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HomeMy WebLinkAbout4251 MAIN ST./RTE 6A(BARN.) - Health 4251 Ruin StreeQt/Rte. €A (Barn) Barnstable P A = 351 045 a i j i u m 1 A u f d 1 a Oct 13 12 08:32a p.1 Commonwealth of Massachusetts -- � Title 5 Official .Ins Inspection Form p Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 4251 Main Street(RTE 6a) Property Address David J Welch Trustee Grandview Trust Uwmer Owner's Name information is required for Barnstable MA 1 Oil 0/2012 every page. CitylTown 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. onlythe tab key Y to move your Wayne Archambeault _ cursor-do not Name of Inspector use the return key. Company Name rob BOX 914 Company Address Hyannis _ _ _ MA 02601 A" City)Town State Zip Code 508-775-1362 _ 355 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 S� "on 15.3a of Title 5(310 CMR 16.000).The system: ^rw r-`) ' C ® Passes ❑ Conditionally Passes ❑ Fails -� o ❑ Needs Further Evaluation by the Local Approving Authority o' co _ 10/10/2012 _ ' in pector's Signature Date eIq 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. 'i'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. t5�s•11110 Title 5 Official Inspeeton Form:Subsurface Sewage D sposal System-Page 1 of 17 Oct 13 12 08:32a p.2 Commonwealth of Massachusetts Title 5 official Inspection Form J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4251 Main Street(RTE 6a) Property Address W David J Welch Trustee Grandview Trust Owner Owner's Name information is required for Barnstable _ MA _ 10/10l2012 every 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"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•11/1 D Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Oct 1312 08:33a p.3 Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _4251 Main Street(RTE 6a) Property Address David J Welch Trustee Grandview Trust _ owner Owners Name information is Barnstable MA 10110/2012 required for _.. every page. Cityfrown State Zip Code Date of Inspection B. Certffication (cunt.) 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 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 Gins•11 n0 Title 5 official Inspection Form:Subswface Sewage Disposal System•Page 3 of 17 Oct 1312 08:33a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4251 Main Street(RTE 6a) Property Address David J Welch Trustee Grandview Trust Owner Owner's Name information is required for Bamstable MA 1 011 012 01 2 every 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 y g that protects the public health p 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 %day flow f5ns•11H0 Title 5 Official Inspection Form:Subsafas Sewage Disposal System•Page 4 or 17 Oct 13 12 08:33a p.5 Commonwealth of Massachusetts --- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4251 Main Street(RTE 6a) _ Property Address David J Welch Trustee Grandview Trust Owner Owner's Name information is required for Barnstable MA 10/10/2012 --- - every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply 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. r5ms•11110 Title S Official h Vechon Form:Subsruface Sewage'JisFosa:System•Page 5 of 17 Oct 1312 08:34a p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4251 Main Street(RTE 6a) Property Address -— - David J Welch Trustee Grandview Trust owner Owner's Name information is Barnstable required for _ MA 10I1012012 every page. CityrFown 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 NIA) ® ❑ 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 - t31ns•'WO 0 Tale 5 Official Irtspection FoTn:Subsurface Sewage Disposal System•Page 6 of 17 Oct 13 12 08:34a p.7 Commonwealth of Massachusetts �a Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4251 Main Street(RTL- 6a) Property Address David J Welch Trustee Grandview Trust Owner Owner's Narne information is Barnstable MA 10/10/2012 required for _._ every page. Cityfrown 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 M No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d na 9 ( Y 9 {gP })� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 10/10/2012 Date Commerciallindustrial 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: Sins•17M0 Title 5 Official Inspection Fom�Suoswlaoe Sewage Disposal Syslem-Page 7 of 17 Oct 1312 08:34a p.8 Commonwealth of Massachusetts Title 5 Official Inspection Form 1=) Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4251 Main_Street(RT_E 6a)_ Property Address David J Welch Trustee Grandview Trust Owner Owner's Name information is required for Barnstable MA 1 0/1 012 01 2 every page. City/Town State Zip Code Date of Inspection D. System Information (cant.) Last date of occupancyluse: Date Other(describe below): General Information Pumping Records: Source of information: owner Was system pumped as part of the inspection? ❑ Yes No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic lank, 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): 15ins•11110 Title 5 ORcial inspection Fenn:Subsurface Sewage Disposal System•Page 8 of 17 Oct 13 12 08:35a p,g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4251 Main Street(RTE 6a) Property Address David J Welch Trustee Grandview Trust _ Owner Owner's flame Information is Barnstable MA 10/10/2012 required for every page. CitylTawn State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 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.): TANK#1 Barn System installed 1111412002 permit#02-524 TANK#2 septic tank at house age unknown Septic Tank(locate on site plan): Depth below grade: tank#1 1' TANK#2 1.5' 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: TANK#1 10.5'X5'X5' TANK#2 8.5'X5'X5' Sludge depth. TANK#1 3" TANK#2 4" 15i,.s•11110 Title 5 OMciai nspedion Fcrm:suosurtace Sewage Disposal 5ystem-Page 9 of 11 i Oct 13 12 08:35a p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4251 Main Street(RTE 6a) Property Address David J Welch Trustee Grandview Trust Owner Owners Name information is Barnstable MA 1 011 012 01 2 required for _ every page. cityyfr"n State Zip Code Date of inspection D. System Information (cont.) Septic Tank(cunt_) Distance from top of sludge to bottom of outlet tee or baffle TANK#1 37" TAN K#2 36 Scum thickness TANK#1 4" TAN K#2 3" Distance from top of scum to top of outlet tee or baffle TANK#1 5"� TAN K#2 6 Distance from bottom of scum to bottom of outlet tee or baffle TANK#1 11 TANK#2 12 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.).