HomeMy WebLinkAbout4084 MAIN ST./RTE 6A(BARN.) - Health 4084 MAIN STREET/RT.6A, BARNSTABLE
A=336.051
L O LION EWAGE PERMIT NO.
9 ,-t 2!��v ;&-41� 3
VILLAGE
IN T A Ll 'S A i ADDRESS
a U I L 0 E R ._.-OR
DATE PERMI ISSUED
DATE COMPLIANCE ISSUED
CY J��
- J
\V
. a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Application is hereby made for u Permit to Construct ( ) or Repair ( Sewage Disposal
System at:
Type of Building Size Lot.---'.---------'So. feetD.�liog--l�o. of Bc6r000�»'.-----'~�L-_---.-_-..Expun�oo Attic ( ) Garbage ( )
Other—Type of Building ............................. No. o6 persons............................ Showers ( ) -- Cafeteria. ( )
^� Other
.
r
S.
Septic Tank—Liquid --4� ...... Width..... Diameter._---.. D _
Trench �o� l��b6_- Total Total �� `
~� Disposal -''-__-- ' _- __�-- _- �
0.
�� Sr�yu�� Pit l�o-- ,--. D�m�er.',����.--- Depth below ��ot.._4� ----- Tota leaching- ar��-------'�Sq. b.
�� Other Diu��odoo�n� ( ) Dosing tank � )
'- Percolation Test Results Performed bv.......................................................................... Date......................................
'
Test Pit No. l................minutcuyerinc6 Depth of Test Pit.................... Depth toground
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Dont6to ground woter--_ lep
-
og .......................... ...............................................................................................-.................................
0 Description u6 Soil...................................................................................................--'_----'_------'.--'-----'^'�-----
'
'--''._-.'__.
.`
............. ....... '-.............................................................................................................................................................................
U Nature of Repairs or Alterations--Answer when applicable---------'_--__________.__._._____ �
_-.'--'-''''-' . ----
AqgreencoC:
The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with
the provisions oJTZT LE 5of the State Sanitary Code The undersigned further agrees not to place the system in
operation no6l a Certificate of Compliance
- ~ ....~.` ----'----------' -'-r'-----------
o"*
Application Approved By.......................... ........................................
v*"
Application Disapproved for the following reasons:..........................................................................................
......................
......... ........................................... .....................
Date
Permit No '
......................................................... -_--_........................................................
- �
Date
THE COMMomvvsucrH OF xxAssAoHussrrs
BOARD OF HEALTH
'
------------'OF.-------_---.---'---''-''----'-. |
| .°fTomplitturr
�
� THIS
'
by
TI kTh,
has been installed in accordance with the provisions of TIME 5 of The State Sanitary Code as described in the
applicationfor-
THE US L NOT C��NST GUARANTEE
SYST .
THE oowMomvxsAcrH or mAs c*ussrrs
|
| ^ BOARD OF HEALTH
Zid -------------'��F--_'- --.
No.t 7 7
............. |
� - -/r - -
|
� -'-- �
to Constr /
N 0 ........ ...
Street
as� shown ^ D ,�sal Works Construction- Permit i' _
� ~
............__...
�� "=� m �"��
_''^��. ~., -_--_-------`--_.---___ ^^ �� � -._~--
ronm /ass M. SuLmm. INC., BOSTON ^
N1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4084 Main Street
Property Address
Anita Parker
Owner Owner's Name
rouiratlon fore Cumma uid MA 02637 0628/12
required for every 4
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
filling out.forms 22 n/
on the computer, J�
use only the tab 1. Inspector:
key to move your
cursor-do not Michael Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspections
Company Name
PO Box 896
Company Address
East Dennis MA 02641
City/Town State Zip Code
508-385-7608 SI 3742
Telephone Number License Number
B. Certification _
I certify that I have personally inspected the sewage disposal system at this address and that the _y
information reported below is true,accurate and complete as of the time of the inspection.The;iflspectipn
was performed based on my training and experience in the proper function and maintenance of on site-1
sewage disposal systems.I am a DEP approved system inspector pursuant to§action 15,.340 of�
Title 6(310 CMR 15.000).The system:
® Passes ElConditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
06/30/12
Inspect r 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.
