �® Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts 42) W Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^M sy0y'+V I� Property Address //SA-rvleoe Owner information is Owner's Name required for every 6 (A 11ek;t d2w t page. Ulty/Town State Zip Code®- System Information (cont.) Date of Ipection Septic Tank(cont.) �� !s Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Le jx Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle o // 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.): oe 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.doc-rev.6/16 ° Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 COMMonwealth of Massachusetts Title 5 Official Inspection or Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. kevevre Property Address Owner Owner's Name !(0r�4 41 information is required for every (/��t/�� 0-(A J y page. City/Town Date Ins ection D. System Information (cont.) State Zip Code Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrit , liquid levels as related to outlet invert, evidence of leakage, etc.): y 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 g El Polyethylene El 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(requiredl. Is copy attached? ❑ Yes ❑ No t5ins.cloc-rev.6116 + Title 5 Official Inspection Forth: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 c4 {/�� M / V l�lil0 Property Address Owner 6wner s Name information is required for every ®�! /e page. Uny/rown ,y o Insp ction ------ D. System Information (cont.) State Zip Code D ate Distribution Sox(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): C/f 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: t5ins.doc.rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts F Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments //S v�he Property Address Hor,Owner 1/ 10�� information is Owner's Name required for every -A-4 p4lM.q&(q! ��/T �� ? g page. --y/tow n /� 9 J State Zip Code Date o Insp coon D. System Information (cont.) Type �✓�T/j j�� �4/ �/ ,�,�6 �� ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ 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.): 0`12 GN� �00 Cl�ce� �® S, ✓!S 0 clrawlf c c! /y,» s 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.doc•rev.6/16 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 Property Address Owner 9c,1/0/4 h Owners Name information is required for every (i(k4j a 644! page. City/Town State Zip Code Date of nsp ction 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 COMMonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Addressv Owner Owner's N a me information is required for every �(� ��� `� .. A4 V a-I j-- �} page. Clty/Town �`°� . State Zip Code Date of ns ction D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties at feast two manent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where is water supply enters the building. Check one of the boxes below: g es to hand-sketch in the area below ❑ drawing attached separately . TG"�" �Tn�llfizf�. c•, /Soo GPI/oy /S��•v r' 3 ,. /(LoivT 0 A t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 COMMonwealth of Massachusetts Title 5 Official Inspection Subsurface Sewage Disposal System Form -Not for Voluntar®Ass As sessments ents �M / Property Address IrCV414,P11, Owner :Ov,-ner"sinformation is Name � llo�A� required for every (f Page• y/Town D. System State Zip Code Date of Inspect on Inf®t-rraati®n (cont) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow 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) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-,(attach documentation) ❑ Accessed USGS database-explain: You mus4 escribe how/you established the high ground water elevation: die I --,1 44. VZ7 �So v✓I Q� Tn7i//fii-G�rs �r�� 5�, l7 ro w✓r cl (en�@ Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts } Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Property Address Owner Owner's Name information is 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 A lic pp able to All Systems)completed Lv1 5 em Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file R R r I _ R t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 - 10/9/97 NOTICE: This Form Is To Be Used For the Rep air 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 !J//8�0 , concerning the property located at !/,-/�e.b-foyey �g, Gt�r G��"i�/� 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 not 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) b B)Observed Groundwater Table Elevation(according to Health Division well map) SIGNED : DATE: `zgh LICENSED SEPTIC SYSTEM 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 TOWN OF BARNSTABLE 0 6 LOCATION S' Ir-"?y®'7 G SEWAGE # f VILLAGE- ASSESSOR'S MAP &LOT !E-GS t INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type)-���L7c>��o�J � �(size) ILA NO.OF BEDROOM BUILDER OR O PERMITDATE: i/ �d� COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility s Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist ,Feet within 300 feet of leaching facility) Furnished by de . f � f No. 57e, THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for �Di!5pogaf 6potem Conotruction Permit Application for a Permit to Construct( )Repair( t/)Upgrade( )Abandon( ) L✓1Complete System El Individual Components Location Address or Lot No. / - leweoe� j Owner's Na e�d ss and Tel.No. /` Assessor's Map/Parcel Cellelvele4_1 f� Installer's Name,Address,and Tel.No. �j Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building e-ylCe No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow L gallons per day. Calculated daily flow q?® gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /c5,0&!P 4!11 Type of S.A.S. o s 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 Certifi- cate of Compliance has been issue by t is o of H Signed Date /` 1,0r Application Approved by . Date Application Disapproved for the following reasons Permit No.�G_ 7-n Date Issued 70 Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:`7 Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 01pprication for Miopooar 6pgtem Construction Permit Application for a Permit to Construct( )Repair( ✓j Upgrade( )Abandon( ) C complete System E!]Individual Components Location Addressor I:ot No. 11 "vea Owner's N e,Address pnd Tel.No. �y �• Assessor's,Map/Parcel Fi Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder Other Type of Building A ?tf,14 ?-dee No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title AllI Size of Septic Tank " Type of S.A.S. Description of Soil �6 1 S"ji'�/ 4/A-2a Nature of Repairs or Alterations(Answer when applicable) Dto last inspected: Agr anent: The-undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- f ca of�Compliance has been issued by t is o of�lth (� Signed P Date A Application Approved by - Date I/ ? t App ic ion Disapproved for the following reasons - Y :t Permit No. n Date Issued t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of QCompliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired ( kel)"Upgraded( ) Abandoned( )by B©tAP11_fl11*/ 1f 57` at //5-ke-!/W h e Y 1w, ' G w?!!�°Aevi2 has been constructed in accordance�1 with the provisions of Title 5 and the for Disposal System Construction Permit No.� °771 dated ; Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date f� - �� —) Inspector —//------------- -------- —�.---- — No. �7-Co 70 33 C'/e,�/ Fee 4S®r 2 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwigogal *p!5tem construction Permit Permission is hereby granted to Construct( )Repair(✓)Upgrade( )Abandon ) Systemlocatedat //- /GeelI.-eey �/9 c'`Ll `G//'�✓ and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this rmit. 7 Date: Yl ` Z U / Approved by �t 10/9/97 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 hho-Ay'? , concerning the property located at !/vr��v°1✓���� �'o Gu�l�Gl�l!/d 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 not 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) b B)Observed Groundwater Table Elevation(according to Health Division well map) /V ` SIGNED : DATE: LICENSED SEPTIC SYSTEM 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 TO_�V,N,OF BARNSTABLE / LOCATION // h.av�►� Lw SEWAGE# : 7-6 70 'VILLAGE ASSESSOR'S MAP& LOT M-G32 rAdi� INSTALLER'S NAME&PHONE NO. `42 9-M2(� SEPTIC TANK CAPACITY �— LEACHING FACILITY: (type).f-�/C,4-Q /o f &) :- - (size) NO.OF BEDROOM $UILDER OR O � r,0w ' o PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: ;Maximum Adjusted Groundwater Table and Bottom of Leaching Facility S.� Feet Private Water Supply Well and Leaching Facility (If any wells exist. on site or within 200 feet of leaching facility) Feet Edge of Wetland and.Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by F R.s,c'� i s�- 11 I yyb a\� - F - i-wr+A