- LIQUID LEVELS IN BOTH TANKS AT PROPER HEIGHTS TEES AND TANKS ARE IN GOOD CONDITION _ 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 t5as•11f1 G The 5 Official Insped on Form:subsurface Sewage Disposal System•Page 10 of 17 Oct 1312 08:35a p.11 Commonwealth of Massachusetts Title 5 Official inspection Form 7 y Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4251 Main Street(RTE 6a) _ Property Address David J Welch Trustee Grandview Trust Cwner --- — _.. -- Owner's Name - - iequire fo d for ti is require Barnstable MA 1 011 0/2 0 1 2 every page. City/Town 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 Desfgn 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•1 Ill Title 5 Official Inspection Fear:Subsurface Sewage Disposal System Page 11 of 17 Oct 13 12 08:36a p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4251 Main Street__(R_TE 6a) Property Address David J Welch Trustee Grandview Trust _ Owner Owner's Name information is required for Barnstable MA _ _ 1 Oil 0/2012 _ _. every page. Cityrrown State Zap Code Date of Inspection D. System Information (cons.) 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.): NO SIGNS OF DETERIORATION AND BOX IS WATER TJGHT 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.): Soil Absorption System (SAS)(locate on site plan,excavation not required): If SAS not located,explain why: t5uts•11110 Title 5 Official IrWacticri Form:Subsurface SewNaCe Disposal System•Page 12 of V Oct 1312 08:36a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form = - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4251 Main Street_(RTE 6a) Property Address David J Welch Trustee Grandview Trust Owner Owners Name —`_ .... information is required for Barnstable MA 10/10/2012 every page. Cityrrown State Zip Cade 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 -- ❑ innovativetalternative system Typelname of technology: - Comments(note condition of soil, signs of hydraulic failure, level of pcnding, damp soil, condition of vegetation, etc.): LIQUID LEVEL 1.5' BELOW INVERT PIPE NO STAIN LINES OR SIGNS OF 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 15ns-11 mo Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Oct 13 12 08:36a p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 4251 Main Street(RTE 6a)_ Property Address David J Welch Trustee Grandview Trust owner Owner's flame information is Barnstable MA 10/10/2012 required far _ every page. Cityf own 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.): t5irw-1111 D Title 5 official lns"lan Form:Subsurface SawaV Disposal System-Page 14 of 17 Oct 13 12 08:37a p.15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �:. 4251 Main Street(RTE 5a) Property Address David J Welch Trustee Grandview Trust Owner Owner's Name require fo d for ti is require Barnstable MA 10/10/2012 �._ _— every page. Crtylrown 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 1,?A1.1`f of 7' J3 S ee-cj i S �� �hRrh �C25 f06CSf I f^^IDC/S~ © � 1= 1=z i3i=23:s G� 3Z395' t33:�/ � A4�= 36 r3 `f t5ms•11110 Title 5 W16M hnspecdon Form:Subsurface Sewage Disposal System•Page 15 of 17 Oct 1312 08:37a p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form 1. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4261 Main Street(RTE 6a)_ — Property Address David J Welch Trustee Grandview Trust Owner Owner's Name information is Barnstable MA 10A012012 required for __.. . _ every 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: 12' -- - —- 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 160 feet of SAS) ❑ Checked with local Board of Health-explain: TOWN GIS MAPS ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: TOWN GIS SHOWS WATER TABLE AT 12' BOTTOM OF SAS AT 5' SEPERATION 7' Before filing this inspection Report, please see Report Completeness Checklist on next page. t5tns-11110 Title 5 Gffidal Inspection Form:Subsurface Sewage Disposal System•Page 16 o197 Oct 13 12 08:37a p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 9 p Y rY 4251 Main Street(RTE 6) Property Address David J Welch Trustee Grandview Trust Owner Owners Name information is Barnstable MA 1 011 0/201 2 required for 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 (Sins-11110 Title 5 official Inspection Form:Subsutace Sewage Disposal System-Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMEN,-TAL a DEPARTMENT OF ENVIRONMENTAL PROTECTION 0 s a� 3SI O TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMEv'TS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A _ RTIFICATION �2 11 C�1 _ Property Address: �o� �p ti f� GA Jb C_CA . /lq oa63 )' 07 Owner's Name: Owner's Address: Pa Bax 173 C. _ CA#-I eti RH Date of Inspection: CD Name of Inspector:-(please print) cY"k o l /X • Company Name: O — G r p> Mailing Address: O pX Telephone Number�',Sai3 1 2 S— 7 qY 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 Sectio 5 340 of Title 5(310 CVIl2 25.000). The system Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails I Q � Inspector's Signature: G�'✓C I 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 10,00o 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 salve or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSME.NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Tj Owner: (.✓e(��H�e►Ai emu.- Date of Inspection: 0 b Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy m Passes: ✓r have not found any information which indicates that any of the failure criteria described in 310 CIMR 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial.infiltration or exfiltration or tank failure is imminent System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken 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 obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will Pass inspection if(with approval of the Board of HeaIth): broken pipe(s)are replaced obstruction is removed NI D explain: T41. All Sl 2 Page 3 of 11 - OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: `�� S� J� �- 6 Owner: l,/eI � L4� G �vvlw�tiQ ' /'✓ ©�b3� Date of Inspection: O C.�Further Evaluation is Required by the Board of Health: Conditions exist which require fiuther 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 C-NIR 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 Z. 