t51ns•1 7/10 Title 50fticzInspectio F bsurfaca Barrage Dbposal m•Pa 1 of 17
I
f
Commonwealth of Massachusetts
Title 5 Official Inspection ,Form
_ Subsurface Sewage Disposal System Form Not for Voluntary Assessments
4084 Main Street
Property Address
Anita Parker
Owner Owner's Name
information is
required for every Cummaquid MA.. 02637` ' 06/2.8/12 '
page. Citylrown State . Zip Code Date of Inspection
B. Certification (cont.) -
Inspection Summary:Check. A,B,C,D or E!always complete all of Section D°
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:.
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health,will pass. �..
Check the box for"yes","no"or"not determined"(Y,N, ND)for the following statements.If"not
determined,"please explain.The septic tank is metal and over 20 years old*orthe septic tank{whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfdtration 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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection. Form , .
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'< 4084 Main Street
Property Address `
Anita Parker
Owner Owner's Name
information is required for every Cummaquid MA 02637 06/28/12'
page. City/town State Zip Code Date of inspection
B. Certification (cont.)'
B) System Conditionally Passes(cone:):
❑ 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 ❑.l N ❑' ND(Explain below):
❑ distribution box is leveled or replaced ❑: Y ❑ N ❑' ND (Explain below):
r
❑ 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 T ❑'+ Y ❑- N ❑' ND (Explain below):
d
i
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 rnannerwhich 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 '
i�ii5 c f ii iv Ttue-rJ Oii[i-1 inspedul Form$uiau,iI ce Sewage usposa;SWeir=Page 3 of i i
f
�'N- Commonwealth of Massachusetts,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4084 Main Street
Property Address.
Anita Parker
Owner Owner's Name
information is required for every Cummaquid MA 02637 06f28/12
page. Cityfrown 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: f
❑ 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 t 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 aseptic 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
El ® 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
ElLiquid depth in cesspool is less than 6"below invert or available volume is less
than'h day flow
t5ins.11/10 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form t
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4084 Main Street '
Property Address
Anita Parker
Owner Owner's Name
information is required for every Cummaquid MA 02637 06/28/12
-
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cone.) ,
Yes No
El ® 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 160 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 watersupply 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.
t
❑ ® The system fails.I have determined that one or more of the above failure
criteria e)dst as described in 310 CMR 1'5.303,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 sysfiem must serve a facility with�a
design flow of 10,000 gpd to 115,000 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
El Elthe 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
x -11 Area—IWPA)or a mapped Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has faded.The owner or operator of any large
system considered a significant threat under Section E or faded 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•11/10 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
4084 Main Street
Property Address ;
Anita Parker
Owner Owner's Name
information is required for every Cummaq uid , MA- 02637 06/28/12
page. Citylrown State` Zip Code Date of inspection
C. Checklist
Check if the following have been done.You must indicate."yes"or,"no"as to each of the following:
,Yes No a
®° ❑ Pumping information was provided by the owner,occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑. ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?,(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?'
®` ❑ _ Was the site inspected for signs of break out?
0 ❑ Were all system components,excluding the SAS,located'on site? i
y
® ❑ 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'•tocation 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)1310 CMR 15.302(5)]
D. System Information
Residential flow Conditions:
4 >. 4
Number of bedrooms(design): Number of bedrooms(actual): k
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins-11/10 - 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
4084 Main Street
Property Address
Anita Parker
Owner Owner's Name
information is required for every Cummaq uid MA 02637• 06/28/12.
page. City/Town State Zip Code Date of inspection
D. System Information
~ Description:
• Number of current residents: 2
Does residence have a garbage grinder? • ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® .No
Laundry system inspected? ❑ Yes ® .No
Seasonaluse? ❑ Yes ® No
s s r
Water meter readings,if available(last.2 years usage'(gpd)):
Detail:
ti
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date .
