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HomeMy WebLinkAbout0020 KIDD'S HILL ROAD - Health 20 `Kidd's Hill Road Barnstable A = 276 - 01.5 p Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Kidds Hill Rd. �. Property Address Paul Rebelo Owner Owners Name _ information is required for every Barnstable MA 02630 5-2-12 page. Cityrrown State _ Zip Code . Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Important:when' A. General Information ,��``�""""►"���ii filling out forms OF Af4 on the computer, �o ,.• S �i�� use only the tab 1 Inspector a�o�' . 9cy� key to move your I,/ I I D. a g c JA M ES u'' cursor-do not James D Sears I t = SEAR use the return s ra key. Name of inspector Capewide Enterprises, LLC ';,�j •.FRT11: "► I Company Name IN N Sp��������` 153 Commercial St. Company Address Mashpee MA 02649 Cityrrown _ State' Zip Code ,. 508-477-8877 s1623. Telephone Number license Number B. Certification I certify that I have personally inspected the sewagedispo'ssl 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 ❑ Fa£is _o ❑ Needs Further Evaluation by the Local Approving Authority* 1 l spector's Signature Date y , � Y 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. tSlns•11110 Title 5 Official In Form:SuGsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora' Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 20 Kidds Hill Rd. Property Address Paul Rebelo Owner Owner's Name information is required for every Barnstable MA 62630 5-2-12 page. Cityrrown State •Zip Code Date of Inspection B. certification (cont.) Inspection Summary: Check A,B,C;D or E 1 always complete all of Section 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 ' r indicated below. Comments: y° 4 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 followirig 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): r p .. ,. t5ins 11110 + Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 " Commonwealth of Massachuidtts Title 5 Official Inspectionn Form? ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Kidds Hill Rd. .. Property Address fir' Paul Rebelo Owner Owner's Name ': .• k information is T `' required for every Barnstable ` MA 02630` 5-2-12 - page. City/Town r - " - „ State Zip Code_ .: Date of Inspection B. Certification (cunt.) ` B) System Conditionally Passes(cunt): ® Observation of sewage backup or break out or,high static water level in the distribution box due p p O W en, settled'or'uneven distribution box. System will to broken or obstructed i e s or due to a brok ass ins ection if with a royal of Board of Health 4° • r p p ( ,Pp )�. .. 0 ^ broken pipe(s}are replaced' ❑ Y F 0` N N[?(Explain.below): 0 obstruction is removed w ❑:Y 0'N ❑'ND(Explain below): distribution box is leveled or replaced Q"Y ® N Q ND(Explain below): Need to replace D Sox , !r '❑ 'The system required pumping more than 4 times a year due to broken or obstr acted pipe(s). The system will pass inspection if(with approval of the`Board,of.Heakh): broken pipes}are replaced Y '"�'N ND(Explain below): ): ❑ obstruction is removed : Y N ND(Explain below): Al _ r'..• >. taw C) Further Evaluation ls'RegWred 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: � r w0t 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 11110 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts t Title.5 Official Inspection Form Subsurface Sewage•Disposal System Form-Not for Voluntary Assessments 20 Kidds Hill Rd. 1 = Property Address Paul Rebelo f Owner Owner's Name information is required for every Barnstable MA 02630 ' -5-2-12 page. Cityrrown State Zip Code . Date 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. } E "The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. f ❑ 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**. a 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 its 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 ali Inspections: Yes , No ' { t 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 a due to an overloaded or clogged SAS or cesspool w * Static liquid level in the distribution box above outlet invert due to'an overloaded or clogged SAS or cesspool _Liquid depth in cesspool is less than 6"below invert or available volume is less ❑ ER: than %a day flow ,• t5ins•.11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form: Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Kidds Hill Rd. Property Address — 1 Paul Rebelo Owner Owner's Name w information is required for every Barnstable MA `02630 5-2-12 page. Cityrrown State Zip Code Date of inspection B. Certification (cont.) ; Yes _ No ❑ 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 well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply welt. ❑ ® 'Any portion of a cesspool or privyis 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`system1s