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HomeMy WebLinkAbout3625 MAIN ST./RTE 6A(BARN.) - Health 3625 Main Street/Rte 6A (Barn; Barnstable, P i �— esa _ _ A 317 042 n , r. , v w } u - TO ko » Y� r + :9c K r R h , ° � � ,�`. `" - ..,-,c, y�. ,-�r�- ,,gy x-.. - v�� � -�- �r..�,�.�.,..T.a � .,.� �•,�.:,tSrpF'��3r�a ❑ a.r.. .. .. - , -.c;;a" � - .,� •. j,� x :t , „ . e t --_. _:� _�-..__ -< -f:, .. •_: �:'-Rs,�-�..+,-psi..-- all -oqa- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3625 Main St. Rt. 6A �•_ Property Address Shuck Owner information Owner's Name is required for every page. Barnstable VY MA 02630 2/5/19 _ 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. A. General Information 67# 18&IC— 1. Inspector: Frank Nunes III Name of Inspector saa Company Name Box 841 Company Address East Falmouth MA 02536 City/Town State Zip Code 508.272.6433 13010 Telephone Number License Number . B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and 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 2/5/19 Inspect Signatur 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.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 .t I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name is required for every page. Barnstable MA 02630 2/5/19 Cityrrown State Zip Code Date of Inspection B. Certification (cont.)` Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.. - Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name is required for every page. Barnstable MA 02630 . 2/5/19 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water . ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G M , 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name is required for every page. Barnstable MA 02630 2/5/19 City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ® Discharge or ponding of effluent to the surface of the ground or surface waters El due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y day flow t5ins.doc•rev.6/16 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 M , 3625 Main St. Rt. 6A Property Address Shuck Owner information Owners Name is required for every page. Barnstable MA 02630 2/5/19 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 well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name is required for Barnstable MA 02630 2/5/19 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No a ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank_ inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 5 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 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 Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,•' 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name is required for every page. Barnstable MA 02630 2/5/19 Cityrrown State Zip Code' Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El 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: weekendsDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name is required for every page. Barnstable MA 02630 2/5/19 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped 2016 and post inspection per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ❑ Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name t is required for every page. Barnstable MA 02630 2/5/19 City1rown State Zip Code Date of Inspection D. System Information (cont.) • P Approximate age of all components, date installed (if known)and source of information: 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): . 12„ Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 411 Depth below grade: feet p 9 • feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) H-10 tank under Bluestone patio appears to be structurally sound If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500g 411 Sludge depth: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 3625 Main St. Rt. 6A Property Address Shuck Owner information Owners Name is required for every page. Barnstable MA 02630 2/5/19 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle >12" Scum thickness 1" >2„ Distance from top of scum to top of outlet tee or baffle >2„ Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 years to prolong the life of the system 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 g 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 Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M , 3625 Main St. Rt. 6A Property Address Shuck Owner information Owners Name is required for every page. Barnstable MA 02630 2/5/19 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ' ❑ concrete ❑ metal a ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): t "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11'of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name is required for every page. Barnstable MA 02630 2/5/19 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0„ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 D-box is 18" below grade, it appears to be structurally sound 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - M > 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name is required for every page. Barnstable MA 02630 2/5/19 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 6 ❑ 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.): 6 infiltrators per BOH record, infiltrators were video inspected and are damp at this time, no indication of past hydraulic failure, bottom of chambers is approximately 4' below grade, per 1995 compliance the seperation distance between the maximum adjusted groundwater table and the bottom of the leaching facility is 6.5' 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 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name is required for every page. Barnstable MA 02630 2/5/19 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): .p 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 Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name is required for every page. Barnstable MA 02630 2/5/19 City/Town State Zip Code 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 On01 l � 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 Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 3625 Main St. Rt. 6A Property Address Shuck - Owner information Owner's Name is required for every page. Barnstable MA 02630 2/5/19 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells >8, 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: plan not available, Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: >4' seperation per 1995 compliance, GW at 14.7' per previous inspection report ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: TOPO mapping shows the site at approximately 30' msl and nearby surface water at 22'msl You must describe how you established the high ground water elevation: Per 1995 compliance the seperation distance between the maximum adjusted groundwater table and bottom of the leaching is 65, The engineering plan is not available, TOPO mapping would suggest groundwater at about 8'which would give the system about a 4'seperation, the presence of a sump would also suggest a higher than previously reported groundwater elevation. In my best professional judgement I would say that the system is not within high groundwater but the 4' seperation may not be met Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6116 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 , 3625 Main St. Rt. 6A Property Address Shuck Owner information Owner's Name is required for every page. Barnstable MA 02630 2/5/19 City/Town State Zip Code Date of Inspection E. Report Completeness Checklist , ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED NOV 4 Z003 TO.V'VN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A �• CERTIFICATION 614 Property Address: a 7 �Air� --C - Owner's Name: ar✓!s a /I7A l7d16.?0 _ � '& h , ,. • Owner's Addresk ff,03e -reo, MAP n a 6tH" PARLEI Date of Inspection: �,OT - Name of Inspector: (please print) /' '/Gc✓ham Imo���� . Company Name.• IVV✓ ' Mailing Address: O v d 4!9As Oa6��l Telephone Number. S'o a7 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000� The system; Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: o The system inspector shall submi a copy of this inspection report to the Approving Authority(Board of Health or' DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments -k M l V1 0 0Cj 0 C / cp T GI F Vl-ee cfs /0 ' 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. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A 1 CERTIFICATION(continued) Property Address: Owner t Date of Inspection: /p ,? p Inspection Summary: Check AAC,D or E/ALWAy�complete all of Section D x z System Passes: . I have not A- found arty information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: � One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of thereplacement or repair,as approved by the Board of Health,will pass, Answer yes,no or not determined(Y,N,ND)in the for the following statements,If"not determined"please explain. 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. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken on obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pass inspection if(with approval of the Board of Health): y pipe(s).The system will broken pipe(s)are replaced obstruction is removed ND explain: • Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: /*t o Date of Inspection: 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determinetthat 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 **Tbis system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 4 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: �G a� Ci,a ' si- e y, 6' Owner: I C 1 �T Date of Inspection: 41 ,? p D. System Failure Criteria applicable to all systems: You must indicate`yes"or"no"to each of the following for all inspections: Yes Ng� _ ✓✓ kup of sewage into facility or system component dire 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 AS or cesspool 6/ Atatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6 below invert or available volume is less than%:day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number /of times pumped T ,,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. _ ..IZ',, portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. r/ 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 conform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] 0(Yes/No)The system fa0s.I have determined that one or more of the above failure allure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either`yes"or"no"to each of the following: ('The following criteria apply to large systems m addition to the criteria above) yes no the system is within 400 feet of a sur�ce ddnldng water supply the system 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitroge tive area(Interim Wellhead protection Area—1WPA)or a mapped ~ Zone II of a public water supply well If you have answered"yes"to any question in Section E the systemic 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 ll shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM PARS'B CHECKLIST Property Address: Owner: +I"[ c�✓ r+'!1 P, '�� i Date of Inspection; O ,3 p Check if the following have been doge:You mast iodic ate"pees"or"no"as to each of the k1lowing: T _ Pumn ng information was provided by the owner,occupant,or Hoard of Health , ere any of the system components pumped out in the previous two weeks — Has system received normal flows m 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 ofthe system obtained and examined? were riot .(�� available note as N/A) Was the facility or dwelling inspected for signs of sewage back up F Was the site inspected for signs of break out- Were all system components,excluding the SAS,located on site ere the septic tank manholes uncovered,opened,and the interior of the tank of or mnspeeted for the condition tees,material of car�truction,moms,depth of liquid,depth of sludge and depth of scum _ Was time facility owner(and occupants if different from owner)provided with information on the proper., maintemanoe of subsurface sewage disposal systems. The she and location of the Soil Absorption System(SAS)on the site has been determined based on:. Yes `e, 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)f 310 CMR 15.30Z(3)(b)] Y Y Page 6 of I 1 • OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C n SYSTEM INFORMATION Property Address.- Owner: f�, Date of Inspection: /n J 0 7 OW CONDMONS. RESIDENTIAL fie, e::flf-- Number of bedrooms(design):S Number of brooms DESIGN flow based on 310 CMR 15.203 for (actual): . ( example: 11Q gpd x#of bedrooms): Number of current resideft: Does residence have a garbage grinder(Yes or no): IVP Is laundry on a separate sewage system or no}:A�[if Yes SCparaW inspection regmr4 Laurxky system im�(Yes or no): Seasonal use:(yes or no): ti0 Water meter re adhW6 if available(last 2 years usage(gpd)): Sump pump(Yess or no):to f Last date of occupancy: Chi N/�crr COMMERCIALn"USTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persoffi/sgft etc.): Grease trap present(yes or no):— Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): f. Water meter readings,if available: Last date of occgxmcy/use: OTHER(descnbe): ' GENERAL INFORMATION Pumping Records Source of information l�10 ✓'i /e oZ �' (a P y S m L vivu Y Was system pumped as part of the inspection(yes or no): If yes,vohune pumped Mons—How was.quantity pined determinee Reason for pumping: GToF SYSTEM —Septiic tank,distnbution box,soil absorbion system _Single cesspool _Overflow=spow _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternatve technology.Attach a.copy of the cu ffmt operation and maintenance contract(to be obtained from system owner) _Tigbt tank —Attach a copy of