CommerciaUindustriai Flow Conditions: '.
1
Type of Establishment:
Design flow(based on 310 CMR 15203): 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
k Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:,
t5ins-1 MO Title 5 Official Inspection-Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4084 Main Street
Property Address
Anita Parker
'i
Owner Owner's Name
information is Cummaquid MA 02637 06/28/12
required for every
page. City/town 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:
Was system pumped as part of the inspection? ❑ .Yes ® No '
If yes,volume pumped: ;
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes,attach previous inspection records,if any)
❑ Innovative/Altemative 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 VA system by system operator under contract,
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
F
Commonwealth of Massachusetts
Title 5 Official Inspection Form _
"s Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments
4084 Main Street '
Property Address
Anita Parker
Owner
Owner's Name
information is Cummaquid MA 02637 06/28/12,
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.) v
Approximate age of all components,date installed(if known)and source of information: '
5 years
Were sewage odors detected when arriving at the site? ❑ Yes Z No
Building Sewer,(locate on site plan): "
25
Depth below grade: feet
Material of construction: `
❑ cast iron ®40 PVC' ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage,etc.):.
Septic Tank(locate on site plan):
1.5
Depth below grade: feet
Material of construction: -
® concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain)
If tank is metal,list age: years 7
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) _ ❑ Yes ❑ No
• Dimensions: 1,000 gal
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,
4084 Main Street
Property Address
Anita Parker '
Owner Owner's Name .
information required for ev is ery Cummaq uid MA 02637 06/28/12
page. • Cityrrown State Zip Code 'Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottoml of outlet tee or,bafffe
28"
2 Scum thickness
Distance from top of scum to top of outlet tee or baffle
16"
Distance from bottom of scum to bottom of outlet tee or baffle .
How were dimensions determined? measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.The inlet from the garage
end enters next to the outlet tee.The concrete tee should be replaced with a PVC tee with a filter in it
to help keep solids from entering.the leaching.Regular pumping with the filter being cleaned will help
keep the system going.
o
Grease Trap(locate on site,plan)
Depth below grade: feet
Material of construction:
❑ concrete ❑metal El.fiberglass 0 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts -
Title 5 Official Inspection Form '
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4084 Main Street
Property Address
Anita Parker
Owner Owner's Name
information is Cumma uid ° - MA 02637 06/28/12
required for every q
page. Cityfrown 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: Or +
❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: 0 Yes [I No
Alarm level: Alarm in working order:. ❑ Yes ❑ No
Date of last pumping: Date
4 -
Comments(condition-of alarm and float switches,etc.):
}
+
*Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No'
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System=Page 11 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspectidn' Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4084 Main Street
Property Address
Anita Parker `
Owner Owner's Name
information is ' ,-
required for every Cummaquid MA 02637 0628/12.
page. City/rown State Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate.on.site plan):
Depth of liquid level above outlet invert -
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.):
No box present
Pump Chamber(locate on site plan): -
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: -t. a '❑ Yes ❑ No
Comments(note°condition of pump chamber,condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS)(locate on site plan,excavation not required):
Jf SAS not located,explain why:
t5ins-11/10 -Title 5 Official Inspection Form:Subsurface Sewage Disposal system'•Page 12 of 17 ,
f
Commonwealth of Massachusetts.
Title 5 Official Inspection- Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
4084 Main Street
Property Address
r
Anita Parker f
owner Owner's Name
information is required for every Cummaquid MA 02637 06128/12.
page. Citylrown State Zip Code Date of inspection
D. System-Information (cons.) '
Type: n
.leaching pits number: 1 °
® leaching chambers number: 4
❑ 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.):
This system has four flow diffussors surrounded four feet of stone.There was no liquid in the
diflussors.