a cesspool serving a facility with a design flow of 2000gpd- ❑ . ® A O'000gpd. ® The system'falls. I have determined that one or more of the above failure t 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 16,000 gpd. " For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the r questions in Section D. r 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 Q , I ❑ 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 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•11l10 + Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pap 5 of 17 Commonwealth of Massachusetts Title 5 Official- inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Kidds Hill Rd. k Property Address �- Paul Rebelo $° Owner Owner's Name information is required for every Barnstable MA 02630 ,' 5-2-12 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 Now k ' R ®• 0: 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? a - , . . Have large volumes of water been introduced to the system recently or as part of this inspection? ® 0 Were as built,plans of the system obtained and examined? (If they were not available note as N/A) ® 0 '• Was the facility or dwwelling inspected for signs of;sewage back up? ® ❑ - Was the site inspected for signs of breakout? T ® 0 Were all system components,.excluding the SAS, located on site? A� ® C1 ' '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? ® El Was the facility owner(and occupants if different from.owner)provided with informetion.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. k r 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 y Residential Flow Conditions:"; Number of bedrooms(design): NA Number of bedrooms(actual): . 3 `. 330 , DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):., . t5ins•11/10 Title 5 Official inspection Form:Subsurfece Sewage Disposel System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Kidds Hill Rd. i Property Address Paul Rebelo Owner Owners Name information is required for every Barnstable MA 02630 5-2-12 page. Cityrrown State Zip Code Date of Inspection D. System Information a Description: The System is a 1500 Gal Precast Tank `D Box and three flows Number of current residents: Does residence have a garbage grinder? ❑ Yes Na Is laundry on a separate sewage system?_[if yes separate inspection required] r ❑ Yes ® No Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if;available last 2- ears usa e y 2010-54,000 Gal' g y g (gpd}�' 2011-43,000 Gal Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Present " ' 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.): .t Grease trap present? T 0 .Yes ❑' No Industrial waste holding tank present? ❑ Yes ❑ No +t Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water.meter readings, if available: t5ins-11110• - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 a r r Commonwealth of Massachusetts " Title 5 Official Inspection'Form' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . y� 20 Kidds Hill Rd. n Property Address Paul Rebelo » - Owner Owner's Name information is required for every Barnstable MA 02630 5-2-12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt) " Last date of occupancyluse: ' ;Date Other(describe below): r , General information . q a.M•. d .. .a 4 Mk ' .. r Pumping Records: 5 Source of information: 2010_ a Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: . gallons How was quantity pumped determined? '• Reason for pumping: Type of System: ® Septic tank;distribution box,'soil absorption system ❑ Single cesspool E Overflow cesspool ` ❑ Privy ❑ Shared system.(yes or no) (if yes, attach previous inspection records, if any) Innovative/Aitemative 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.;y ❑ . Other(describe): • t5ins•11110 Title 5 Official Inspection form:Subsurface Sewage Disposat System-Page 8 of 17 Commonwealth &Massachusetts Title 5 Official Inspection Form q Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Kidds Hill Rd, Property Address Paul Rebelo Owner Owner's Name information is Barnstable MA ` 02630 5-2-12 ` required for every ' page. Cityfrown State Zip Code Date of tnspWion D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1996 Permit # 96-526 Were sewage odors detected when arriving at the site? Yes ® No Building Sewer(locate on site plan): !. k_. Depth below grade: feet Material of construction: « "- F1 cast iron ®40 PVC [:1 other(explain): Distance from'private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): 4" PVC SC 40 Septic Tank(locate on site,plan): 1011 Depth below grade: feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years 6 Is age confirmed by,a Certificate of Compliance?(attach a copy of eertilicate)' ® Yes F] No Dimensions:. 