the DEP approval Other(describe): . a . Approximate age of all components,date installed(if bum) of information, 9 � Were sewage odors detected when arriving at the site(yes or no):/+'V , Page 7 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner. l G`✓! �n Date of Inspection: BUILDING SEWER(locate on site an) II Depth below grade: / Materials of construction_ st iron (_ PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,.etc:): SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction concrete metal fiberglass_--polyethylene If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) �" Dimensions: co X 117 Sludge depth: - Distance from of top sludge to bottom of outlet tee or baffie: oZ 9 Scum thickness: L „ Distance from of scorn to top top of outlet we cu baffle-�_ Distance from bottom of scum to botto�}o�outlet tee ore: c.,� •� / How were dimensions determined /`0!C ^445 e w Comments(on pumping recommendations,inlet and outl tee or baffle condition,struchual integrity,liquid levels as yelped to outlet invert, e of leakage,etc): GREASE TRAP✓//(locate on site plan) Depth below grade:_ Material of construction concrete metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scam to top of outlet tee or baffie: . Distance from bottom of scum to bottom of outlet tee or baffie: Date of last pumping _ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,strucpual integrity,liquid levels as related to outlet invert,evidence of leakage,etc.); t. . Page 8 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. 3�O oZs ��l h }— Owner, !c Date of Inspection: TIGHT or HOLDING TANK*."( must be pumped at time of inspection)(locate on site.plan). ... .._ Depth below grade: Material of construction: concrete metal fiberglass_polyethYlene .. other(explain): Dimensions: Capacity: lioons Design Flow: gallons/day Alarm print(yes or no): Alarm level: Alarm in working order(yes or no): Date of last Pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (`� if present mast be ovate on site opened)(1 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 19;out of box,etc). PUMP CHAMBERV (locate on site plan.) Pumps in working order(yes or.no): ' Alarms in working order(yes or no):. Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Addr+esa: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: ; Type . c leaching pits,number n. ��-�ro. j.�. �i✓ r leaching chambers,number: ,S�o kv— leaching galleries,number: leaching trenches,number,length: " leaching.fields,member,dimensions: overflow cesspool,number: innovativeJalternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): -Sol L Gi' A4/� } CESSPOOLS:/!/ (cesspool must be pumped as part of inspectionXIocate 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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:L'!�paste on site plan) " Materials of constriction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): r i , Page 10 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(confirmed) Property Adams: .S}-- Owner: � �. Date of In tion: 3 O SKETCH OF SEWAGE DI$FOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference hm&w s or benchmarks.Locate all wells within 100 feet.Locate where public water supply eaters the building, Flo , /7/ AV _ �2t-C�L I 1 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C _.. / SYSTEM INFORMATION(contim ed) Property Address: - Owner:_ Date of Inspection: 0 6- 3-SITE EXAM Slope _. Surface water Check cellar Shallow wells Estimated depth to ground water T T'feet Please indicate(cheek)all methods used to determine the high ground water elevation: Obtained from system de V plans on record-if checked,date of design plan reviewed: Obsoved site.(abutting property/observation hole within 150 feet of SAS) _L.e� Odd with local Board of Health-explain: ✓','�f t Chocked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You mist describe y established the .0 gad TO AN _ -` . . 0 t � �/Q trt wG T i 1 �: .. .. TOWN OF BARNSTABLE LOCATION SEWAGE # J �d VILLAGE /�S�146f ASSESSOR'S MAP & LOT,?/7~ INSTALLER'S NAME&PHONE NO. CPA)Lo 2 7S'Z S/GO SEPTIC TANK CAPACITY �S�r LEACHING FACILITY: (type) /✓� T 21 D� size) NO. OF BEDROOMS s ANJ —3 BUILDER OR OWNER OGEE PERMITDATE: � COMPLIANCE DATE: C! Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �'� Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) IVIA Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Nl� Feet Furnished by '` :M l3 agar Y-Ol2ef7 F� Fr, 2 3��r Fr 3 PARCEL HE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Applirttt"nn fur Diripwial Works C owitrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair (Lan Individual Sewage Disposal System at .. _ .............................I �...6---•---•----•-•4vw,�I&�k----------------------------------------------------------------------------- Location-Address or Lot No. .............................................. ------------------------------- ......