The URL can be used to link to this page

Home My WebLink About3861 MAIN ST./RTE 6A(BARN.) - Health 3861 Main Street/Rte 6A ftBar) Barnstable . F/R A = 335 008002 r d' Commonwealth of Massachusetts ,33J`- 008-DDT Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 3861 Main st r r_Y1 Property Address p,t MASTROMAURO, FRANK JR "' Owner Owner's Name information is 3> required for every Barnstable Ma 02630 10/19/17 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information fin the computer, �7# �a�6(P on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain r� Company Name 35 Content Ln Company Address Cotuit MA 02635 Cityrrown State Zip Code 508-364-9587 SI 13522 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 10/24/17 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 o a VS JV ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. 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: System contains a 1500 gallon septic tank. As well as a concrete distribution box and 3 500 Gallon leaching chambers in stone. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is Barnstable Ma 02630 10/19/17 required for every page. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M ,••'" 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 i� page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: `* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•3/13 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 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 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 El ® tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must,be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 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 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 l5ins•3/13 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 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 218 Gpd 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ 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: l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts N Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. Cityrrown 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: Not provided Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: gallons How was quantity pumped determined? 1500 Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 P 9 P Y 9 Commonwealth of Massachusetts = Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 3861 Main st Property Address MASTROMAURO, FRANK JR Owner , Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed 2002 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ® cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented at the roof line Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. City1rown 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 24" Scum thickness 311 Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•3/13 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 GSM ,•'" 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. 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 ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts u - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. Cityfrown 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 Level and at normal level Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): 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•3113 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 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 ❑ 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.): No signs of back up or failure 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-3/13 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 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official,Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. Cityrrown 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 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal S a stem Form Not for 9 p Y Voluntary Assessments 4M 3861 Main st Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar i ❑ Shallow wells Estimated depth to high ground water: 5+ft below leaching 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: 7/22/02 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 10/25/2017 Assessing As-Built Cards TOWN OF BARNSTABLE LOCATION yA.o,, SEWAGE# VILLAGEQg, ,-r<d� (r_ ASSESSOR'S MAP&PARCEL" .4aSE NAME&PHONE ,—,z&t �a A St�Si'-605 r SEPTIC TANK CAPACITY p LEACHING FACILITY:(type) _Soo 6 1 Lsect_(size) 33,s"x �z'r z' NO.OF BEDROOMS �I OWNER PERMIT DATE: (9I a? O COMPLIANCE DATE: a a I 0 a ^ Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of teaching Facility ? S Feet Private Water Supply Well and Leaching Facility(if any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY t r awe 6� No U,S-L Q r _ ___ � I At: 3q' 43_ cy� � 3 1 I I i I I http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=335008002&seq=1 1/2 Commonwealth of Massachusetts F v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main st M Property Address MASTROMAURO, FRANK JR Owner Owner's Name information is required for every Barnstable Ma 02630 10/19/17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ti T At = 30' i 3fy I I I 3 � i TOWN OF BARNSTABLE LOCATION .5?( PAA-�, SEWAGE# ASSESSOR'S MAP&PARCEL ' Q A �NAME&PHONE NO.�cacSl,o �re�.nc.. Sow-iZ -6os`� SEPTIC TANK CAPACITY t S O O LEACHING FACILITY:(type) - Soo 6a 1 Lcr�i.,(size) -3 x t2.'z GIHv w��4l�,j NO.OF BEDROOMS L( OWNER PERMIT DATE: 6 ' a'? /O a COMPLIANCE DATE: a a 1 b a Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility > Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY �acQ�v � f�'�•�C ` Commonwealth of Massachusetts Title 5 Official Inspection FormCOPY Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is Barnstable MA 02630 January 5, 2011 required for ry every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer,use 1. Inspector: . only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name P.O.r 0-b Box 371 Company Address Sandwich MA 02563 City/Town State Zip Code 508-888-6055 SI 12843 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. 