1500_Gal Precast 1 1f Sludge depth: t5ins-11110 d Tate 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17' f Commonwealth of Massachusetts Title 5 Official Inspection Form- MOW - Subsurface Sewage Disposal System Form-Not for Voluntary'Assessments 20 Kidds Hill Rd. ` Property Address v • 9 Paul Rebelo ` Owner Owner's Name information is Barnstable MA 02630 . 5-2-12 required for every ' page, CitylTown State Zip Code Date of Inspection w D. System Information (coat.) Septic Tank(cunt.) £. Distance from top of sludge to bottom of outlet tee or baffle 2911 2„ , ` Scum thickness Distance from tap of Scum'to top of outlet tee or baffle - $1 Distance from bottom of scum to bottom of outlet tee or baffler ' 1611° How were dimensions determined? s Tape-Aub6ilt Comments(on pumping recommendations,inlet and.outlet tee or baffle condition,,structural integrity,. liquid levels as related to outlet invert, evidence of leakage, etc.): Tank and cover at.10" Below Grade, in and outlet Tees, Tank at working level, No sign of leakage or over loading - { Grease Trap(locate on site plan): Depth below grade: �t ' feet Material of construction: ,} ❑concrete El metal $'D fiberglass Elpolyethylene .n [Iother(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: • bate t5ins•N/10 ,' Title 5 Otriciat tnspebtion Form:Subsurface Sewage Disposal System•Page 10 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form"' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Kidds Hill Rd. . Property Address - Paul Rebelo ' Owner Owner's Name information is Barnstable - MA 02630 5-2-12 required for every page. Cityfrown State Zip Code Date of Inspection -, D. System Information (cont:) 4 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural•intigrity, liquid levels as related to outlet invert, evidence of leakage, etc.), . s Tight or Holding Tank tank must be pumped at time of inspection) e o siteplan); g g ( p p p )(locate _n s t- Depth below grade: Y 4 'y Material of construction.. a ❑concrete ' ❑ frietal f ❑fiberglass ❑ polyethylene ❑other(explain;:t Dimensions: Capacity: k gallons Design Flow: gallons per day Alarm present r ❑ Yes ❑ No ; Alarm level: 'Alarm in working order: ❑ Yes No4 " • F Date of last pumping: r Date Comments(condition of alarm and float switches,etc.): "Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No t5ins•11M0 Title 5 Offiaal Inspection fwm Subsurface Sewage Disposal System•Page 11 of 17' Commonwealth of Massachusetts y, ` Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 20 Kidds Hill Rd, Property Address Paul Rebelo Owner Owner's Name information is Barnstable MA 02630„ 5-2-12 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert `. 0`" Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover;any ti evidence of leakage into or out of box,etc.): D Box is 16"x167 1' Below Grade w/one line out, wall's are gone, need to replace D Box, No , Sign of solid carry over , Pump Chamber(locate on,site plan): - Pumps in working order: - ❑,Yes• No ' Alarms in working + ° order: - `❑ Yes• [l No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):, Soil Absorption System (SAS)(locate on site-plan, excavation not required): If SAS-not located, explain Why t5ins•11M0 :, ,; Title 5 Official k4acdon Form:Sulwurface Sewage Oieposal System Page 12 of 17+' Commonwealth of Massachusetts Title 5 Official Inspection Fora , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 20 Kidds Hill Rd. y° Property Address Paul Rebelo Owner Owner's Name information is Barnstable 'MA 02630 '5-2-12 required for every • - page. Cityrrown ,, State Zip Code Date of Inspection D. System Information (cont.) Type: t ❑ leaching pits number: leaching chambers -number: ❑ leaching galleries number. ❑ leaching trenches number, length: El leaching fields number,dimensions:~ ❑ overflow coly number: ❑ innovative/altemative system U Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of . vegetation, etc.): . Leaching is three flows, 'Flows are 40"below grade,, Camera line out to flows, did T.H. Above and beside flows, Dry and clean. Sand and stone, No sign of over loading or solid carry over Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration f ' Depth top of liquid to inlet invert Depth of solids layer 'Depth of scum layer Dimensions of cesspool, Materials of construction y Indication fgroundwater.ca o inflow 'Y e t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official inspection 'Form ' Subsurface Sewage Disposal System Form Not for Voluntary Assessments •20 Kidds Hill Rd. Property Address f . Paul Rebelo •' Owner Owner's Name information is required for eve Barnstable MA 02630 5-2-12 page. every Cityrrown State Zip Code r, Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level'of ponding, condition of Vegetation, etc.): , Privy(locate on site plan);, Materials of construction: 4 Dimensions H r Depth of solids - Comments(note condition of soil;signs of hydraulic failure,,level of ponding, condition of vegetation,_ etc.): ` t I t5ins•11/10 r a, Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts ' Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments. �t 20 Kidds Hill Rd. Property Address Paul Rebelo Owner Owner's Name information is Barnstable 02630 5-2-12 required for every page. Cityrrown State Zip Code a Date of Inspection D. System Information.(cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate_ where public water supply enters,the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately. 3 - t • t` 4 - ` r i t5ins-11l10 Tide 5 Official inspection form:Subsurface Sewage Disposal System-Page 15 of 17 T6WN OF IiARNSTAELE t LOCATION! 2.6 <��CI�S ��`� ' �� X SEWAGE VILLAGE ASSESSOR'S .MAP LOT j (. INSTALLER'S NAME & PHONE NO, \ f i.r� n�7��- ``; SEPTIC TANK s � cAPACITY, LEACRING FACILITY:( pe) NO. OF B9D.R'0014S . PRIVATE TmEI.L OR PUELIC WA'TEIL , ` BUILDER OR OWNED tt i � DATE,PERMIT ISSUED-, DATE 'COMPLIANCE-ISSUED: VARIANCE GRANTED: Yes NO 1p g��� i' { ` -p. . a Cis z z,,.��fit^-�y4°��s' -�"�'7, i' `:�' u�a„, s ,; ;� q, 1 =F ; •. r c Commonwealth of Massachusett s t Title 5 Official Inspection'Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 20 Kidds Hill Rd. ` Property Address 4 Paul Rebelo Owner Owner's Name information is required for every Barnstable -MA 02630 : 5-2-12 page. Cityrrown State Zip Code Date of Inspection D. System-Information (cont.) w t Site Exam: ❑ Check Slope ❑, Surfaee water x 0 Check cellar ❑ Shallow wells . 12+t . 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 y, If checked, date of design'plan reviewed: Date ® Observed site(abutting property/observation hole within 150 feet of SAS) ❑ " y Checked with local Board of Health-explain: . ❑ ° Checked with local excavators; installers'-(attach documentation) ® Accessed USGS database-explain: 'You must describe how you established the high groundwater elevation: t . Area high , Abutting property and main Rd.- Drops off w , • rIN ,. Before filing this Inspection Report;please see Report Completeness Checklist on next page. 11 t5ins-11/10 Title 5 Official Inspection Form:Subsudace Sewage Disposal System-Page 16 of 17 c Commonwealth of Ma SSachuset Title 5 Official lnspectior Frmi , Subsurface Sewage Disposal'System Form=Not for Voluntary;Assessments 20 Kidds Hill Rd. .h Property Address _ Paul Rebeio Owner owners Name • �: information is fi} required for every Bamstabte MA '02630 5-2-12 - page, CitylTown ` . 'State Zip Code Date of Inspection E. Report Completeness Checklist° 41 ❑-inspection Summary:A,'B, C, D,,or E checked ❑ 'Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ,System Information-Estimated"depth to high groundwater # a ❑ Sketch of Sewage Disposal System either drawn on page,'15'or,attached in separate i'~le - 0. e s ♦ 4r. n x a x r r m V t•�.sp ,. � ,�1 -. t " � �e - - u ,t iy' a .4+# ' if + v# t5ins•11110 1 ' e TIW 5 Official inspection Form Subsurface Sewage Disposal System•Page 17 of 17 a 9 _a No. �� Fee V`00 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ppliCation for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair(_11"Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. yp /Lirf d S Ni)) Rd Owner's Name,Address,and Tel.No. Assessor's Map/Parcel `-7 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Mt Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) Nr► gpd Design flow provided ANT gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) R e. Ic c_r 7_7 Date last inspected: Agreement: i 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 Health. Si ed Date Application Approved by Date Application Disapproved Date for the following reasons Permit No. 2FJ rZ— 2+( Date Issued uc Zol L .: _—------------------------------------- - - -� - - -�-� - -- - -- No. Zo 1 Z — t Z Fee /00 THE COMMONWEALTH OF:MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS i 1 Zipplitation for -Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. yp /LlJd s A);)) Rd Owner's Name,Address,and Tel.No. /2obt//v Assessor's Map/Parcel 7 Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: A '�y Dwelling No.of Bedrooms /U 1 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) i Other Fixtures ij Design Flow(min.required) r9 gpd Design flow provided /V VT gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil } Nature of Repairs or Alterations(Answer when applicable) / ,��,.