------------------------------...._...... owner Address a ----------------•-•--•.............................................. ----------.._.....------------------•---...--•-----------•--------•------........------........... Installer Address UType of Building " ` Size Lot............................Sq. feel ,., Dwelling— No. of Bedrooms----------___________-----------------------Expansion Attic ( ) Garbage Grinder ( aOther—Type of Building ------------_------------___ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures ...................................................... W Design Flow_..........................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench— No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.-----. ---•---------------------•-•-----------------..._..-----••-----... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water.._.------_-_-_--_-- G74 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 -------------------------------------------------------------------•--•---------•---•-----------........-.......----....-•----......•-----•---........_.--•-- 0 Description of Soil....................................................................................................................................................................... W V -••.._........-•---••----•----••--•••••-----•••-----------•-----------•-•------•-•------•-----------------•-•----•--•---.....-------•--------...-•--------•----•------------------------•-------•....... MW .......................................................•------.._.............--------- --------------------- g �.............................. ......_......................._....�.�_ ....f...!.// .. --.-.... U Na�tire of Re sor Alterations—Ansver when applicable . : G........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been inssued b he board of health. Signed ............. . ram'........... -.- ..-... = ........... ....... ........................................ Dace ApplicationApproved ........ .. ................................................... . ............. ...... .. - .5�-- Dace Application Disapproved for the following reasonr: ........................... ........ .......... ..... .. .. . ............ ..................................... ............ ..................................................................... ........ ........ ... .............................. ......... . . .............D..a.t.e............. . Permit No. ....`�-97 .~ -���� :.............. Issued ............ ...: Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE V ertifirat e of (gantylianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �� by ..................................................... ..--------............................. -------------------1------------------------------------------.._._..------------------------------............ at .......... ".1 ........ ....... }` - ;;l/ST.-9.6- -e... -- ......--. ...................... --......... ........ has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described.in the application for Disposal Works Construction Permit No. --------- dated-��.:..'�-`T'�_ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT B CONSTR EA AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFA T_ORY. ----- ..1 DATE....... .......�.�.........�,,�_..._........... _...._..._. Inspector - � _.. . -... . . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE N.X� .. 7�� FEE.---:�U......... Displatitt1 Workii Tomitrudwn "permit Permission is hereby -granted � � Kc').......................................................................................... to Construct ( ) or Repair ( . Individual Disposal System strcet� as shown on the application for Disposal Vl'orks Construction Perini o "� � Dated-c � Board of Health DATE '°�y-.. F FORM 36508 HOBBS&WARREN.INC..PUBLISHERS /J4d .y.yr•_�J�v �L. � ` - —� eyr y�r V .... .. ...... . .(h.V, W,_�.._.. (jf .. 'V - ., .r `Y �..__ v_-- � I oq 3_ No..? ". �� FHB... .......... THE COMMONWEALTH OF MASSACHUSETTS 4 , BOAR® OF HEALTH TOWN OF BARNSTABLE Appliratiun for Diripwial Murku Towitrnrttun Permit Application is hereby made for a Permit to. Construct ( ) or Repair (,,)-an Individual Sewage Disposal System at: Ogj 5 a r........� - .