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HomeMy WebLinkAbout0024 MARASPIN ROAD - Health 2� Maraspin Road Barnstable A= 299 074 WN OF BARNSTABLE ° I LULATION SEWAGE # '20 7— VILLAGE s' c� ASSESSOR'S MAP & LOT Z99-v `7 3 INSTALLER'S NAME&PHONE NO. A,1f-A;0&16 � �� e✓ y$'8c/2G SEPTIC TANK CAPACITY 13 av "4L LEACHING FACILITY: (type) lrc 314 (size) . `g 1-/� XP/ NO.OF BEDROOMS BUILDER OR OWNER 46/oeha,h PERMITDATE- ° Y—c(—ZpO l�_COMPLIANCE,DATE: 7,7 7-00 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 5� Feet Private Water Supply Well and Leaching Facility (If any wells exist ./ on site or within 200 feet of leaching facility.) iV Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) ,lO Feet Furnished byz�c�• ��a f r �� A �� ./�� _ � P ' , � � � � ;� � � j � l (, � � i i �� 1 �I. Commonwealth of Massachusetts o- Title 5 Official Inspection Form Subsurface Sewage:Disposal System"Form -Not for Voluntary Assessments M 24 Maraspin Road'°. Property Address INJ Chriustopher F. Conlin & Kristen Vennberg Owner Owner's Name information is required for every Barnstable ✓ MA 02630 April.23,2017 ' page. Cityrrown State :Zip Code Date of Inspection 1�5 Sh 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 �j f a on the computer, use only the tab 1. Inspector: key to move your cursor-do not David D. Flaherty Jr., IRS, REHS: use the return Name of Inspector key. Flaherty Environmental Services Company Name P.O. Box 81 . Company Address Yarmouth Port MA 02675 City/Town - State Zip Code 774-994-1166 SI#4713 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am-a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by.the Local Approving Authority April.24,2017 Ins ors Signature Date The system inspector shall su mit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000:gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DER The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time'of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 ®�5�d vie Commonwealth of Massachusetts Title 5 Official :Inspection Form Subsurface Sewage,Disposal System�Forw-; Not for Voluntary Assessments M ,•''r 24 Maraspin Road Property Address Chriustopher F. Conlin & Kristen Vennberg Owner Owner's Name information is Barnstable MA 02630 April 23, 2017 required for every page. CityrFown 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: ® 1 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of'Massachusetts W Title 5 Offidal 'inspectio.n Form _ o Subsurface Sewage Disposal.System Form, Not for Voluntary.Assessments '�M ,•''V .24 Maraspin Road Property Address Chriustopher F.Conlin & Kristen Vennberg Owner Owner's Name information is Barnstable MA 02630 April 23, 2017 required for every p page. Cityrrown State Zip Code Date of Inspection .B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or breakout 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 um in` more than 4'times.a year due to broken or obstructed pipe(s).The P P 9 Y 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"Re uired b the Board of Health: Q Y ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. _System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 24 Maraspin Road Property Address Chriustopher F: Conlin & Kristen Vennberg Owner Owner's Name requir reqitionuired is Barnstable MA 02630 Aril 23, 2017 required for every p page. Cityrrown State .Zip Code Date of Inspection .B. Certification (cont.) 2. System will fail unless-the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in-a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water. supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system.has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins.doc-rev.6116 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts u v Title 5 Official 'Inspection Form Subsurface Sewage Disposal,System Form- Not for Voluntary Assessments •';r .24 Maraspin Road Property Address Chriustopher F. Conlin & Kristen Vennber Owner Owner's Name information is Barnstable 'MA 02630 April 23 2017 required for every p � , page. CityrTown 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 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 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 coliforrn bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or,less than 5 porn, 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 designflow.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'll of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 24 Maraspin Road Property Address Chriustopher F. Conlin & Kristen Vennberg Owner Owner's Name information is Barnstable MA 02630 Aril 23, 2017 required for every p page. City/Town State .Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans•of the system obtained and examined? (If they were,not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑- Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedroom's): 330 t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form 'Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments °wM ,•''- 24 Maraspin Road Property Address Chriustopher F. Conlin & Kristen Vennberg Owner Owner's Name information is Barnstable MA 02630 Aril 23, 2017 required for every. P page. CitylTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑.Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears Usage d '16: 170 gpd; '15: 9 ( Y 9 (gpd)): 162 gpd Detail: Sump pump? ❑ Yes ® No current Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design:flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Maraspin Road , Property Address Chriustopher F. Conlin & Kristen Vennberg Owner Owner's Name informrequired is Barnstable MA 02630 April_23, 2017 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: owner's agent, last year Was system pumped as part of the inspection? ❑ Yes ®. No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page B of 17 - - Commonwealth of'Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ,M 24 Maraspin Road Property Address Chriustopher F. Conlin &Kristen Vennberg Owner Owners Name information is Barnstable MA 02630 Aril 23, 2017 required far every p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: C. of C. from BBOH shows compliance date of 8/5/1991 Were sewage odors detected when arriving at.the site? ❑ Yes ® No Building Sewer(locate on site plan): 2.5 Depth below grade: feet feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): >50 