�. Z-7 Date last inspected: Agreement:-N 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 Health. Signed Date 5- y Application Approved by Date 5 Application Disapproved Date for the following reasons Permit No. Zp i-7 — 12 Date Issued s��� Za1 Z - - - - - - -- -- - - - -- -- --------- ---------- -- - THE COMMONWEALTH OF MASSACHUSETTS �_ / � BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ' Upgraded( ) Abandoned( )by at Rell has been constructed in accordance / with the provisions of Title 5 and the for Disposal System Construction Permit No.o a- t 2`1 dated 51y f 20 Installer � �« /�,�,,�,✓ Z"i c Designer #bedrooms Approved design flow gpd The issuance of this permi shall not be construed as a guarantee that the sys,atom wTill-fu%cuon`a/ss'desi, d. i i Date y Inspector •._� — / ------------7 ------ - - - - ------------- -------------------- -------------------------------- 27017 1 --q Fee_*�Oy THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem onstruction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at ,2 R'/ /A,DNS f G A and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with i Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. �~ f Date L/ Pp 12— Approved by j ,fir /G 4 r - 90/ P � TOWN OF BARNSTABLE Q LOCATION )0 J<\AS R 11 P9 SEWAGE VILLAGE �(,lf Y1s�a�l ASSESSOR'S MAP & LOT a76 • ats-- INSTALLER'S NAME & PHONE NO. V ��Lt ��n��S wDjC� JA AAI SEPTIC TANK CAPACITY 15 OO LEACHING FACILITY:(type) F low I (size) 3 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER `BUILDER OR OWNER R V` Rf 6 E 0 O . DATE PERMIT ISSUED: 16 -a( 6 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No U e v0,At- 1*6- �- o E_ a� CMG II 0 a ASSESSORS MAP NO: (� No. ""®°D Feel-0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 3pprication for Mi!9pogar *pgtem Cow5truction Permit Application for a Permit to Construct( )Repair('✓)Upgrade( )Abandon( ) O Complete System El Individual Components Location Address or Lot No. 0 'ss N;e,Ad ss an¢Tel.Np. 3 69,3?3 6 Assessor's Map/Parcel 9 7� ® / �`—� sy,,1, �s b q G 0` �J (� 1 Installer's Name,Address,an5 Tel.No. Designer's Name,Address and Tel.No. V e1*1k1�,� °s c� vt �I 1 o s L 6 3G Type of Building: Dwelling No.of Bedrooms Lot Size sq ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank _f Type of S.A.S. Description of Soil A4 eil�. lij m4— ,5 Nature of Repairs or Alterations(Answe when appli able) 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 issued s Board f f Signed ✓% Date ,o Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued ` "� ch No. �� Feet/V THE COM Entered in computer: MONWEAL H OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Application for Mtopozar *pgtem Construction Permit y Application for a Permit to Construct( )Repair Upgrade(, )Abandon( ) ❑Complete System ❑Individual Components B� Location Address or Lot No. �+ _Ow �s�Name,Ad ss ancj Tel.ND. 3 69.3�3 6 Assessor's Map/Parcel71 1 e b / O led j Installer's Name,Address,al Tel.No. Designer's Name,Address and Tel.No. a dds lr 5i_ � t 1 3 �36 Type of Building: � 4'_C/2 Dwelling No.of Bedrooms Lot Size�sGft. Garbage Grinder( ) Other Type of Building Qn C No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil's � {� �IL,At- 5 t11,"c Nature of Repairs or Alterations(Answes,when.appli able) 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 issued this BoardJ ea� Signed Date A /,—P ,/ Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued �Q THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE IF ,th t the On-site Sewage Disp sal ysteZCo tru t d( )Repaired( )Upgraded Abandoned( )b �� S a VG at 9V _5 ( as bbeeen constructed in accordance/ with the provisions of Title 5 and the for Disposal System Construction.Permit No. �15 dated Installer ue l t l Aue) Designer The issuance of this permit shall riot be construed as a guarantee that the system�will function as designed. Date i I / Inspector, . . .4 t. ` THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpozar *pgtem Construction Permit Permission is hereby.granted to ons t( ) ep ) p rade( Abandon System located at �t �S -� � 6 Q#&S IV / and as described in the above Application for Dis posal sposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. I Provided:Construction must be completed within three years'of the date of this BASM Date: `" / Approved b I 4 F r• j CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS-CONSTRUCTION PERMIT(WITftOUT DESIGNED PLANS) f� ereby certify that the application for disposal works construction permit signed by me dated r I Ig concerning the � I ----� propertylocated at © - C meets all of the= �% following criteria: N,: } T e are no wetlands within 30�0 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system i The observed groundwater table is 14 feet or greater be o wthe bottom of the leaching facility ZThe is no increase in flow and/or change in use proposed_ There are no variances re quested needed. SIGNED : r DATE: t Id LICENSED SEPTIC SYSTEM INSTALLER IN,TflE TOWN OF BARNSTABLE uNUMBE 1 [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. I ' C9 �n 1 f^VA, f `. a