1 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 January 14, 2011 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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. �J 1 - t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 1 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is required for Barnstable MA 02630 January 5, 2011 every page. city/Town State Zip Code Date of Inspection ,B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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 he replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no" or"not determined" (Y, , ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltr Ion or exffltration or tank failure is imminent. System will pass inspection if the existing tank is repi eed with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspectio If it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is ss than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 f Commonwealth of Massachusetts Title 5 Official inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is required for Barnstable MA 02630 January 5, 2011 every page. City/Town state Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cunt.): ❑ 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 B/aced ❑ broken pipe(s) are replacedY ❑ N ❑ ND (Explain below): ❑ obstruction is removedY ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or 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 and of Health: ❑ Conditions exist which require further aluation by the Board of Health in order to determine if the system is failing to protect public ealth, safety or the environment. 1. System will pass unless Bo d of Health determines in accordance with 310 CMR 15.303(1)(b)that the system i not functioning in a manner which will protect public health, safety and the environmen . ❑ 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M •''y 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is Barnstable MA 02630 January 5 2011 required for ry every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absor ion system (SAS) and the SAS is within 1 UO feet of a surface water supply.or tribu ry to a surface water supply. ❑ The system has a septic tank and SAS d the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and S and the SAS is within 50 feet of a private water supply well ❑ The system has a septic tank and SAS an 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 nalysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the pre ence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no o er failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is Tess than 6" below invert or available volume is less than '/day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is Barnstable MA 02630 January 5, 2011 required for rY every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or ❑ ® q P P 9 Y 99 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 ppin, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"o "no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 0 feet of a surface drinking water supply ❑ ❑ the system is wit n 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is I Gated in a nitrogen sensitive area (Interim Wellhead Protection Area— IWP or a mapped Zone II of a public water supply well If you have answered "yes"to a question in Section E the system is considered a significant threat, or answered "yes" in Section D bove the large system has failed.The owner or operator of any large system considered a significa t threat under Section E or failed under Section D shall upgrade the system in accordance with 3 0 CMR 15.304. The system owner should contact the appropriate regional office of the Depa ent. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is required for Barnstable MA 02630 January 5, 2011 every page. City/Town State Zip Code. Date of Inspection C. Checklist Check if the following have been done.You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ 0 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): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 454.3 GPD t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,.' 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is Barnstable MA 02630 January 5, 2011 required for fY every page. City/Town State Zip Code Date of Inspection D. System information Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No GPD Water meter readings, if available (last 2 years usage (gpd)): 2 2009= 153 010= 153 GPD Detail: Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate 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 th Title 5 system? ❑ Yes ❑ No Water meter readings,if availabl t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 II Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is Barnstable MA 02630 January 5 2011 required for ry every page. cityrrown 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: Owners records: Pumped Summer 2009 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) ❑ In 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 09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >'r 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is Barnstable MA 02630 January 5, 2011 required for rY every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed (if known) and source of information: System installed July 22, 2002. Certificate of Compliance on file at Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: T811 feet Material of construction: ❑ cast iron 0 40 PVC ❑ other(explain): Distance from private water supply well or suction line. N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 3 feet Material of construction: ® concrete ❑metal ❑ fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1 V X 5.5'X 5' 1500 gallons Sludge depth: lit t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is Barnstable MA 02630 January 5, 2011 required for ry every page. Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 39" Scum thickness 1/2" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. Risers bring covers within 6"of grade. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑/rglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of utlet tee or baffle Distance from bottom of scum to ttom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is required for Barns January table MA 02630 J 5, 2011 every page. 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 /FC-1fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day . Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 • Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is Barnstable MA 02630 January 5, 2011 required for fy every page. 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.): One inlet w/tee,three outlets,level.No solids carryover. No sign of high water staining over outlet inverts. Riser brings cover within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of p/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•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is Barnstable MA 02630 January 5,2011 required for ry every page. CityrTown state Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: ® leaching chambers number: 3-500 gal ea.w/4'of stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): Chambers located and inspected with camera. Liquid level 1"above base of units. No high water staining. No sign of past hydraulic failure. 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 inflo ❑ Yes [ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is Barnstable MA 02630 January 5, 2011 required for ry every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of/gnsofic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments •'" 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is required for Barnstable MA 02630 January 5 11 every page. cityrrown State Zip Code Date of Inspection- D. System information (cunt.) 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 r >` mow♦ i A t - 3<n i lea= 3c'a" a ou I I I t5ins•09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System,page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is ry Barnstable MA 02630 January 5 2011 required for , every page. Cityf town State Zip Code Date of Inspection M System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: '5 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: April 30, 2002 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database-explain: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Test hole to elv= 87.5 found no ground water. (2002) Base of SAS at elv= 99.1.Accessed local ground water contours and topo mapping. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 16 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3861 Main Street/Route 6A Property Address Frank Mastromauro Owner Owner's Name information is Barnstable MA 02630 - January 5 2011 required for ry every page. CitylTown 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-09/08 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17 �� fo No. - - - ----- Fee-------- ----------- BOARD OF HEALTH ` 40 TOWN OF BARNSTABLE ApplicationfforlVell Con.5truct ion Permit 1 � Applicyto is.hereby. a e for a permit to Construct ( ), Alter ( ), or Repa' )an individual Well at: Location — Address <ssessors Map and Parcel -------------- ---- 0 Address Installer — Dri ler Address _ Type of Building Dwelling -- -- -- - ---- -- Other - Type of Building--=- ---______.____ No. of Persons--_------_-_---__ Type of Well ---- Purpose of Well--------------- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation - The undersigned further agrees not to place the well in operation until a Certificate.of Compliance has been issued by the Board of Health. Signed 411A —_— _ S �� —ate Application Approved By - date Application Disapproved for the following rea ns: ---- - -------- -- - -------- -------------- ---- —��' — date ` >r Permit No. . __ Issued---_-_ - - . -------- -------- - d e BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate ®f (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) by--- ----_-- ---- ---- ------ --- - - -- - -- ---------_ —-- —Installer at___ —_ _— ----------- has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ------__-___---____Dated-------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE--- - -- Inspector---- - -- ------ --- - No.—�--- -------- Fee—------y------ W BOARD OF HEALTH TOWN OF BARNSTABLE Application ffor Vell Coot ermit A lice a,i h eb a-e fora rmit to Construct ( ), Alteran individual Well at: �r / p�PP �F 1 , [O f7J �a� �/Location — Address .A_ ssessors Map and Parcel �i2o��v2 ----------------------------------- ---------------- O 4 Address ----- "� Installer — Driller Address _ Type of Building Dwelling -- --- - - - —-- — Other - Type of Building--- .