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•11/10 4 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form n '.
s Subsurface Sewage Disposal System Form Not for Voluntary Assessments
4084 Main Street `
Property Address
Anita Parker `
Owner Owner's Name
information is Cummaquid `MA 02637 06/28/12
required for every
St
page. Cityrrown ate ,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.):
,
, _ • e _ III
t5ins•11f 10 Title 5 Official Inspection Form:Sutswface Sewage Disposal System•Page 14 of 17.
Commonwealth of.Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System forth Not for Voluntary Assessments
4084 Main Street
Property Address
Anita Parker
Owner Owner's Name
information is q
required for Cumma uid MA 02637 06/28/12.
every
page. Cityfrown 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
Ili
e
'4r
too
. - I%
t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 4084 Main Street-
Property Address
Anita Parker
Owner Owner's Name
information is required for every Cummaq uid MA 02637 06/28/12
page. Cityfrown State Zip Code Date of Inspection
D. System Information. (cont.)
Site Exam:
® Check'Slope
•❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20.0
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans.on record.
If checked,date of design plan reviewed: Date
❑ Observed site(abutting,,property/observation hole within 150 feet of SAS) „
❑ Checked with local Board of Health-explain-
❑ Checked with local excavators,installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet. .
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
,
Commonwealth of Massachusetts
Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form-'Not for Voluntary Assessments
01
4084 Main Street
Property Address
Anita Parker -
Owner Owner's Name +
information is Cummaquid MA 02637 06/28/12
required for every
page. Cityffown 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
BARNSTABLE FIRE DEPARTMENT
`�P61J1�•'r�s
as; _e Ms
3249 Main Street
a .4c
of 18 27 o F Barnstable, Massachusetts 02630
10 508-362-3312
WILLIAM A. JONES II1, CHIEF GLENN B. COFFIN, CAPTAIN
UNDERGROUND STORAGE TANK REPORT FIRE PREVENTION
Property Address: 4084 Main Street/
Property Owner: Timothy J. Flaherty
Removal Date: July 8, 1998, 09:1Ohrs
COMMENT: Witnessed the removal of a 500-gallon U.G.S. Tank from this
location. The tank appeared to be in good condition, and there were no signs
that it had been leaking. The excavation site appeared clean with no signs of
discoloration or fuel odors. The contractor was advised to remove the tank
from this location and backfill the site.
William4� Js III '3 3
Fire Chief
v
.y Make application to local Fire Department.
Fire Department retains original application and issues duplicate as Permjr
it
�eh.cr��f��iCo���rike
APPLICATION and. PERMIT Fee:
for storage tank removal and transportation to approved tank disposal yard in accordance with the provisions
of M.G.L. Chapter 148 p , Section 38A, 527 CMR 9.00 application is hereby ma pp y de by:
Tank • _[No A.
Tank Owner Name(please print) X
igna permrt
Address Rto �(o UM►IA t
Street C* W State Z!p
RemovalContractor
• •
Company Name Enviro-Safe Co.or individual
Prim
Print
Address P-0-BOX 810, E.Sandwich, MA Address
Print
Print -
Signature 'f plyin for pe Signature(if applying for permit)
IFCI ertified " Other CST IFCI Certified ❑ LSP# Other
Tank Location qo F q R 4-q_. (PA
Steet Address city
Tank Capacity(gallons) a_tl4u,0 Distance Last Stored 2- O I
Tank Dimensions (diameter x length)
Remarks:
Firm transporting waste Enviro=Safe State Lic.# 329 MA
Hazardous waste manifest# NA E.P.A.# MAD 9 8 5 2 6 9 3 2 3
Approved tank disposal yard Turner Salvage Tank yard# 002
Type of inert gas Tankyardaddress 235 Commercial Street Lynn, MA
City or Town ` S FDID# ` Permit#
Date of issue U G ` Date of expiration
Dig sate approval number. 2fh QS afeToll Free Tel 11. Number 800-322-4844
: t
Signature/Title of Officer granting permit
After removal(s)send Form FP-29OR signed by Local Fire Dept.to Regulatory Compliance Unit,One Ashburton Place,
Room 1310,Boston, MA 02108-1618.