( )S`�/� ( P......................... ...........•--..........---•-----.....------... Location-Addn'ss or Lot No. f Ouncr Address W C' i Installer Address d Type of Building Size Lot............................Sq. feelf aDwelling— No. of Bedrooms...-----.- ------------------------Expansion Attic ( ) Garbage Grinder ( lf p,, Other—Type of Building ............................ No. of persons.--------..-------.-.-..---- Showers ( ) — Cafeteria ( ) Iad Other fixtures ------------------------------------------------------------------------ -------------- ----•----•--•---••--•-•-•-•-••--••••-••••---•-...-•-......... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length....:........... Width-..------------- Diameter---------------- Depth................ x Disposal Trench—No. ....................Width.................... .Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No..................... Diameter----------.-...----- Depth below inlet.................... Total leaching area..................sq. ft. Z Other 'Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------- --------•------•-•••--•-.........--••••......•-•-----............ Date........................................ a Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water..--.................... fx, Test Pit No. 2................minutes per inch Depth of Test. Pit--............--.--. Depth to ground water........................ �+ ---•--•----------------------------•----•--------••-•-----------.-----------.....------•--------.......................--•--..------._........••--••------ i0 Description of Soil......................... -•••--•••------•-------•-------------------•-•------------------------------•--------•-----•---.............................................. 'I x V ........-•-....-•-------------------------•----......•-•-•-•---•--•....-••---------•---...----------------•--------•--------•------•----•-------•--•--....-•---------•----......._-••--•-••--••......... ---------------------------------------------------------------------------------------------------------------•-- ----... ----------------- -•--•---------••----...................... Nature of Rep rs or Alterations—Answer when a plicable...- ?��.�j..--.. V - ". .vDG1••-•-••,a9- __- i •.. T�� --• -•---..--6-'-.— ......-7- -�--- --------�-�..... ?fin�i��.�"�.7��(.S......-�ts' `�--.`. :��i�3Y�'........I.............. Agreement. _ The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by ;he board of health. /1 � �- ?J Signed ......:......../ � .,........ _..-..................-- ................. ......................................... Dare Application Approved B .......-.. ....L- ���. - - - --------------------------------- Application Disapproved for the following reasons: ........----....----------... .... ...__..--.. . ................--.---..---.. ..... . ............................... ................................................. ......... ..................................... ........ -- .......... ........... .................. Dale Permit No. ....;/.�,- �------ ............. 1 Issued .............,_. ,— Mm Q 1 L (dV- FI-V L _ r / } is V 'a• �, f t --- ,� j -- -------- I � ��.r_ i �� i �� i! 4 ,�, �;� i ; � �� t4 j i i �; � ; I y, I 1 � i ?� � ;� i li i` _( i ?. i , ;i � � -- 1 i �. ' � }tytyiiii £. j' f 1 EXCERPT FROM THE BOARD OF HEALTH MEETING 5/12/09 MINUTES: III. Hearing - Underground Storage Tank: A. Bill Larmee, ownerZ; 625-MaineStreet„Barnstable .- ;.. Issue was resolved prior to the meeting. The Fire Department submitted the paperwork showing the tank was removed in 1998. t TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRAA}TIIOON" MAP NO. t PARCEL NO. ,.�. v/ ADDRESS OF TANK: 3 G9 a2.5 i �'T �l VILLAGE: 1�•- Ivumbir. i� alr��t MAILING ADDRESS ( IF D I FF Lb'ENT FROM ABOVE) : �� l"3 >X ,673 /, �4krN.���hf�E OWNER NAME: � / U/l) PHONE: .6-o 34 G 7 7 0,r4,INST.ALLAILO.N .DATE:. !_ V4 HYdV11Et�t� �,- �_ ._.� v INSTALLER ADDRESS: Mo, 'CERT.�JO. *TANK LOCATION: �RST Si @ 6� Wo L-1 � . by l if hf=ll! wi"Y.G y/ A (Dam nP 4 T `v L T k OCAION W S TH "momacT TO =U I L,D S NO) lk , CAPACITY ,� d0 T\Y�PE;e©F TANK � ' :.` AGE A�YRS. FUEL/CHEM I CAL . C /z.- L%o�v TESTING CERTIFICATION C PASS C ] FAIL DATE LEAK DETECTION C CHECK IF N/A TYPE/BRAND i ZONE OF CONTR �B:U�T�hON- -[]--Y S�— ]-NO—DATE T0-B.E.