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form 3. Other: Page 4 of 11 . OFFICIAL INSPECTION FORM—NOT FOR VOLUTNT_ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ��J Owner: l/'�>✓� C 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 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or /cesspool '' xiquid depth in cesspool is less than 6"below invert or available volume is less than%day flow - _✓✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).NI umber /of times pumped /C y portion of the SAS,cesspool or privy is below high groundwater 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 we1L portion of a cesspool or privy i 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] —R14 (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CTMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Xyesthe 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—TW-PA)or a mapped one 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 larg1:1e system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CNIR 15.304.The system owner should contact the appropriate regional office of the Department. Titln 4 Tncnanf;— Tz—m Fit cnnon Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNT-A Y ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: cn 1-7yvla 6Z 141 , 2114 Owner: G Date of Inspection: 5Z, Lo 6 Check if the following have been done.You must indicate eyes"or no-as to each of the following: Yes i o- _ Pumping information was provided by the owner,occupant,or Board of Health v 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 inspecaon? V Were as built plans of the system obtained and examined?(If they were not available note as ti/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 p tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the b ffles or tees,material of construction,dimensions' depth of liquid,depth of sludge and depth of scum? Was the facilityowner and occupants if '( p 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 om Yes no 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 CMI R 15.302(3)(b)) T;tlo G incncrtinn Fnrn, 41,ci�nnn 5 f Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLL"NT_ARY ASSESSIYIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM INFORMATION Property Address: / 7 Owner: �/2 (oh Date of Inspection: 5 5 LOW CONDITIONS RESIDENTIAL Number of bedrooms(design): t7c Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Lly-O Number of current residents:_01— Does residence have a garbage grinder(yes or no): A0 Is laundry on a separate sewage system�ye or no):?/O [if yes separate inspection required Laundry system inspected(yes or no):N Seasonal use: (yes or no): /" Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Crease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):— Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL LNFORNLATION Pumping Records Source of information: 005 to c Was system pumped as part of the inspection(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPF F 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) Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: W ere sewage odors detected when arriving at the site(yes or no): 6 Title G Tncnortinn T:nrm �.11 C/7nnn Page 7 of 11. OFFICIAL INSPECTION FORM—NOT FOR VOLLIiT_A-RY ASSESS'a.NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1I PART C SYSTEM INFORMATION(continued)0� Property Address: 4 aJ'9 J- 64 � " , u rM wr a Q-,c, W W /LlA¢ fJa 6 3 Owner: VV 2�G� Date of Inspection: .S 016 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: iron 48'PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_(locate on site plan) Depth below grade: 0213 Material of construction:_ oncrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confu-med by a Certificate of Compliance(yes or no):_(attach a copy of certificate) ' Dimensions: X Sludge depth: 02 ' Distance from top of sludge to bottom of outlet tee or baffle: d`� Scum thickness: Z-e.5S / '' Distance from top of scum to top of outlet tee or baffle: 6 Distance from bottom of scum to bolter of outlet tee or baffle: How were dimensions determined: /'o/e- 2 Ir, —mac eW c e Comments(on pumping recommendations,inlet and outl tee or baffle condition,structural integrity,liquid levels as elated to outlet invert,evidence of leakage„etc .): u in ✓Io f7 cJe G, 1 fr vvie -, 4— G" eo �a.. co" /l/t9 2a l,.s , GREASE TRAP:-/!/(locate on site plan) De pth 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural inte_��, Liquid levels as related to outlet invert, evidence of leakage,etc.): Tito 1--tinn V,, 411 cnnnn 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S SUBSURFACE SEWAGE DISPOSAL SYSTE., INSPECTION FORM PART C. SYSTEM IirFORMATION(continued) Property Address: 401,6-1 a� 6� (.� wI wt A(fit, Owner: Lve(c Date of Inspection: 3' 0 TIGHT or HOLDING TANK:4 (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(expiain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBU T'ION BOX: (ifpresent 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 carry-over; any evidence of leakage ip;o or out of b9 etc.) �� / L /�bX Le i cif r 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.): Title 1 lncr+crtinn Rnrm �i/1;/onnn 8 Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA PART C SYSTEM INFORMATION(continued) Property Address: Owner: t✓e(C Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) I AS not f S o located explain why: Type leaching pits,number:_ (✓ It/o leaching chambers,number: 5 leaching galleries,number: leaching trenches,number; length: �O 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.): as��r� G� �'_ Life S oZ (4 -e Oz- �� i 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 or no): Comments(note condition of soil,signs of hydraulic failure,level ofponding,condition of vegetation,etc.): PRIVY: /1/ (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.): T;tto c t o +; �r 9 Page I0 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNT RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: CA cMcMA G2u Owner: (,✓-e l co 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-&=L o ate where public water supply enters the building. / �vdG ✓ /Vp 5� �Ie- Xl- 31.6 _ X w r Page 11 of i l •' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C l SYSTEM INFORMATION(continued) Property Address: `� / " �4 Owner: Date of Inspection: SITE EXAM Slope �} Surface water �v Check cellar Shallow'wells Estimated depth to ground water C�.� 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: 0 ed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: /7,7 f- Ala 1-7 Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describee'how you establish tl hi h ground water levation: l eqcco /! rl A heve DE C BORTOLOTTI\CONSTRUCTION,INC. Uy 'Ilk e ! 765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 508-771-9399 508-428-8926 FAX: 508428-9399 j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Date of Inspection: Inspector's Name: �s Nam arld�lddress:l�7,'r����P �� c� J O G CERTIFICATION STATEMENT*:. I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per- formed based on my training and experience.in the proper function and maintenance of on-site sewage disposal stems. The System: I/ Passes Conditionally Passes Needs Further Ev luation B th Local Aproving Authority Fails Inspector's Signature: i Date: The System Inspector shall submit copy of this inspection report to the Approving authority.within thir- ty(30)days of complg 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 the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTIONSUMMARY: A)SYS PASSES: I have not found any information'which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.Any failure criteria not evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair, passes inspection. _ Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is imminent.' The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. 