1.292(revised 9196)
CRAIG R. SHORT, P. E.
235 Great western Road
P.O. Box 1044 Telephone(508)398-831.1
South Dennis,(CIA 02660 Fax (508)398-3063
PROFESSIONAL CIVIL ENGINEER, SOIL EVALUATOR, SEPTIC INSPECTOR
SEt?TrC S i s;cf'vr uCviG1163, 10:rr;S rnL a oUiLviNv DESIGNS
July 09, 1999
Ms. Deborah Blakely, Broker/REALTY EXECUTIVES
1582 Route 132
Hyannis, MA 02601
RE: 4084 Main Street, Currmaquid/Oar File#1-0854
Dear Ms. Blakely:
As requested, I have calculated the leaching capacity per the mathematical equation used by the
Commonwealth's Title 5 requirement, before and after the new regulations of March 31, 1995. 1
must stress that this is in no way an indication of the condition or life expectation of the existing
system, since I have not inspected its condition. And it is based on the information with which
you provided me, i.e. Joseph Kennedy's Installer's permit date 04/04/96, and 04/12/96 Certificate
of Compliance,and the"As-Built"card and Ed Barry's ftom the Board of Health Department.
Ed Barry's sketch indicates that the system is 19' X 26.5' to the outside of the stone. However,
since only 4' of stone is allowed beyond the chambers. The allowable leach area would be 16' X
24' X 1'.
Therefore the capacity would be calculated thusly:
Capacity of Bottom Area = 16X24X.1 gaI/SF = 348 GPD
Capacity of Sidewall Area= 80X1'X2.5 gal/SF = 200 GPD
TOTAL CALCULATED CAPACITY: 548 GPD
The required capacity for four(4)bedrooms by Title 5 was
4 X 110 GPD= 440 GPD
So the system would be sufficient for four(4)bedrooms and almost for five(5)bedrooms(550).
However, the new Title 5 regulations since March 31, 1999 is calculated thusly:
[(16X24)+ (80' X 10.74= 343.3C GPD
which is less than 440 GPD.
Or if actual size is usedt.9' X 26.5)+(91' X 0.74= 439.93 GPD
which is only slightly less than the 440 GPD required now.
I hope this provides you with the information needed. Remember this is only a mathematical
analysis and does not say anything about the condition of the present system.
Very truly yours,
Craig R. Short, P.E.
CRS/cwk
COMMONWEALTH OF MASSACHUSETTS
e - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
t
ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: Name of OwnerT i In Flaherty
Address of Owner: 40 Plain Zt. , Cummaqui d, Ma
Date of Inspection: 0 6/16/9 9
Name of Inspector:(Please Print) ert )J. Saben.. Sr.
I am a DEP approved system inspector pursuant to Section 15.340 of Title,5(310 6-MR 15.000)
Company Name: Same
Mailing Address: 30 N a t h, •Ma '
Telephone Number: -7 7 -7 7 5
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes
Conditionally Passes
Needs.. urther Evaluation By the Local Approving Authority
Fails`
Inspector's Signature: Date: !1l✓ / (,
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to tfte
system owner and copies sent to the buyer,if applicable, and the approving authority. _
NOTES AND COMMENTS
C.0 /-
revised 9/2/98 Page Iof11
i�Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A r
J CERTIFICATION(contirwed)
P►operty Address: 4o84 Main St . Cummagiaid, Nia
owner: Tim Flahgjrtx
Date of Inspection: o b/i b/99
INSPECTION SUMMARY: Check A, B, C, o/ D. 'Y
A. SYSTEM PASSES: j5, `
X I have not found any information which indicates that any of the failure conditions described in 310 CMR 1.5.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES: .
One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon
completion of the replacement or repair,as approved by the Board of Health, will pass.
Indicate yes, no, or not determined(Y,N, or NO). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or.exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or,obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of.
Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced.
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system wfll pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
I
revised 9/2/98 page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 0)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
j
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A .
CERTIFICATION(continued)
Property Address:
Owner:
Date of Inspection:
D. SYSTEM FAI
LS: `+ ;
You must indicate either "Yes" or "No" to each of the following: -
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facilityor system componentAue to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
_coliform bacteria,volatile organic-compounds, ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS: `
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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 If of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412). Please consult the local regional
office of the Department for further information. -
revised 9/2/98- Page 4ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
i CHECKLIST
Property address: 4084 Main St . Cummaquid'; Ma.
owner: Tim Flahert
Date of Ins on:peeb o 6/i�/9 9
• a I
Check if the following have been done:You must indicate either"Yes" or"No" as to each of the following:
Yes No
Pumping information was provided by the owner,occupant,or Board of Health.
None of the system components have been pumped4ar-atJeast two weeks and*the system has:beemseceiving nmraal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this.
inspection.
X _ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow. u
_ The site was inspected for signs of breakout.
X All system components, excluding the Absorption$ stem, have been located on the site.
_ _ Y P 9 P Y
The septic tank manholes were`uncovered,opened,and the interior of the septic tank was inspected for condition of baffles
'or tees, material of construction,dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on-the site has been determined based on:
_ Existing information. For example, Pian at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[15.302(3)(b)1
The facility owner(and occupants,if different from.owner)were,provided.with informatiomon the.prnpermaintanaoccof
SubSurface Disposal Systems.
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
4
_ Prop"Address: $Tt Main St . Cummaquid Ma
Owner: Tim Fl ah r
Date of Inspection: 0 1 9
/ /99
FLOW CONDITIONS '
RESIDENTIAL: -
Design flow: g.p.d./bedroom.
Number of bedrooms(design): 4 Number of bedrooms(actual): `
Total DESIGN flow
Number of current residents.
Garbage grinder(yes or no):--N—O
Laundry(separate system) (yes or no):_BQ If yes, separate.inspection required
Laundry system inspected (yes or no)
Seasonal use(yes or no):No
Water meter readings,if available(last two year's usage(gpd):
Sump Pump(yes or no): No
Last date of occupancy: n urre nt
COM MERCIALIINDUSTRIAL:
Type of establishment:
Design flow: gpd ( Based on 15.203)
Basis of design flow -
Grease trap present: lyes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system:(yes or no)_ ,
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy: ,
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Septic tank num P= d 2/-2Z99 -per* 14ater pni uti nn n
, , , � n trol division
System pumped as part of inspection: (yes or no)-iLo
If yes, volume pumped: gallons
Reason for pumping: norma procedure
TYPE OF SYSTEM
X 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).
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed lif known)and source of information: _-9, n-ew; i ngt al 1"e d -04f 9 6
Sewage odors detected when arriving at the site:(yes or no),SO
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4084 Main St . Cummaquid r, Ma
owner: Tim Fla e rt
Date of Inspection: 0616/ 9
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction:_cast iron_40 PVC other(explain) ^.
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan) i
Depth below grade:"
Material of construction: Xconcrete metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ Is.age.confirmed by Certificate of Compliance_(Yes/No)
Dimensions: 10 0 0 g_al.
Sludge depth: 1 "
Distance from top of sludge to bottom of outlet tee orbafflei r ' -"
Scum thickness: oil
Distance from top of scum to top of outlet tee or baffle:--"
Distance from bottom of scum to bottom of outlet tee or baffle: 1 6"
How dimensions were determined: Numbered measuring rods
Comments: ,
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structurel-integrity,
evidence of leakage,etc.) Liquid level t bnttnm r)f' nilt1 et lnve�2t • struntural
integrity_ood; no PVl denf'P of 1 PakagP .