___—__ _________ No. of Persons----------------___ —__—___ —_ Type of Well - ---------------_---- Capacity--------------------------;'----------- Purpose of Well---------------------------__—___ Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed - —� — J� -- -- ® -— ---- ate — r J� J _ Application Approved By _ ` !! ` _— ��/ --� date 7 Application Disapproved for the following reasons: --- --------------- -- - -- date Permit No. —— --- Issued--- --------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE (Certificate Of (Compliance THIS IS TO CERTIFY, That the Individual Well Constructed ( ), Altered ( ), or Repaired ( ) b ------- ------------------ Installer r at___— -- -- --- --_—_-- - -------------------------------------------------------------------------- has,been installed in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Construction Permit No. ---------------______Dated----------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. DATE---- --- ---- - —-- Inspector---------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE well �Con0ructionPermit �- No. ---- —_— w O e 1 Fee—y-------- �L/row Permission is hereby granted to Constry t t1ter� o Re it ( ) InAA a] at: No. — `..�— ��-� -- — �e ---- — ----- ------------------------- - �— street as shownVn Mhp�p�ficatio fro Irell Construction Permit No.- -------— Dated-—'^ -- -------------- ,,, 1� /k3 Board 6t Health 4DATE , ---- -- COMMONWEALTH OF MASSACHUSETTS Ex,ECUTrvE OFFICE OF ENVIRONMENTAL AFF.A.IRs DEPARTMENT OF ENVIRONMENTAL PROTECTION t Y• TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY''ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A nnJJk6AIMff/)�O CERTIFICATION Property Address: 3g 6t K..T S'T . �- �� 9?Owner's Name: / Owner's Address: . c U-n An Date of Inspection: p — Name of Inspector: lease print) �.pi1,l�Tr Company Name: r t rbh„ 1,0 s Mailing Address: iw pab�t Telephone Number: d - -L=09 O �60�8 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: 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of I I OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART A CERTIFICATION(continued) Property Address: � A Owner._ 2e— q�-e O Date of Inspection �r j g Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I havemot found any information which indicates that any of the failure criteria described in 310 CMR 15. 03 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"sectio eed to be replaced or repaired.The system,upon completion of the replacement or repair,as approved a Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the follo ' g statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic -Approved by the Board of Health. *A metal septic tank will pass inspection if it is ciurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years of available. ND explain: Observation of sewage bac or break oirt or Ingh sta&water level in the distribution box due to broken or obstructed pipe(s)or due to a bro n,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipes)we replaced obstruction isremoved distrii iution box is keeled or replaced ND explain: The sy in required pumping more than 4 times a year due to broken or obstructed pipe(s).The sysbm will pass inspe ' n if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of=_ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_ -TA it,1 24- ,b A Owner: Q `2 Date of Inspection: Q C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determin 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 CM 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety d 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 o a salt marsh 2. System will fail unless the Board of Health(and Public ter Supplier,if any)determines that the system is functioning in a manner that protects the public alth,safety and environment: _ The system has a septic tank and soil absorption tern(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water pply. — The system has a septic tank and SAS and a SAS is within a Zone I of a public water supply. The system has a septic tank and SAS d the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method ed to determine distance *"This system passes if the well ater analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic c pounds indicates that the well is free from pollution from that facility and the presence of ammonia ni gen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are trigger .A copy of the analysis must be attached to this form. 3. Other. 3 f Page 4 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE O'SPO>SAL:SYSTEM INSPECTION FORM PART A- CERTMCATI4N{continued) Property Address: (�c__ in b 6 Owner: Date of Inspection• D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Y 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'/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I 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.IThis system passes if the well water analysis, performed at a DEP certified laboratoM for colif wm bacteria and volatile organic_compaands 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 mast be attached to this form.] XJO (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 OAR 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- fi You must indicate either"yes"or"no"to each of the foIlowina (The following criteria apply to large systems in additi a criteria above) yes no _ the system is within 400 feet of a drinking water supply the system is within 200 of a tributary to a surface drinking water supply the system is locat in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a pu 'c water supply well If you have answere es"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D ve the large system has failed.The owner or operator of any large system considered a significant threat der Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The s in owner should contact the appropriate regional office of the Department. 4 I Page 5 of 1 I OFFICIAL INSPECTION FORM-NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 0-1 Property Address: 1 T Owner.• 4� Date of Inspection: Check if the following have been done.You must indicate"yes"or`�no"as to each of the following Yes No Pumping information was provided by the owner,occupant,or Board of Health Were any of the system components pumped out in the previous two weeks? 