'H Sewage backkup 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): " - 1 - r s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)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 will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed � f C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: 4 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. ; 1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 's Cesspool or privy is within 50 Feet of a surface water k Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt'marsh. A,W-1111111 TIN. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATERa SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface F? jd watei4gply or tributary to a surface water supply. a"r The systedbas a septic tank and soil absorption system and is with a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. `Y The system has aseptic tank and soil absorption system and 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' the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 m. �? PP D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined "4' in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health r�r s e should be contacted to determine what will be necessary to correct the failure. >� Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. f ' Discharge or ponding of efluent 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 clog- 3 ged SAS or cesspool. * Liquid depth in cesspool is less than G 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 -2_ ' M1 fT �J1 rik q{ tt fy i�p�p{yy SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 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 s compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: - The following criteria apply to a large system in addition to the criteria above: The design flow of a system is 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: . The system is within 400 Feet of a surface drinking water supply The system is within200 Feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IW&k)or a mapped Zone II of a public water supply well. The owner or operato.of any such system shall bring the system and facility'into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B ' } CHECKLIST Check if e following have been done: Pumping information was requested of the owner,occupant,and Board of Health. one of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been /introduced into the system recently or as part of this inspection. '� n As-built plans have been obtained and examined. Note if they are not available with N/A. v,the facility or dwelling was inspected for signs of sewage back-up. _,/Lthe system does not receive non-sanitary or industrial waste flow. z r 4he site was inspected for signs of breakout. !/I system components,excluding the Soil Absorption System,have been located on site. The septic tank manholes were uncovered,opened,and the interior of the septic tank was in spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. , (-Tl'e size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3 t, SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST(continued) } �F The facility owner(and occupants,if different from owner)were provided with information on the maintenance of Subsurface Disposal System proper i in.Y r i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION FLOW CONDITIONS /- 1,s RESIDENTIAL* a Design Flow: gallons Number of Bedrooms: _ Number of Current Residents:_ Garbage Grinder: Laundry Connected To S stem: Y F Seasonal Use: ,c nD � ►t«; g rY Y � Water Meter Readings,if available: Last Date of Occupancy, COM_M .R LAL11NDUSTRIAL:/VV Type of Establishment: Design Flow: Rallons/day Grease Trap Present: (yes or no) w:' Industrial Waste Holding Tank Present: Non-Sanitary Waste,xJL harged To The Title V System: Water Meter Readings,If`Available: Last Date of Occupancy: Fy� OTHER: Describe) Last Date of Occupancy: s; GENERAL INFORMATION G&t PUMPING RECORDS and source of informat' n: ���/" n� c fir✓J'- °1 U� System Pumped as part of inspection: If yes, olume pumped: gallons Reason for pumping: TYPE SYSTEM: Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes,attach previous inspection records, if any) Other(explain): ROXIMATE AGE of all components,date installed(if kn wn)and source of information:' - Sewage odors detected when arriving at the site. r 4F 7A'j i.•y}l..kn. A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENEItAL INFORMATION (continued) SEPTIC TANK: (/ Depth below grade: f 8,/ Material of Construction: 1­�concrete metal FRP Other (explain) — Dimisions: 3,S'.1'Co ' Vh, Sludge Depth:_ �/ Scum Thicyess: Distance from top of sludge to bottom of outlet tee or baiTle: g Distance from bottom of scum to bottom of outlet tee or bale: /Z Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in la on to outlet invert, structural int�e ty,evidence of leakage,etc.) 7-v /006 GREASE TRAY: -� - Depth Below Grade: Material of Construction: concrete metal_FRP—Other (explain) r; Dimensions: Scum Thickness: �� ;. Distance from top of scum to top of outlet tee or baffle: 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;. 0 lo TIGHT OR HOLDING TANK— Depth Below Grade: Material of Construction:_concrete metal_FRP—Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day h1 y{ Alarm Level: r L Comments: (condition of inlet tee,condition of alarm and float'switches,etc.) 5 DISTRIBUTION BOX: r/ Depth of liquid level above outlet inver(�- / Comments: (note rel and distrib lion is 1,ev iddice of solids capyover,evid nce of leal9ge into or out of box,etc. S it u a 7 r a.i,k.z,✓•v PUMP CHAMBER: ... Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) Y'x 1 —5— t i � t sF n � lai SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) j SOIL ABSORPTION SYSTEM(SAS): l/ required,but may be approximated b non-intrusive if possible;excavation not re u y pp Y (Locate on site plan, po q methods) If not determined to be present,explain: Type: ` Leaching pits,number: Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields, mmnber,dimensions: Overflow cesspool, number: Comments: (note condition of soils ns of hydraulic failure level of pondion 'don of ve eta ' n, et G �� 0 ►� O� V_ 4 ; r^ x tit CESSPOOLS: t z k Number and configuration: Depth-lop of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: 4 Materiels of construction: Indication of groundwater: r, Inflow(cesspool m4bg:pumped as part of inspection) Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation, r{" etc.) 35"r f S 1 r PRIVY:,Z�6 , t Materials of construction: Dimensions Depth of Solids: Comments: (note condition of soil signs of hydraulic failure, level of ponding,condition of vegetation, "-< etc.) i 3 -G- �u LLp{�tT w i a� r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. I r.. Cr i i U r. DEPTH TO GROUNDWATER: Depth to groundwater: _Feet Method of Determination or A pro imation: 4 w _7- ,r C Town of Barnstable r#11/b 04 Department of Regulatory Services I SEP 17 f#TPublic Health Division, Date � ie'e a1I 200 Main Street.Hyannis MA 02601 — Date Scheduled / f7�' Time Fee Pd. oo_ soil Suitability Assessment fog' Sewage Disposal Performed By: By: sIg In b•. YD i t 2 1 y1 d.•. ' r fNi q�l .g:�Y'dirt 1 .. ,..t �_ a c t "Owner's Name W -t cation Address S) 0 /lAk(NS� t —((d Y/ Address Aid Assessor's Map/Parcel: 3 S1-V yS Engineer's Name �� d►�c E NEW CONSTRUCTION REPAIR X Telephone Land Use Slopes(%)_ Surface Stones NC)A"V, Distances from: Open Water Body /V A ft Possible Wet Arca2jUIC ft Drinking Water Well ZLP—Ift Drainage Way 7 /0 V ft Property Line ®_ ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes) t 1 n a Parent material(geologic),_ ✓r 4 LA_ Depth to Bedrock 7 r Depth to Groundwater. Standing Water in Hoie: > Weeping from Pit Face Estimated Seasonal High Groundwater � 41Ifi '.`t 1. 1 F M .r �•r y y v,' [S ' YIa 'ryc`Plu Irr r a . Method Used: in. Depth Observed standing in ohs.hole: in. Depth to soil mottles: in. Groundwater Adjustment ft. Depth to weeping Vtom side of obs;.hole: Index Well a Reading Date: Index Well level Adj.factor Adj.Groundwatet Level_ L k... e. p ' 'p j f �� m...0-a:+'1�"�d�' l � ^^qc . 1W;nti '� •,�' Y'm � •I r .' Observation / Time at 9" Hole# -- 9 Depth of Pcrc Time at 6" Start Pre-soak Time @ Time(9"-6-) , ?4 l-,�tto pus �. 2 M•^���� End Pre-soak — QkOR Nan I�r'1 iN Rate Min./inch Site Suitability Assessment: Site Passed _ Site Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back------- f Q:HEALTH/WP/PERCFORM I _ I • I ii',1j��' �,� ��'13yy,,• �I Y9bU a .s S '.. a�a r .> TIME,� l � S�'P i*Rt I 4 t�rfi},�iu!1�p1 C�hii u mil��x�r�e tir � .i '. � 'J�FnII�n�h� 6W!VIr.41uv11 . Depth from Soil Horizon Soil Texture Soil Color Soil other { Mottling :Structure,Stones,Boulders. Surface(in.) (USDA) (Mansell) j Consistxnc�+,°h Gravel) a ��P gANL7 Z�5 7 413 ,! ' Depth from Soil Horizon Soil Texture Soil Color Soil other Surface(in.)' (USDA) (Mansell) Mottling 'Structure,Stones,Boulders. onsistetic '/o Gravel) I ;w�pJ "' 1pf" a= .. ., �j 11'� I,�2i.U�`� b.} �. 7:.:� �'e �Be �t tq_ �s��4 ( }9,1 �N'+ kg Ilp P.uhb�c�l Depth from Soil Horizon Soil Texture Soil Color Soil Other i Stm%w(in.) (USDA) (Munsel!) Mottling Structure,Stones,Boulders.on istenc %Gravel — Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface('rn.) (USDA) (Munsell) Mottling Structure,Stones,Boulders. Consistenev %Gravel) i Flood Insurance Rate IV1ap: Above 500 year flood boundary No— Yes Within 500 year boundary No Yes�— Within 100 year flood boundary No X Yes De th of Natureiiv Dccurrin Permious Material Does at least four feet Of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption System? Y E5.S If not,what is the depth of naturally occurring pervious material? _Certification I certify that on (date)I have.passed'the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required Mg,expertise and experience described in 310 CMR 15.017. Signature Cr^�'�, Date ���• Q:HEALTW"/PERCFORM TOWN OF BARNSTABLE -Z.CATION SEWAGE # r VILLAGE ASSESSO MAP &LOT NAME&PHONE NO. �' SEPTIC TANK CAPACITY /dOO �/l/� 1� �� ` /J�S� 0ex LEACHING FACILITY: (type)�� C�� (size) �OoQ �iGi NO.OF BEDROO 3 BUILDER O OWNER PERMITDATE: COMPLIANCE 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 lea hing faci ' Feet Furnished� � / n� ��=D`� •�'�C TOWN OF BARNSTABLE �—__, `lr SEWAGE #I:UCATION i1 ivMu M ii VILLAGE Luf ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N . 6poly!�®m- 4ao)v K4i�? SEPTIC TANK CAPACITY LEACHING FACILITY: (type),? Q&1A ° f (size) 1��..�� 6Z NO. OF BEDROOMS T BUILDER OR.OWNER PERMITDATE: �� '� COMPLIANCE DATE: 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 [ oadd 10 No. FEE �lsd COMMONWEALTH ®F MASSACHUS ETTS 2 bU _U! Board of Health,T' '�S` � MA. APPLICATION FOP DISPOSAL SYSUM CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) UpgradeX Abandon( ) - 0 Complete System ❑Individual Components Location ZSi /44i/v CA Owner's Name phVj,9 W(5;LGp4 Map/Parcel# MAP l-k2C-C-L- Address .564%-tCy Lot# to 3 Telephone# Installer's Name : Designer's Name N N �t2 &j0/ULS Address ZCU --� 61ZO1-L Affjq)Wj Address Z3 Pa�oa HO uj Ap Telephone# 4;b IZ&48 Telephone# 7. � /' M4 7-644 Type of Building Lot Size 47, 4`78 -t sq.ft. Dwelling-No.of Bedrooms 3 FL,U,S' % 1'uIli✓Z0 J✓y QW2A s Garbage grinder( ) Other-Type of Building NZ4- No.of persons Showers ( ),Cafeteria ( ) Other Fixtures Design Flow (min.required) 446 gpd Calculated design flow 4-40 Design flow provided gpd Plan: Date Number of sheets Revision Date Title P/%PUaeo 5, '.5,07rc sy.SQ�M /51715'15. }Al, -f2_Yj a-T-t 6-4 , C-UM 'lA-GZyiT,7 VLA- Description ofSoil(s) _q 4 _�, CI (FJ�/'!�✓! L� g� `� L'Z: YA-Alo Soil Evaluator Form No. � /tskbtf A7-^^- Name of Soil Evaluator/044-&- /t14` Date of Evaluation /«a DESCRIPTION OF REPAIRS OR ALTERATIONS The undersigned agrees to install the above descri d Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to t to place th tem m tion until a Certificate of Compliance has been issued by the Board of Health. Signed Date r" 0 �/ D Inspections `//�C' /l P /� 0 { f!i t, s L�?.•n.F-i^-. 4::y....r-tir •• ,,,. '.15 � .'",',e>f"c-^..�-.�-"'y:�'-'�A."'-'�:i^F-.. .l,.,y �-d .. -'- - sa--- � Al � f"�' �� / � 3 •4. . No. M FEE _ v �� - J�a c•r TV S ; Board of Health;,-FA ` MA. `"'' '�"�� APPLICATION FOP, DISPOSAL SYSTII'J[ CONSTRUCTION PERMIT Application for a Permit to Construct( ) Repair( ) Upgradepo Abandon( - :W'Complete System ❑Individual Components Location Z.SI M A.iN S-7- T'C 6A Owner's Name 9AVIL7 WL5:-L r I--( Map/Parcel# MAP P s-I A, c� 4-1 ;F Address 5A.M 6 r _ Lot# 3 t l Telephone# Installer's Name YOM Designer's Name}, N( tNCL�YC tNCT 1Jl/C121L S Address ZU T/ j2 VA A J Address Z,3 !/5 'G 14G,Luxj AP si _S zQ C r Telephone# �r��'4 Z&4/ q Telephone# ? ��i � Z�-�4 Type of Building Lot Size 47. 428 t` sq.ft. Dwelling-No.of Bedrooms 4� Fl,US I /�-UTL//ZC- )A) 9442 ) Garbage grinder ( ) Other-Type of Building /V114- No:of persons Showers ( ),Cafeteria (_) Other Fixtures Design Flow (min.required) 44eJ gpd Calculated design flow f} Design flow provided gpd Plan: Date Number of sheets Revision Date Title P/ sP°sc'p 5C.077C S�°Sa'FM lS/T�/�'LA✓�. 