GREASE TRAP:
(locate on site plant
Depth below grade:_
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:
Comments:
(recommendation for pumping,condition'of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
I
revised 9/2/98 . Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4084 Main St Cummaquid, Ma '•'
Owner: Tim Flaherty
Date of Inspection: o 6/1 6/99
TIGHT OR HOLDING TANK: (Tank must be pumped prior to,`or 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/day
Alarm present
Alarm level: Alarm in working order:Yes No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of'leakage into or,out of box, etc.) -
No "D" box evident
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4084 Main St . Cummaquid, Ma
Owner: Tim Flaherty
Date of Inspection: o 6/16/99
SOIL ABSORPTION SYSTEM(SAS)
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers,number:
leaching galleries,number:_
leaching trenches,number,length:
leaching fields, number, dimensions:
overflow cesspool,number._ a
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation, etc.)
SAS• Four (4) 4x8 flow di fugerc npened raver—& Found bottom to
,1
failure . No bondinge vt�getatio-n -normal
CESSPOOLS:_
(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 (cesspool must be pumped as part of inspection)
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.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 4084 Main .St . Cummaquid Ma
Owner: Tim Flaherty
Date of Inspection: o 6/16/9 9
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked "
Groundwater depth: Shallow Moderate . Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 3-0—'Feet „
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed.Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records f '
Checked local excavators, installers
X Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
.Due to the difficulty in digging in this area I `used, topo maps
to determine the ground water level .
revised 9/2/98 Page 11of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
o PART C
y SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspwtion:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
4' .
Ncr b na n±0k4
S
IP2 -Orly— /31 loco
revised 9/2/98 Page 10of11
L
` ASS�SSJR`S MAP' N0. PARCEL
LOCATION SEWAGE PERMIT NO.
.Bonehill/6A, Cu_�unaouici, Ma. 86-442
VILLAGE
BARZISEPABLE,
INSTA LLER'S NAME i ADDRESS
CASH'S TRUCKING IlgC .
OFF Union St . , Box 7, Yarr..outhFort., Ma. 02675
e U I L D E R OR OWNER
FLAHERTY, TIMOTHY
I
DATE PERMIT ISSUED 5/11/86
DATE COMPLIANCE ISSUED 7/17/86
_ _ �
f
{
h ______.--'�
�'
Y.�
..�
. �
�.
�I __
f '
./
H,EAETH bEP` . e�
No.� -�-��- Town Office Building !'
..._.._....... F � _... ....._
BOARD OF HEALT_H
OF.... ...
Applutttion for Disp agal Marks Towitrurtion rantit
Application is hereby made for a Permit to Construct ( ) or Repair (�n Individual Sewage Disposal
Sy at: ; .. .. .. 004 . ....
• ocation• r `���� a9'� o..................................................Lot No....... .............................
caner dress
a ------------------ --------
-
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building _..... No. of persons............................ Showers
a YP g ------•--------------- P ( ) — Cafeteria ( )
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 ( )
0-4 Percolation Test.Results Performed by................................................................:...._.... Date.........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................
R+ ................................ -...........................•-•-•-..............................................................
O Description of Soil........................................................................... F-
W .............................................. .......................•---••---._._.- f-{pv<;�---•- ,,.. St aSQ.YS---•-----------••-•--_-_
x .................•-•--.................._._.....__................................................................... .............. s... ...........
U Nature of Repairs or Alterations—Answer when applicable_.. -(--r x --••-.
••••--•-•••-••••-••••-.................................................... ......• -- .-•--• -•--....... --•.. ...... ......
Agreement
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'LI'A!, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the boa f 1
Signed,_..- - _ ...... ------ ------ - /
IS -
Application Approved By..................................... .. ... . • .....
.-..... •-- ......... 1...........................
�
Date
Application Disapproved for the following reaso s:---•.............................,....-•--------•-...............--••-•---•..._........._....._._..-•••....._.
...............•..............................-••---••••--•-••.........---...---•-•------........•........_...........•--•-•----•.•...........__........-----••...................... --•••••----••.
Date
PermitNo.......................................................... Issued.......................................................