0' ____ Has the system received normal flows in the previous two week period 0( 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? l _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition fthjbaifles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? l _ Was the facility owner(and occupants if different from owner)provided with information on the proper intenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on. Yes no —T _ Existing information.For example,a plan at the Board of Health_ 0( _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable){310 CNM 15.302(3)(b)] 5 f Page 6 of I I OFFICIAL.WSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: �C Owner- Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): •� DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Number of current residents: 1 Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no): I [if yes separate inspection required) Laundry system inspected(ye or no):00 Seasonal use:(yes or no): Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): 0 Last date of occupancy:rLt COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15_ ): =Pd Basis of design flow(seats/person gft,etc.): Grease trap present(yes qr no): Industrial waste holding tank resent(yes or no): Non-sanitary waste dischardQ to the Title 5 system(yes or no):— Water meter readings,if vailable: Last date of occupy c se: OTHER(describe . GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no): If yes,volume pumped: _gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _X�eptic 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) Tight tank Attach a copy of the DEP approval , —Other(describe): Approximate age of all compone date' stalled f known)and source of information: Z4? Were sewage odors detected when arriving at the site(yes or no): Ab 6 Page 7 of I OFFICIAL, INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURI+ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: �Q Date of Inspection: �p faS BUILDING SEWER(locate on site plan) . Depth below grade: 3a Materials of construction: cast iron X'40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: K (locate on site plan) Depth below grade:te Material of construction: DC concrete metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:_ 16�5Q� Sludge depth: N a Distance from top of sludge to bottom of outlet tee or baffle: c7'7 _. Scum thickness: Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom of outlet tee o baffle: /A How were dimensions determined: &e=u Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related tg outlet invert,evidence of leakage,etc.): 4f w 4165 ;k a.c e 4, GREASE TRAP:____(locate on site plan) Depth below grade: Material of construction: concrete_metal fibe s__polyethylene_other (explain): —' Dimensions: Scum thickness: Distance from top of scum to top of outl tee or baffle: Distance from bottom of scum to bolt of outlet tee or baffle: Date of last pumping; Comments(on pumping reco ndations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evi ce of leakage,etc.): 7 f Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address• ( I 6A T a — Owner: Date of Inspection: Q p TIGHT or HOLDING TANK: (tank must be p t time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete fiberglass _polyethylene other(explain): Dimensions: Capacity: ga ns Design Flow: allons/day Alarm present(yes or no): Alarm level: Al in working order(yes or no): Date of last pumping: Comments(conditio f alarm and float switches,etc.): DISTRIBUTION BOX:__A_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: t°ym 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.): �-dAk 10OX� a ,A �- �� PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no):. Alarms in working order(yes or no - Comments(note condition of p p chamber,condition of pumps and appurtenances,etc.): . 8 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSUIOAC]f SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3 (�( �� Owner: p Date of Inspection: 43 ps' SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ Ot leaching chambers,number. 3 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, . 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 Iayer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater infI (yes or no): Comments(note condition o 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 condit' n of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 i Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 86( b Owner: c7 >ti5 Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. -Lb th IV S--T T chi 70( Page 11 of l l OFFICIAL. INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.. SYSTEM INSPECTION FORD PART C SYSTEM INFORMATION(continued) Property Address: Owner• - Date of Inspection: pS'' SITE EXAM Slope q 426 Surface water IW Check cellar Shallow wells Estimated depth to ground water e K, feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe ow you established the high ground water elevation: V lam vu,�c le o n v y +�i rRS-1 pit Il . 13 I� I� I la I� I IA I� I IA I I I I I la I IA I I$ I I a I I IA I p Lir p ..... ... ..... I I I I I n I Ii I C Gl uk II I = II d Z 10 I I rn 11 := I III I 1 I I O I. rn I II Z I r i II G — i ZO II I I I I I! II I I I I II ��` `� I i'1 I I I I `_ f♦ I I i I I Exi5tin Elevation5 Date:07.20.2020EX-5 9 La Casa Studio (ram McCullough Residence Po Box I I OG-HarvAch,MA 02645 \— '' . 38G I Main St., Barn5table,MA 02630 Phme:(508)-308-8614 d� zZ'= ?Q o m Flo iiI o � O toil FpyFpF y 20 ,np im as OOaaa p o p S.smr r� 70 0 a A z pz z . II I Ag II L. r-0 I a0 T-O• V-O• zG y I I noIII �loZ sss� �m II ® . W i O g g— N Li Oo �� rsrer rsrer 0 F �j rz f L J If0) 4--1 e b 1 ' 4-0 O g p W o I5'_I r0 I as r0 U�E ---�- ._ _... _. __ Z' A: 2410• �► r 5 SETBACK LINE c Pro osed First Floor Plan Date: 10.28.2020 P La Casa Studio A-- 2 McCullough Residence PO Box I I OG-Harwich,MA 02645 38G 1 Main St., Barnstable,MA 02G30 Phone:(5W)-30B-8G 14 z 1 O t 1 N —......