44.S'"j /Z,7-6- 64 . COMM f}-a0iT� . %-* Description of Soil(s) '�� �}T N S y�r'�Q� q% `!� ��tr��; Y,+AIO � /- Soil Evaluator Form No. Ai/!Sf'4 C✓ Name of Soil Evaluatoro&�/ ll.k�� Date of Evaluation DESCRIPTION OF REPAIRS OR ALTERATIONS t• r The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and further agrees to not to place th tem m o e ahon until a Certificate of Compliance has been issued by the Board of Health. Signed -xl Date r f`" Inspections ���f.0 //1,"t- , �/! l/ P _ 9S `�- V V y No. COMMONWEA T14 OF MAS-SACflUSETTS FEE �(l Board of Health, RA1Z1M$Wt�c- MA. CERTIFICATE OF COMPLIANCE Description of Work: ❑Individual Component(s) ❑Complete System The undersigned hereby certify that,the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded ( ),Abandoned ( ) at• 1 �V/ 1 has been installed in accordance with the provisions df 310 CMR 15.00 (Title 5) and,the approved,design Aplans/as-built plans relating to application N/o�. ��.-S?`� dated O 1 510 Approved Design Flow �O (gpdj Installer t7(- A,4y nn Designer: i�9-4 Y+ !L p Inspector: Date: cr r The issuance of this permit shall not be construed as a guarantee that the system will function as designed. NoAla FEE 1 f COMMONWEALTH Of MASSAC14USETTS Board of Health, R6!NSVA4LE MA. DISPOSAL SYSTEM CONSTRUCTION PERMIT Permissionn is hereby granted to; Cons ruct( ) Repair( ) Upgrade(\� Abandon( ) an individual sewage disposal system at I //� j ( ! l,f y r r I 1 i as described in the application for Disposal System Construction Permit No. dated Provided: Construction shall be completed withit three years of the date of ss per!!it. All local conditions must be met. rr Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date I Board of Health AsBuilt Page 1 of 1 l{ TOWN JOf BARNSTABLE s LOCATION_ AAAi'A SEWAGE # VILLAGE , a.l "J" ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N ._rICIA)I I, O 7-20-K� SEPTIC TANK CAPACITY < Oa LEACHING FACILITY: (type)_� e c}>tf (size) '- — NO.OF BEDROOMS BUILDER OR OWNER__ Q-09W PERMITDATE: Il'� __COMPLIANCE DATE: I>✓��I/'� . 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 yAe , fl h8'y �vr" PAOX y http://issgl2/intranet/propdata/prebuilt.aspx?mappar=351045&seq=2 9/10/2013 TOWN OF BARNSTABLE LOCATION iV1fn t SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N �� SEPTIC TANK CAPACITY -_ /Sao LEACHING FACILITY: (type) (size) 3 NO. OF BEDROOMS op BUILDER OR OWNER Uo6W PERMITDATE: . COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and LeachingFacility (If any wells existFeet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by Feet L � III �rO�O i c ,r �o 1 7 TOWN OF BARNSTABLE LOCATION ��� �,q /3�rn�lA��P ~�°.SEWAGE # iP7-/Z7 VILLAGE ASSESSOR'S MAP LOT l- O `f S INSTALLER'S NAME 6z PHONE NO. 4( rime, ,p-jos r. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) , _/�a,�,;, �,j` (size) 6 NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER &/,,U,4, BUILDER OR OWNER DATE PERMIT ISSUED: - 7 DATE COMPLIANCE ISSUED: 11- G _E 7 VARIANCE GRANTED: Yes No i G Ss� l�=CI zh -p oz=Sr Q J� ASSESSORS MAP NO: No... Z:12.7 PARCEL NO: . Fmc ....�' THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH OF..........&L.......... .......... - -- App ira#ioai fear Dhipoii al Works Tomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ----- ��� Location-Address � � cv�Ar -- ..._� .. --._ —� r .........................._..... U �lu� O ress (� Installer Address U Type of Building Size Lot.... ��Y._._S, feet Dwelling—No. of Bedrooms.............. .................:.......Expansion Attic ( ) Garbage Grinder ( } aOther—Type of Building ............................ No. of persons............................ Showers ( ) - Cafeteria ( ) dOther fixtures ---------------------------------------•-------------.....----------------------------.... Design Flow..... ! _Q_. Q _ gallons per person per da4y. Total daily flow............................................gallons. W -------- W Septic Tank—Liquid ca acit 0.0. _. allons Length ___4'.._ Width_ '.C n__ Diameter Depth P � 9 P Y� g 1� -� P �----------- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area------------ ft. Seepage Pit No._(_D-C'0------ Diameter......&........_--- Depth below inlet..... Total leaching area...Vy°e. . ft. Z Other Distribution box ( ) ' Dosing tank ( ) Q' ✓i a� ." Percolation Test Results Performed bY.......................................................................... Date........................................ Test Pit No. 1___ 'a-----minutes per inch Depth of Test Pit---l9_.......... Depth to ground water./V.�P/(`C------- rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ . = ----------••---.....---- _-•.................. •------- O Descriptiop of Soil - e x ------ - UW =- E ----- ---------------------------------------------------------------------------- Nature 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 i';LE }of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has.4aqi issued b the b )arrd of health. ;I............... Signed ,.... Le Application Approved B Date Application Disapproved for the following reasons-------------•---------•----•--•----•-------------------•---•--•-------------------------------------------•---- .....-•-•-•--------•......................•----------•--------••••-•••--.....-•••----....-•---•-••-------••----------•-.._..----••---------•-•--••-•------•----•--••-----------•-----------•-•---•--•-•- Date Permit No------?£..7 ' t---------Ell--------------------------_ Issued_----- .................. Date No.Z:...L°2---.[. FEs..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH : _...... ...........OF........ 'r -------------------------------- Appliratiou for Disposal Works Tomlrurtiun Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syste�mA at: . Location-Address or Lot•.-o. \ � a 1• �y tC��=. .� .dl... 4 . ....... da....` ......: .5LA..Sq. � -------•--- Installer Address U Type of Building Size Lot....)s2� feet �. Dwelling—No. of Bedrooms.........................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- . . W Design Flow.....WO G 0..................gallons per person per.,day. Total djily Sow............................................ga_1lons. P4 Septic Tank—Liquid capacity4apa....gallons Length f._i..._._.. Width._15�1...... Diameter................ Depth_V........... Disposal Trench—No..................... Width......t------------- Total Length___--.�`....... Total leaching area...��..___._...sq. ft. Seepage Pit No._�1 .......... Diameter....__..6........ Depth below inlet.......-......... Total leaching area..__.__D�sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0,7'S'�oZ-� Percolation Test Results Performed bY................................................. ........................ Date........................................ Test Pit No. 1 A*—' 'A......minutes per inch Depth of Test Pit....i(.......... Depth to ground water-_V_L,-k--------- Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -••-••-•-•i. rt----- O Descripti of Soil t V `` 1'"t• z: J! �2� �� � --------- V .._ `�`-���-..V-t�-(,r-`-----�` y Q4-_ ........ -------------------------- UW •---••-------------------------•------------------------------._...-------------•-------------•---------•--------•-------•----•----••-----•-------•--------•-----------------••......-----...._......... Nature 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 T i'i:. p 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 board of health. Signed.- a ...S.-.... / � t `` �4o Application Approved B .. . ate Date Application Disapproved for the following reasons:----•--------------•---------------•----------------------•--------------------•--------------•------........._ ----------------------------------------------------------------------------------------------------••-------------------------------••-------•-------•----...--•--•------•-••--------------•---...---•- Date Permit No..2...7.........L_"1"7---••............•----.. Issued. - 1--- ..................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ` ............ OF........... ....................... t................................... � � ..... rr C rr i irtt r ,af �a v tat THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired* } by........ C . ......................................................................................................................... at--..f; 511..... ` ----------------------------------------------------------•---•------------------------------- has been installed in accordance with the provisions of Ti T E 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------- __ JJ ..... dated__......_ _..._. ---- THE ISSUANCE OF THIS CERTIFICATE SHALL A-?, C TRUED AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... k,;,, %✓" THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .... .. .... OF........... ......................... NO .� +l L.—..... Q.t ��y FEE Z5:"'�' Permission is hereby granted......V-,./-----------------------------•-----....----•--•---- --------•--------------------....... --------- ---.............. to ConstruLV("`-) &-Repait� "urbTndiv�n�ewage Disposal System at No............................................. i -•-------------------------....... -- _ Street —,a ,,,� as shown on the application for Disposal Works Construction Per it No.......... V-\ _. Dated..........................................` ^ � 7 .............. ..............------• ------------••------....................... Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS I� A No. -- Fee-- BOARD OF HEALTH TOWN OF BARNSTABLE ApplicationforVell Cootructionjermit Application is hereby made for a permit to Const uct ( ol, Alter ( ), or Re a,_ir_j )an individual Well at: -- — —— — — — -- --— — / Location — Address Assessors Map and Parcel / --- --- -- !-------------- Owner Address ZA e_Lt.NesA----------------------------------------------------- ---------- ----9-C - ------------- --- Installer — Driller Address Type of Building Dwelling---------------------------------------------------------------- Other - Type of Building----------------------------------- No. of Persons-------------------------------------------------- Typeof Well— - - —- -- - - Capacity-----------------------------------------------------— ---— Purpose of We --Ll - 7�io- ° ------------- 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 C mpliance has been issued by the Board of Health. Signed -- - -- - ------- — - 1`T ll---------- date Application Approved - `- —- -- -— � �----- date Application Disapproved for the following reasons:----------------------------------------------------------------------------------------------------- -------------------------------------------------------------------------- -------- - - - - -- -- ----------- - date PermitNo.------------ --- — - Issued------------------------------------------------------------------------- date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Compliance THIS IS TO CERTIFY, That the In// 'dividual Well Constructed ( ), Altered ( ), or Repaired ( ) bY- at,! Cr--------------------------------------------------------------------------------- -- -------------- ------------------ Installer at Ig 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. '-`--U -mated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY. Y DATE- --- --——-- —--------------- — — -- Inspector--------------------------------------------—- - ------------ �-.0 No.----- ----------- Fee==-- - - BOARD OF HEALTH : : . TOWN OF BARNSTABLE ica 1 n' r V ell �C.00trurfi n permit Applicati n is ere made for a permltto Construct ( ✓�, t r of Rep )an individual Well at: -M-===L-ti!�-��..� a t,u; I' 17 �rh S _a 1 G --T-.�----------------------------- �y' Location Address rl Assessors Map and Parcel III - ---=-- q Owner j — Address Installer — Driller 3�. ^- I Address i Type of uilding l s ` I wellies.` -..... -..... ----------- -----{. - I j g"- then/ 'e o�uil in --- No. of Persons-------------------- - ------------------------ r. y g - , - I _L ----- Ca acit Type of ell- - P y:- - - - -—— : -}t9. o -- <--Purpose W i I Z �% CAgreemen � The ndersigne agrees o install the aforedescribed individual well in accordance with the provisions of The h Town of tell rnstable Bo�of Health Private.Well-Protection Regulation - The u_ ndersigned-further agrees not to.' i place the in op ration ulntil a Certificate .of mplianc�s been issued by the Board of Health.a l -- - - - - Is1 -�-Signed; - -- --- - ---- date Application Al ed. Application Disapproved for the following reasons:-------------------------------------------------------------------------------------------------- ----------------------—------------ - ------ - - - - �1 date r _Permit No.. - - f — date • �ma7c Aram saea..sao�zalfalC.'Ka!�rs.�9de Gem:sr3o:. ._. . M:Itsr9s BOARD OF HEALTH TOWN OF BARNSTABLE -`-C tificate Of Compliance - - THIS IS TO CERTIFY, That the Individual Well Constructed Altered ( ), or Repaired ( ) 4 Installer at �1� S� � r �cA- c. Q cA 1 -------------------------------- - p '�' - t om ~ t 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. a ed THE ISSUANCE THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL,FUNCTION SATISFA..CTORY. DATEM —-- -- Inspector---------------------------------------------------------------------------- -_-.-a � _ .4 .".C.4��:CLtr" -i'i4Yi� MA8;9r• .' .L'•C,."