Date
Aw
THE COMMONWEALTH OF MASSACHUSETTS
• F `
BOARD OF HEALTH
}.........."'OF,... _e.-.................................
Appliration for Disposal Warks Tanstrnrtinn Permit
Application is hereby made for a Permit to Construct ( ) or Repair (e_)"an Individual Sewage Disposal
System at: ,
64 . 1/tw'wl
GT ,u f
---...,.. ».___................. -... -----.......--•-••••--'•-•- -•--•••-----•-•---'----••••-..._..._..__...--••"•-----•-•-••'••-••--•-•.....-•--......---........
✓ --Location �Ad ress
( ,�+ or Lot No.
.................�/ ........ I� ?7- Yj?" 11.� C�i.—•—•.... ......................................
(� Owner '` Address--_____•___-_'_---_^^.............».....
...........- - • _...
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a Other—T e of Building a Other—Type g ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures •------••--------------------------•----......•-----........------•---
W Design Flow............................................gallons per person per day. Total daily flow---------.-____---__--„_--...............gallons.
WSeptic Tank—Liquid capacity............gallons Length.................Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width.................... Total Length....____....... Total leaching area....................sq. ft.
3 Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by.........................:..................... ..� _.. ............. Date...............-........................
Test Pit No. I................minutes per inch Depth of Test Pit.........I......... Depth to ground water........................
Lx, Test Pit No. 2................minutes per inch Depth of Test Pit........._.......... Depth to ground water................-.......
-'
= 1 r
O Description of Soil......................................................1_... °`1- = r P .f_�
U ................. ...•-•.....___•--._......------•••---........... ..}..t'"J' Z... ........L:.......------ =�-�;i� �te_ ./. C .. -
W 1 � t
U Nature of Repairs or Alterations—Answer when applicable.---_,` __. -_.:_ a.-.:_'? 'y- _ :{xi._ •_<:�: !...........
f
Agreement: I
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT:..f•, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the Zoard®f health77
Signed.
f ` ..........
cit
t f ti at
ApplicationApproved By................•------------ _ -�• --- - •--••------ ........................ ....
Date
Application Disapproved for the following reaso s---------------:.. .................»
......................... ..--•-------•--- -••--------••-------
7.
Date
PermitNo....................................................... Issued.:::-•--•--'----•-•••:_... ......................»:
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a,
f� .tea �
a f 9—:°w�!_.........0F.... 'It,lr/, I(..1 tt 1. ....:..........................
Trrtifiratt of •f umptianrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (L,.)--
b .............. ../fr_A A E-.-- ` ,• �
Installer
has been.installed in accordance with the provisions of TITiZ 5 of The State Sanitary Code as described in the
FrappliCatioxljor Disposal Works Construction Permit No......................................... dated...............................................
.
q; THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 6E CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL F NCTI SATISFACTORY.
DATE................
l
...-�..__ ............................... Inspector........---� VVV
.................................................................--
,... _.._...._--...-__
THE COMMONWEALTH OF MASSACHUSETTS lftJ� �� 1Z-W40V-4
BOARD AlF HEALTH
6, �-,t� OF.... %A a� a 1-w Al + �..................
.. .... . ...... . . .... Q'
1
No...�`.. ...
. i Disposal nrkii Tonstr inn Permit
3 Permission is hereby granted_..-- �` ' .. t `"1!•Ara.. ✓ �.,.%r "% 'r
to Construct ( ) or R p�it (�) an Individual Sewage Disposal System
at
r Street Jai"
as shown on the application for Disposal Works Construction Permit No--------------------- Dated........ ................
�- 3 � ' 2.c................................. Board of lfealth
DATE.. -
TOWN OF BARNSTAB E 0
LOCATION _4Ae2& SEWAGE # q46 a2�
VILLAGE ASSESSOR'S MAP &LOTi✓�'� 1
INSTALLER'S NAME GHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)CFZ (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPL CE DATE: �� �
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
s
59
� b r