_._ ....... n m N I- G F ° n I y 8s2 o ff p�p 0 I �wTgz A y Q F z U z T — z I. 2 = 4 N �J I I 2'-0 za-0' 2-0 - 6-0' 3'-1' 6'-61 6-6' C. N '(Q i N. I. r MT It"MT. (9 - —- - Z N— I z I ry2 6 § N z _. ......... �. o ® 10 I 00. I � ss tic IIT. V sa nears HT: 51-0'.HI'M WALL 5'P MIGM WALL y I ` Z I -I Q i 2 f, - 6,-0, 2'-0'. 20'-0 2-O' C 24'-0• _ 15�-1• m . o Pro osed Second Floor Plan Date: 10.28.202° A-' p La Casa Studio Mcculloucgh Residence PO Bm I I O6-narmch,MA 02645 CO 3Phone:(508)-308-8614 �� 386I Main 5t., Barnstable,MA 02630 1\V 0 12 12 /V^7 12 � 1 CLAPBOARD WOOD SIDING ALL POUR SIDES ('j`�� O J d ® SECOND FLOOR NEW 5ECOND FLOOR I f N -- 0 �® r o o �® 1 RTM M � 1 o® Effl 0---� I,� 1 3 — FIRST — FLOOR PROPOSED NORTH ELEVATION O cm 0 LU _ SECOND FLOOR —— In t c_ I co ® O E L vl9 .. --,.. FlRST FLOOR . LL--J, '. GAS METER PROP05ED SOUTH ELEVATION 'scram:ua•=ro° __ TOWN OF BARNSTABLE L e t o .LOCATION foJe h A SEWAGE # 'oC VILLAGE — 18c, ASSESSOR'S MAP & LOT 335 INS TA 4ER'S NAME&PHONE NO. SEPTIC A,NKf CAPACITY GAU,;C 4-5 LEACHING FACILITY: (type) 3 (size) 33--S Nt I 2�D NO.`OF'BEDROOMS , BUILDER OR OWNER .� `-PERMIT DATE:' b Z COMPLIANCE DATE: ? 2 O 2 `+" Separation Distance Between the Maximum Adjusted Groundwater Table to the Bottom of.Leaching Facility , _ h! Feet Pnvate WaterSupply Well and Leaching Facility (If any wells_ezist .= on site or within 200 feet of leaching Will No k u 'JE Feet -Edge of Wetland and Leaching: acility(If any wetlands exist; G k -gDis► within 300 feet of leachin facili g, ry) w`Ja - Feet 1 Furnished by.. �: 2-211 -?low �9J G✓�61C1�iv6 38Go k3�A - `� `u rnrna�,u►� O - NO. ® r Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0[pplication for Mig aal &potem Com5truction VCrmtt Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ®,Complete System ❑Individual Components Location�Alddress or t No. Owne' ame,Address Tel. o wl e— Assessor's Map/Parcel 3145�` d 13 Lis OA I4 Installer' Name,Address,and Tel.No. Des' is Name,Address and Tel.No. 747s-e_ �`(��'4`Vie✓ Type of Buildin : Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building S l s� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow h n gallons per day. Calculated daily flow �" gallons. Plan Date s IV' '/�2 Number of sheets 0dV1 Revision Date Title Size of Septic Tank Type of S.A.S. 4W1C.-z 450Q6tA[_- n�hj r S Description of Soil Nature of Repairs or Alterations(Answer when applicable) e >nl 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 by this Bo of Heal . n Signed Date �vr�oS�t�ofGb2 Application Approved by -1/ Date 02 4;2 Application Disapproved for the following reasons Permit No. 7 UUo2-a(, g Date Issued a (1 :a n11.a 6 0 ) Fee x K 1 d 41 X. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye%..r►' PUBLIC HEALTH DIV'ISION -TOWN OF BARNSTABLE, MASSACHUSETTS, . 01ppItcatton for Mtgogal *pgtem Congtruction Permit Application for a Permit to Construct( . )Repair Upgrade( )Abandon( ) __5kComplete System IndiVidual Components r Location Address or L t No.�✓ Owner ame,Address a�Tel.,rlo,l,, Y{lla Assessor's Map/Parceld I pB •� 11 Lo5� Installer's Name,Address,and Tel.No. Des'g er's Name,Address and Tel.No. sol— �3 Type of Buildin : Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria'( ) Other Fixtures Design Flow 112 gallons per day. Calculated daily flow 4 gallons. Plan Date f1\ :A 12�` �Z Number of sheets Q-V,, Revision Date Title Size of Septic Tank r,.;C+-VA , Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) `��.�` �ca w _3Y11,A . t . 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 by this Bo Healt . I Signed Date Application Approved by Date 612 ;? Application Disapproved for the following reasons Permit No. f)Ua- ?6 Date Issued 60 U 1 ---------------------=------------------ 2(� C5 -Tr)r. ��1��(n1 COMMONWEALTH OF MASSACHUSETTS a BARNSTABLE, MASSACHUSETTS ` . .. (Certificate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( )Repaired ( -x)Upgraded( ) Abandoned by by -,l,n. 11r,c at _ has been constructe in accordance with the provisions of Title 5 and the for Disposal System Cons ction Permit No. 0 dated r a Installer Cenq- ,",r 1-j� Designer .. The issuance ofi this Dkinit shall not be construed as a guarantee)that the sys will fu tion as deJ&�� 0 Dated Inspector, ' 6 No. ��10� a(n� --------------------------Fee -- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migpogal *pgtem ComAructton Permit Permission is hereby granted to Construct( )Repair(�)Upgrade( )Abandon( ) System located at 03 a-f b1a and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Con/structi n must be completed within three years of the date of this p rmit. Date: b / (10 Approved by /Ij. TOWN OF BARNSTABLE L LOCATION 1 �- SEWAGE # -� 2 VILLAGE- / - kr� t¢ ASSESSOR'S MAP &LOT 335 >$- INSTALLER'S NAME&PHONE NO. � . �} �,tx�s�'c+w�-►t>>.I ?O$ 77 S=3R SEPTIC TANK CAPACITY I�� -��►u-c�./S LEACHING FACILITY: (type) 3 e-Cp&n"%1 Deg" 1s (size) 33-S'e 13x �'D NO.OF BEDROOMS 4. BUILDER OR OWNER PERMIT DATE: b�' COMPLIANCE DATE: 2 2 2 Separation Distance Between the: n' Maximum Adjusted Groundwater Table to the B.ottgin of Leaching Facility NO C Q Feet Private Water Supply Well and Leaching Facihty'(if any wells exist No k ao uE SFeet on site or within 200 feet of leaching facility) :. Edge of Wetland and Leaching Facility (If any wetlands exist �o J ��-I1MWFeet within 300 feet of leaching facility) Furnished by �v �sQ a �nttit�bl")le� s 5; "9 11 9169, MY 1 ' e�0�7 r�tiMf�l7Jlsta �i��y aos� 9u�l�ox� r , Y L O CATION S E G E PERMIT NO. VILLAGE ILI INSTA LLER'S NAME i ADDRESS U I L D E R OR OWNER DATE PERMIT ISSUED j= 3 ,0 — DATE COMPl1ANCE ISSUED fel- 2_ / ftlf-i C"f�C�1G � f O r 146 I r f J No-_ gl ,,. F.Rs....S........................ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF H ALTH Appliration for Uhipo.4al Works Tnnitrnrtion thrutit Application is hereby made for a Permit to Construct ( ) or Repair Pl_&n Individual Sewage Disposal System at Location-Address or Lot No. ......rC, i�/,�:---------C��_ /% _.�1~. ... ....--... ... Owner --------------•-•---•--Address -------------•-•--•-------•- -.........---------- ---••-----•-------....-•-------....-•-•---- Installer Address dType of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms.........�.........---------------Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building __ No. of persons____________________________ Showers — Cafeteria PaOther fixtures ------------------------- ............................................................... Design Flow..........._................................gallons per person per day. Total daily flow............................................gallons. W Septic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter----------_..... Depth................ 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 ( ) `4 Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •-••------••-•-•••--------•-••--•----•-•---•-----•-----------•--•-•.........................•------•....................................................... ODescription of Soil....................................................................................................................................-.................................. U ---••••------••.._....---•-•--•-•----•------••--••-••-•---•----••••--•-------••-•-•--------------•----•----••--••---••-••-•••-•••----•-•----•--•--••---••••--•----••--•--•••--•--•-••--•--•--•----•--•- W ••--••-••--------------------•---••-•-••---•----•---•--•-•----....---•--•---------•--••-•--••-•-•-•--------•-------------•--------•••-••-....__.. ...................................................... UNature of Repairs or Alterations—Answer when applicable-.__ -------- . ..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i T i'L p 5 of the State Sanitary Code— The undersi ned further agrees not to place the system in operation until a Certificate of Compliance has been s by d o iealth. Sigd•- -•-. ...... -------------------•---•-----••••-• - Date Application Approved By..... .............•------• `' 1) r� --------------- ............................................................Date Application Disapproved for the following reasons____________________________ .........................................................................................................I.................................. - au•-•-----•-•-------- PermitNo......................................................... Issued --- • Date No.)_.yo Fss.�...................... THE COMMONWEALTH OF MASSACHUSETTS /�� j BOARD OF �jEALTH V...` .....-.OF.............,t'!�.... ..1. ..----•--•------- Appliration for Biipog al Works Tonitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair Nan Individual Sewage Disposal System at: ...,. ? .....,c l` ---__-��v iArp t. +........... .................................................................................................. Location.Address or Lot No. JG_t?._u..�.�.E / -•----••-•-------•............................ OwnerAddress,/., •,? ..£ 1f.-Q----Afelo-------_-------------------- ---•----------------•----•---••--•-.-----•-•---.------ Installer Address d Tvpe of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms-_-..__ ..........................Expansion Attic ( ) Garbage Grinder ( ) Other—T e 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. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed bY.......................................................................... Date..................................... Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....-._--_-._--- ___--. --------------------------------•-•--------------------------•-----•----------...._----'-. ................................................................. Descriptionof Soil................................-----------------------•-••-----...---------------------------------------------------------------------------------------'--'---.••--- x V -----------------------------------------------------------------------------------------------------------------------------------------------------------------•--•-------------------=-----------•--- U Nature of Repairs or Alterations—Answer when applicable.-_&-4^4Gf ....... ....... SF �9!' l .-----------1D.a..j6: - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of:T':L p of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ss bil health. Y Sig ed----- �; Da t e Application Approved BY---- ...................... -'--- `3 = ` Date Application Disapproved for the following reasons: -----------------------------•-----------------------------------•-----•-•------'•--- •-••-----•-------•-•-••-•...-•••---"••-•-••'-----------••---'--•--•-•-•-•...----•-•'-'--••-'---•-...•-----•'-----'---•-••'--••--•-•---------•--•••---------•------•-•-•••--------------•--••-----'----- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... ; l �:1...........o F............ . ', I......,....................................... Trrfifiratr of Tomptiana T ITS IS-TO CERT •,Y, That the Individual Sewage Disposal System constructed ( ) or Repaired x Alf— y Installer ...........t................. A yj`� ��-_-- try has been installed in accordance with`the provisions ofj j of The State Sanitary Code..a describe m the application for Disposal Works Construction Permit N .__;, ..........ilJ............... dated__.. ..'.:� -. --.-..-----------. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY:' DATE.......................... ............. °.... '.. ;Inspector -- ---'-- ---- . . --- . THE COMMONWEALTH OF MASSACHUSETTS } BOARD OF HEALTH I . .......... ............. � .................