_' �^'wL BOARD OF HEALTH TOWN OF BARNSTABLE well'Conotruct ion Permit A No. -- � Fee- Permission is hereby granted--Q A-=S ^"�' ell to Construct (.off, Alter ( ) or Repair ( ) an Individual Well at t:. No. ` a -- --- L , -- ---- ------ -- - ------ --------------------------- ---------------------------- i> - - --Street as shown on the application for a Well Construction Permit ;. r No:•---�'�" ---- `- -=--------=--------------------- Dated-------��----`-:= � ---------------------------------- Board of Health DATE-- - T - ----— - i 1 ` III t � i i i y I • 1 � t r __ 1 l ' •EXISTING PIT LEGEND PUMP & FILL W/SAND, 9 BENCHMARK-2 - l38 PROPOSED CONTOUR o RT. COR. CONCRETE STEP Y o EL:100.08 (Assumed) EXISTING SEPTIC TANK 38 PROPOSED SPOT GRAD Rte BA IV 27°1406. BK 451 PO 53 OVCOUT)T EL 99.95t'30f —110 EXISTING CONTOUR 9 a PI- 110 EXISTING SPOT GRADE a o TEST PIT Ln � o, Stony ---- --- 27 ----- -- _____________ ___�, ._.W— EXIST. WATER SERVICE ° 4p 01 ,I F49, E `. ,ti46 r LOCUS g), „ - ---'`� LOCUS MAP N.T.S. _ --------------- w iota � i----- ___ Lot 3 w rr Mo p 351 0 �9� Parcel 45 �--- r 47,478+/- SQ. FT looms �oN I � 1,09+/- ACRES �ih ,. L ,r�� ` 113 Pro ed ` t 150 septic n � n ,� J EXISTING A z 46' o o \��� n 1i ti Porch HOUSE#4251) 1 11 r Coil -- \ `7.3`; .�, ` Z •,�------ ` � .. I �l o � 00 it T17F=103, (rear) rr op ` 981 N wed Inground pout STRIPGUT i �0 SEE NOTE 11 � ` r _ 360,18� Stockade fence _ S I5°24'40' W �F MI r BENCHMARK-1 LT. SIDE GRANITE STEP o PETER T• EL:103.48 (Assumed) McENTEE GENERAL NOTES: ' CIVIL i No, 35109 1. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL 7. WATER SUPPLY TO BE PROVIDED BY TOWN WATER. �FS�C/Sl��NG\�� BOARD OF HEALTH AND THE DESIGN ENGINEER. 8. THERE ARE NO PRIVATE WELLS LOCATED WITHIN 150' OF THE S.A.S. 2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS 9. ALL AREAS CLEARED FOR CONSTRUCTION ISHALL BE RESTORED 1 (� OF THE STATE ENVIRONMENTAL CODE, TITLE V, AND ANY APPLICABLE TO A CONDITION AGREED PON BETWEEN OWNER AND INSTALLER. LOCAL RULES AND REGULATIONS. 10. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY 3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR THE LOCATION OF ALL UNDERGROUND UTILITIES, PRIOR TO STARTING TO INSPECTION ND APPROVAL BY THE BOARD OF HEALTH AND THE CONSTRUCTION. DES s PROPOSED SEPTIC SYSTEM/SITE PLAN 11. WHERE REQUIRED, CONTRACTOR SHALL REMOVE ALL UNSUITABLE SOILS 4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING IN THE AREA BENEATH AND FOR 5 FT. ON ALL SIDES OF THE S.A.S. 4251 ROUTE 6A, CU M MAQU I D, MA FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN AND REPLACE WITH CLEAN FILL AS 'SPECIFIED IN 310 CMR 255(3). ENGINEER BEFORE CONSTRUCTION CONTINUES. i :Prepared for: David Welch, 4251 Route 6A, Cummaquid, MA 5. ALL ELEVATIONS BASED ON ASSUMED DATUM, t Engineering by: Surveying by: SCALE DRAWN JOB. NO. 6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE of i Engineering Works Terry A. Werner P.L.S. 1 "=30' P.T.M. 93-02 THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF 23 Deer Hollow Road 22 Long Road HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. Forestdole, MA 02644 Harwich, MA 02645 DATE CHECKED SHEET NO. f (508) 477-5313 (508) 432-8309 8/29/02 P.T.M. 1 Of 2 PROPOSED TANK: INSTALL RISERS 1N/HEAVY DUTY FRAMES & COVERS IgP OF FOUNDATION OVER INLET & OUTLET TO FINISH GRADE ; HEAVY DUTY FRAME & COVER OVER EL:103.0 HOUSE EXISTING TANK: INSTALL H.D.P.E. RISER W/ COVER OVER HEAVY DUTY FRAME & COVER. CENTER CHAMBER SET TO FINISH GRADE EL:100.5 BARN LR) OUTLET TO WITHIN 6 OF FINISH GRADE SET, TO FINISH GRADE F.G. EL: 99.3 EXISTING F.G. EL: 102.8 (EXISTING/HOUSE) F.G. EL: 100.1 t MAINTAIN 2% MIN SLOPE OVER S.A.S. F.G. EL: 100.0 (EXSTING/BARN) MAX. COVER OVER S.A.S. = 36 NOTE: TO PREVENT BREAKOUT, THE PROPOSED + 3-500 GALLON (H-20)LEACHING CHAMBERS FINISH GRADE SHALL NOT BE <EL:95.5 + IN SERIES WITH 4' OF STONE ON ALL SIDES ' FOR A DISTANCE OF 1 S' AROUND THE PERIMETER OF THE S.A.S. e' L =10' L =18'(from prop. tank) 2' LAYER ❑F 4" SCH 40 PVC L =197'(from exist. tank) L =23' (MAX.) 4" SCH 40 PVC EXISTING(at house) 4" SCH 40 PVC DOUBLE WASHED STONE EL:98.45 at barn @ S= 2%<MIN,> EXISTA000 GAL, �; :[ PROP. 1500 GAL, INV. ELEV.=95.90 INV. ELEV.=95.73 2' EFF. DEPTH ®®®lase® SEPTIC TANKS ` 4' 5.2 4' INV. ELEV.=100.2(exist.-at house) INV. ELEV.=99.95 exist.-at house) FFECTIVE WIDTH = 13,2' 3/4'-1 1/2' INV. ELEV.=98.25(prop. at barn) INV. ELEV.=98.00(prop.-at barn) DOUBLE WASHED STONE INSTALL INLET & OUTLET TEES INV. ELEV.=95.50 GAS BAFFLE TO BE INSTALLED ON OUTLET TEE AS MANUFACTURED BY TOP CONIC, ELEV.=96.3 TUF-TITE, ZABEL, OR EQUAL —BREAKOUT ELEV.=95.5 EXISTING INVERT ELEV.=95.00 Rima®®E' SEPTIC TANK & D-BOX SHALL BE SET LEVEL AND TRUE TO � GRADE ON A MECHANICALLY COMPACTED SIX INCH CRUSHED a®®aaB0MS3" EL;100.33(at barn) ®®®B® ®®®®® STONE BASE, AS SPECIFIED IN 310 CMR 15.221(2). BOTTOM ELEV.=93.00 4' 3 x 8,5' = 25,5' 4' , ,�� �F• Mgff 3-5' DIA, INLET s-5• DIA, OUTLETS F, 5' MIN• ABOVE BOTTOM OF EFFECTIVE LENGTH = 35,5' ��P� q��G z. SEPTIC SYSTEM PROFILE T,P. EXCAVATION, OR G.W. LEACHING SYSTEM SECTION PETER T. ���....`: �: I5• ': 97,6 N.T.S. cm MCIVIL 6' N,T.S, E No. 35109 s o �EGISIE���\�`� Section DESIGN CRITERIA Fssio 7 1/2• -�- NUMBER OF BEDROOMS: 3 BEDROOMS FolU 151 v2' 1 D'-6" SOIL TYPE: CLASS I SOIL LOG DESIGN PERCOLATION RATE: <2 MIN./IN. 30 1/21 3 - 20" Dia. Covers DAILY FLOW: 330 G.P.D. KTs: PILL SIDE KNOCK-OUTS DESIGN FLOW: 440 G.P.D.(FUTURE EXPANSION) WITH MORTAR Top Vlew J DATE: AUGUST 15, 2002(Ref.#10,306) 0�/ C SOIL EVALUATOR: PETER T. MCENTEE P.E. GARBAGE GRINDER: NO DISTRIBUTION BOX 5-8 I INSPECTOR: DAVID STANTON, BARNSTABLE B.O.H. LEACHING AREA REQUIRED: (440) = 594.6 S.F. .74 Elev. TP Depth 99 6 A 0„ SEPTIC TANK REQUIRED: * 500 GALLON ®®®® ® ®®®® -- Top View SANDY LOAM ®®®®®®®®®®® 39" 10YR 3/3 USE 3-500 GALLON LEACHING CHAMBERS IN SERIES INVERT ®®®®®®®®®®® 98.6 B 12". 24" ER�®ER®E3 ER E3 E3®E3 6" Dia. Inlets 8" 6" Dia. Outlets SANDY LOAM SIDEWALL AREA: 2(13.2' + 3-3.5 ) X 2 = 186.8 S.F. 10YR5/6 BOTTOM AREA: 13.2' x 33.5' = 442.2 S.F. CLAY TOTAL AREA: 629.0 S.F. 5Y 5.2 a^ KNOCKOUT DESIGN FLOW PROVIDED: 0.74(629.0) 465.5 G.P.D. 2�. COVER 6'-0" 4'-7' 48"Liquid Level 4'-4" 91.6 d 4: C2(UNSUITABLE) 96„ 4' KNOCKOUT O 4" KNOCKOUT 62" 4„ 3„ - MED. SAND EEngineerningWorAs ROPOSED SEPTIC SYSTEM/SITE PLAN a• KNOCKOUT ' 2.5Y 6/3 4251 ROUTE 6A, C U M MAQ U I D, MA Section 87.6 144" ared for: David Welch, 4251 Route 6A, Cummaquid, MA 500 GALLON CAPACITY, H-20 LOADING 1500 GALLON CAPACITY, H-20 LOADING NO G.W. ENCOUNTERED y: Surveying by: SCALE DRAWN JOB. NO.• PE RATES < 2 MIN/IN. (C2 HORIZON) gWorks Terry A. -Werner P.Gs N.T.S. . F.T.M. 93-02 CHAMBERS SEPTIC TANK ow Road 22 Long Road A 02644 Harwich, MA 02645 DATE CHECKED SHEET NO_ 313 (508) 432-8309 8/29/02 P.T.M. 2 Of 2 E p j--v n�a es i 711 2=1 1 I I i j� i �j r u S i d o t V_ . + r �j�,J v� �i ,✓r�'� eat PA^1 P��