-R,EM:OVE.D 00 1Q FIRE DEPT. PERMIT ISSUED C ] YES C ] NO DATE t T V�v° CONSERVATION CHECK IF N/A DATE t q HOARD OF HEALTH TAG ;6y. C ] DATE 1 r CS PLEASE PROVIDE A SKETC.H '$HOWING THE TANK LOCATION ON THE BACK OF THIS CARD N 5 /Avk` I t r S^ BARNSTABLE COUNTY HEALTH AND ENVIRONMENTAL DEPARTMENT SUPERIOR COURT HOUSE �EG S� p " L V BARNSTABLE, MASSACHUSETTS 02630 0()&0 IW 'rt MA 55 31 1 PHONE: 362-2511 c EXT. 330 LAB 337 CLINIC 340 NAME Thomas Moore DATE TESTED 12/28/88 TANK LOCATION 3625 Main Street, Barnstable, MA TANK AGE 19 TAG # CAPACITY 500 gallons Thank you very much for participating in our program to test underground storage tanks (UST) by soil gas analysis. The free test was offered under a grant the Barnstable County Health & Environmental Department received from the Environmental Protection Agency. Because the use of soil vapor monitoring for UST system release detection is very recent and only limited information and experience exists with using vapor sensors in this manner, we can -- ' ►_1.of'—guarantee-that.. yo,ir- tank has not leaned. --However-, cur tests did not indicate and problem. You should also reaize that a "good" result from our test is no indication. of how long the tank will remain sound. If you ever decide to remove your tank , it would help our work if you notified us so we could take a look at it after excavation. This method has been given an interim approval for 1988 by your Board of Health. Depending on results of research this year, complete approval may be given, otherwise you may be required to pressure test your tank to keep it in service after 1988. A copy of this letter has been sent to your Board of Health and the records reflect that your tank test indicated no problem. If you have any questions, please contact Charlotte Stiefel at 362-2511 extension 334. NOTE: To prevent possible contamination of your monitoring well with oil or other substances, we highly recommend locking or covering the well . xC: Board of Health (Barnstable) TOWN OF BARNSTABLE IRE OF tor. OFFICE OF BOARD OF HEALTH ■nsa 367 MAIN STREET � 0 9 HYANNIS, MASS. 02601 1988 De i is brass valve tag #- _ Please attach to Enclosed - the fill pipe of your underground tan . You must do the following as indicated. ---- Remove your tank. I have enclosed information for you regarding tank removal . Have your tank tested -str ____ . You must test during the 10th, 13th, 15th, 17th and 19th d Rfa- 6 annually thereafter. Removal in the year I - have en-:'•::::cd - information regarding .tank tQstinr ** In _-- order to have your tank tested you must first contact an engineering company (see attached) to have a monitoring well installed. Once the monitoring well has been installed you can then call 362-2511 , Ext. 334 and ask for Charlotte Stiefel or George Heufelder at the Barnstable County Health Department, to have your tank tested via the Soil Vapor Analysis Test. Currently, the test is done free of charge under the auspices of an EPA grant. Due to the unknown age of your tank we must presume it is twenty (20) years of age. You must have it tested every year and remove it by the year 1993 . To have it tested please follow the procedure as indicated above from the ** (asterisk) on. If you have any questions please feel free to call me at 775- 1120, Extension 183. Thn you, o , onnaGMiorandi Health Inspector i y . r f e ., ... >. ..-...._......... ...... .. .�^_::- _�_:.._.Y=-,...._.-..:._.:�..... ..... ..... fir. �� ...y 777iii f t f , 1 �--{ -+ ' ]{j� 1. � �_ _. ,�-_• -�.. � � � �.!___P .�_. � t •i-• ` I :...,w I ' - , 6 _ ,,,+.,.vim—.............w.-�._. . 9 I F I _ t i { t S f � , { x sm 1 } t' .s.... ., �..w...,w.rw.�...w.rw..rw.,.,...�....ue+..,......�,.......«...�.....,..,..._ .,..,,.........a. ,. .,......,,...........,,,.....-.....,.......- ,. _,�.:,.-.n. `•;:M;M..�.....,..,.... k SCAL.E r i' :, 9 APPROVED BY DRAWN BY f! DATF. "r "' V ',. REVISED t j " DRAWING NI.iMETFR f i 1 ww_r�.+•«,r_--w-..�..w•,o!f«n.yr.erauVwr-++„-.r....w-..+.,w.�swr�Mw+rowu..�.van++Y,�a rr•.,m.�R+'tr�,u�v.a.w.m,+a,.,....a.,- .... �. 17 jtS{ i £ r _ r sM1 � y{ .++rta�x-,m....w«.u,.w<rvnr.w.r+:wnwwa.+weww.•_rv..-.:....,•..,...,,,...r....v.ro-wrv:,w�..+nw.w.w��.-.w--.-»+n+�+...w.»,..., ...n,..ww+..+.r-.+....ra...rn.......n-_r.-,r-vn.w..r�..-.w....r.rwn-w...au s.a.'-.....rwn-.,.ww«.-rn-.._w__._,_,..I d v.. V r I f .n , , 1 r i x i I ' .,.,.:....-_. ..............._.»-»,..K.�.,....,.,.......a....�...._«r.,,,,..w-.a..�.,,..•.,.:...•.w•,.«.eu,=...wv...w.rvc.;......._.svrb^,.w.:.._.w;..,.nw..,ri-,.....«,'«.>+w..---+.t 2 k t t p i tt 7� i k } s : L .t i i _.7 p Y I � ._ ..... .....+.i,i.^ w-+...„t.. w..f ' ' j. j i ,% -' "'r' f j.. lY'x '"'}'•� a n...- IjT /• 4 i " BY IT-- dt 77- APPROVED : _ .. .. � j � "'�"'•—'"":`"'.�,-...,..._, ,� y y SCALE: _:•!` DRAW n NI J � t f g t L7ATE. 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