-................. NC� .... � FEE........................ t �to�o F rk� � o�rnr#Uan rruti� Permission is hereb rante --- . = to Constr ct ( )for e r ( an I >Avidual Sew ge Dispo System y ' at No. f <f s d-j R 'yx_ � .�....'._... � , .. 9.�---- �.t treet ` as shown on the application for Disposal Works Construction Per •i No._. .__._.._._.____: ated..- `:�..d.�- i' � -•••--..--'-- ,3 DATE.... � � Board of Health. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ', SHOT i o,= Z 3h/EZ°7',s S _ IZ7.58 r ' �1? A !� �SI•��T� I �? �o I r ISL 3T/^off . S � ZA0, �0 Y 'AGM �1 A + Y} �/I \�� \ ` „ _ � fit! ,.•.�/•;� �� \ \, '' 1` " /VoT�"— �"2.�"✓•�H'7'v.u3 BASEb aAu CERTIFIED PLOT PLAN LOCATION SCALE . .�. '.`'�" . . . . DATE PLAN REFERENCE 6' 7NG LoT L . . . . . . . . . . . . . . . SAbww oN A Ae-4A.+ A02 3s A'9V lam, 7z r't.SAC. 335 PG', 5'y . . . . . . . . . . . _ I CERTIFY THAT THE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REQUIREMENTS OF THE TOWN OF WHEN CONSTRUCTED. SSE7of/ f C'o�n/A�� S2 DATE PETITIONER: C��,J,yAyt�iZ>� M.455 , low REGISTERED LAND SURVEYOR • •SNE�-T Z o�Z S�'�'E'a"-r'-s 0 TOP OF FOUNDATION CONCRETE COVER CONCRETE COVERS n e 4"CAST IRON 12 PIPE (OR 12"MAX. F3/4" EQUIV.)- MIN. 4"ORANGEBURG(OREOUIV) PITCH I/4"PER.FT. PIPE- MIN. LEACH PITCH 1/4"PER.FT PITINVERT ° aEL..S/.• Q INVERT INVE T c .�7 SEPTIC TANK DIST. INVERTEL..$P•.j0. BEL4...3L. j=EL.. 47 �,Jo GAL. INVERT INVERT •' V ww �: 2EL4B.7o �o �: `•• // 6'DIA. DIA. PROR LE OF GROUND WATER TABLE SEWAGE DISPOSAL SYSTEM NO SCALE TE"5T 8d,2in/GS . SOIL LOG WITNESSED BY : DATE SAry � / 8� TIME.�-! �.� .... . . . . . . 20 S. BOARD OF HEALTH TEST HOLE Z TEST HOLE 3 7,Z/or�s15 E_ !��.' . ENGINEER ELEV. .S? 70. . . S DESIGN DATA NUMBER OF BEDROOMS '2. . . . TOTAL ESTIMATED FLOW . ZZ�? . . GALLONS/DAY FiA/b" BOTTOM LEACHING AREA 78.So SQ.FT. /PIT 5/a•rvD SIDE LEACHING AREA . . !BB..Sv SQ.FT./ PIT GARBAGE DISPOSAL . Al. . . (50% AREA INCREASE) TOTAL LEACHING AREA . . U.700. . SQ.FT ��JZ r �9Z•� PERCOLATION RATE 4-'SS.77l'4^! rvwP—• MIN/INCH LEACHING AREA PER PERCOLATION RATE . ?. . SQ.FT. /1/0 .WATER ENCOUNTERED NUMBER OF LEACHING PITS t e/1' W/T71/ 7bvo r*-aT APPROVED . . . . . . . . . . . BOARD OF HEALTH • oni,C}�� Sits_ = /,S'e 7Dus of DATE . . . . . . . THOMAS E.KELLEY CO. AGENT OR INSPECTOR ENGINEERS—SURVEYORS d ^ 346 LONG POND DRIVE SOUTH YARMOUTH,MASS., ��•tti BFtij9sS r j tN " -p #•�t 02664 THO 47 / O� ..�' 4260 y �SFDf/ /� CpWA-+tJ TZ fir, ? ' '• �R� �',�STE�4i��,� PETITIONER � =T `�� SStGNALEN�' ec�!�M,gQu is M.�rSS. w S0 j Z �� ASSESSORS MAP �j��j v 6� TEST HOLE- LOGS NOTES' �U PARCEL, � _�T : SOIL EVALUATOR+ OPre-V l7 fI`aS(/lLl FLOOD ZONE Ci 1. VERTICAL DATUM, \�� 60 EF R NCE+ �-- Q � WITNESS+ M!-L�+�NFt-L• ' ,�Tk$E.� N•I�. 2, MUNICIPAL WATER IS A R E E 2q�;o AVAILABLE. i !''r •1!. Zoo 2.. aS DATE, -- 3. SCHEDULE 40 PVC PIPE TO BE USED THROUGHOUT SYSTEM UNLESS ..] d. 2 ''t�►L1 ?YS% � OTHERWISE NOTED, M PERCOLATION RATEr 4. ALL PRECAST UNITS TO CONFORM WITH AASHTO+ O.+ TH-1 EL . 103 O�' TH-2 163,17- 5. PIPE PITCH - 1/4' PER FOOT UNLESS ❑THERWISE NOTED. a 50N IQyRf A 5A-h+t�r loyR3/' 6. ALL CONSTRUCTION DETAILS T❑ BE IN CONFORMANCE WITH MA. ENVIRONMENTAL LOCATION MAP(N.f-S) 99.90 1511 WA y 101,7S 17'' z_ IOt,70 CODE <TITLE V) AND LOCAL REGULATIONS. S 100 B Si �p�(�QSIy a Siurr io'IR � 7. CONTRACTOR TO VERIFY LOCATIONS OF ALL UTILITIES PRIOR TO CONSTRUCTION. 0.10 99i3 LOAA4 tc�U.29 2$' ►00.67 3y' MHD/FND ��tMd?/� f�l.l.._l1..N.�_U.1_L�kl�.C,.�-:_..SS2��-____�__� �iEQU/�IIJ I.�IQ'Gf1elt'UC,-'�-O : /+ /� 100.58 .56 99.3 �51 c,-1- , SI l.T ----F 100.00 V I+ � �t H ANT G� v 2.$yb// Z,5� �E. e � I- kNi (3 ' _ l,UPrrvl _ ?f v ort rv, ..a c CZ LA y 9'v R pGOgc. _.�wj.0 rNv-�1 .Sthu�__ PAS o� p4V , Mom" 1y $ ! ��.IZ edge , 0 E q Xi TrN -LT., L._ Pumioe ?u5�r`Ea.. ...etc t. r�_..._..__. 100.93 •kl$ Wlc..�!uNt MIu I _ Q _ ._ N ? 12y.38 101.60 ' s A)ID 2.5) 7 L87.5 , �r;GAj7OiliE.E Y:AMPLE ' .: U� 1i4 $ ly U4-"?f wFt.,s W N / Rev- PP-1 y -- - ._... ---- -. .. ..-- _ 100.95 WATE SHUTOFF A10 ROUNOwA-Tt_ f/0 AwiVPw 101, o2s� �l lay er-f?wBPOS� L�9G N ,.---- SEPTIC SYSTEM DESIGN 102.71 31 6 1 Re µlrsl*L To FLOW ESTIMATE I3 S�r1�M fJa (BSI(N tjt CCCJ � 1�1'7i� �j'9 'It�YJ�Y1 , no EL.qq.4 OR-Top o q 102.63 x 1 �� LA R 0�44 t BEDROOM 110 �,,. 102.54 C 10FT SPR. SPRUCE �, O S AT GAL/DAY/BEDROOM � �-- x151?�JG � € (! ilel �1 a 1f 9S 13CJO J GAL/DAY IZttUUEb _ _ _ SEPTIC TANK - 3S+ 103.49 a .00 ° 440 GAL/DAY x 2 DAYS = 900 103.49 WATER SERVIC • r T - 1 a� GAL W USE 104 03.37 � . . GALLON SEPTIC TANK EXi�i�_ �i�A-cE w lSrwl.��r+.c.o a 1 y, x 103. 56f►?�C TNIG /F p+4"t.+�Y7,, WATER SERVIC£ 101.37 SOIL ARWRPTION SYSTEM 7aAw►Aty + aft (/Np SiZ� x 104.98 ^ _ GRO D IERos.84 pel ® 04,69 a� �.f 57VAIE 0/1) �}C ,. S/Des 633.5 Lk 12.8 wx Z D)105.88 SERV 81 1�Wc 10 SE TIC C VER 4 ° It r SIDE AREA 3 S Z i- I2.$ Z /37,U 106 � ,. 3. .�� 2 xo ? 106.05 0 05.1 x 105.71 .27 IC C©VER FLAG POLE 'I BOTTOM AREA+ 33,Sk 12.S� x Paved 107.24 106.62 Drive D SET RT CDR RK STEP 108.12(ASSUME 102.75 106.58 106.75 04.22 SEPTIC . SYSTEM SECTION >q4c' 1 r 106.58 107.37 #3861 DVre 70 Gu M4 106.90 x 1 6. 94- � ��<• ST h , u�r� 109.18 TOF'=108.17 ��,: +Olga. Z. ( A� GRO ND tb 14& UV oY 3 / .6rr,* 3�" EL A92. /p2,t5 o - " ELEV G Srie Lt Q Q } o ELEV D-BOX U1.3 9 `� '� '��nlSTxttrtI2 7v GAL f�©/ � ► y7t'�- ELEV 3 /r ' /e `f 2 o t b yF LtFy SEPTIC TANK EL EV r �r�rtS -�- Y� he S rle IM 69 a e�I$11!J PO_S. 87, • r J , . FSpM 6L OF 4► GRGW5.98 TERRR� SITE AND SEWAGE PLAN Jpyz 4 ANN M - WARNER No.3872t 0it40 LOCATION. 3 &1 Lot 2 Scaler 1'=20' EDS C�rti/ytA�Ul,o r� 1.04+/- ACRES leg PREPARED FOR+ 104.45 5/ Y ��6 /�t/u-lam Map 335 1 1.85 103.26 ._.--ac 0' 20, 40' 60' ��j . (A)- BO L-sT&J Nit 0193 Parcel 6,2 --- ---- --'� Edge of Water (Qg)335-�-36 I � - SCALE+ zo DARREN MEYER, R.S. DATE+ AV 20 _ 43 VINE ST. - --DATE HEALTH AGENT DUXBURY, MA(508)362-2922