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): joints tight,venting through dwelling adequate, no evidence of,leakage Septic Tank(locate or,site plan): Depth below grade: 15 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: r years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes- ❑ No Dimensions: 1000 gallon 611 Sludge depth: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments M ,•''r 24 Maraspin Road Property Address Chriustopher F. Conlin & Kristen Vennberg Owner Owner's Name information is Barnstable MA 02630 Aril 23, 2017 required for every p page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of.sludge to bottom of outlet tee or baffle 2811 2., Scum thickness Distance from top of scum to,top of outlet tee or baffle 611 Distance from bottom of scum to bottom of outlet tee or baffle 1311 How were dimensions determined? dip stick,'tape measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): maintenance pumping required every two to three years, inlet&outlet tees intact, liquid level appropriate, tank seems structurally sound, no evidence of leakage Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts _ r Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,•''¢ 24 Maraspin Road Property Address Chriustopher F. Conlin & Kristen Vennberg Owner Owner's Name information is Barnstable MA 02630 A rll 23 2017 required for every p page. Cityrrown State .Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or'baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on.site plan): Depth below grade: Material of construction- El concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons i Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for.Voluntary Assessments °wM 24 Maraspin Road Property Address Chriustopher F. Conlin & Kristen Vennberg Owner Owner's Name information is required for every Barnstable MA 02630 April 23,2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert n/a 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 dbox Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No" Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments µ 24 Maraspin Road Property Address Chriustopher F. Conlin & Kristen Vennberg Owner Owners Name information is Barnstable MA 02630 April 23, 2017 required for every page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) Type: ® leaching pits number: - (2) ❑ Teaching chambers number: ❑ 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.): - . - (2)6'x6' precast leachpits with stone in series, soils sandy with some gravel&cobbles, no signs of hydraulic failure or breakout,'primary pit with stain line 2' below inlet invert& liquid 3' below inlet invert, secondary pit dry with no staining, vegetation typical (lawn) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):. Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer - Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins.doc•rev.6l16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 24 Maraspin Road Property Address Chriustopher F. Conlin & Kristen Vennberg Owner Owner's Name information is gamstable MA 02630 Aln 23 2017 required for every p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.do6•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments wM 24 Maraspin Road Property Address Chriustopher F. Conlin & Kristen Vennberg Owner Owner's Name information is Barnstable MA 02630 Aril 23 2017 required for every p page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal.System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below:' ❑ hand-sketch in the area below ® drawing attached separately t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 24 Maraspin Road Property Address Chriustopher F. Conlin & 'Kristen Vennberg Owner Owners Name information is required for every Barnstable MA 02630 April 23, 2017 page. City/Town 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 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) El 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: k Groundwater Contour Map published by the Town of Barnstable indicates groundwater+/-20' in the proximate vicinity. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form Not for Voluntary Assessments M 24 Maraspin Road Property Address Chriustopher F. Conlin & Kristen Vennberg Owner Owner's Name information is Barnstable MA " 02630 April 23, 2017 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWNIDF BARNSTABLE LOCATION�o1�'I ,'MIArA Spin Rcl .SEWAGE r °►l-3y Qgrn A . _ VILLAGE ��• AssEsSOR'S MAP&LOT qa o1--]_y_ INSTAUMUSNAME&P.HONE No._b0MIo'�l� ` SEPTIC'LANK CAPACITY 1 oco LEACHING FACI[M:(type) f�'rs (size) NO.OFBEDRooMS 3 BUMDER OR OWNER PERMITDATE: COMPLIANCE DATE: Ff�S 9 1 Separation Distance Between tbe: I' Maximum AdjusWGrotuxly erTable to the Bottom of Leaching Facility Feet 4 Private Water Supply Well and Leaching Facility.(If any wells exist on site or within 2W her of teaching facility). Feet Edge of Wetland and Leachieg Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . IM - 1 t 1 A el- fS" .aa ay• 'AY- ��• �y' yY { COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s _ TITLE 5 i OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART"A CERTIFICATION Property Address: �q m r s /w� Q .d i Li , 44.4 Owner's Name: ) YV m nt Owner's Address:- -24 MQk4 f ,;1 Ifoce arditt�fo Date of Inspection: 9—2 0-OCR Name of Inspector:(please print) rb4ti 91 1#4 It, � Company Name: J61-H a l o 06Ck o1 stub o Mailing Address: Ivim 4 wj' S1'r.e� /1/1c+vt ah i /iT/s /L1/� 076 y8 Telephone Number: 502 -'779 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. am a DEP approved system inspector pursuant to Section 15.340 of Title I 5(310 CMR 15.000). The system: Y Passes Conditionally Passes C.-) , Needs Further Evaluation by the Local Approving Audi rity '-+ cz; Fails , ' Inspector's Signature: Date: _I to zwzll The system inspector shall submit a copy of this inspection report to the Approving Authority( bard of�alth 66 DEP)within 30 days of completing this inspection.If the system is a shared system or has a des flow SP IQ,0R, gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ° ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 4 Page 2 of l l OFFICIAL INSPECTION FORM—NOTI'OR VOLUNTARY:ASSESSMWTFS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: %1 y / PY4 s ra R-0pJ L 17 Owner: Ykosin Alarc AOM" I Date of Inspection: 9— 142 -- DL Inspection Summary: Check A,B,C,D or E/ALWAYS completAN o�Seltiop. ° A. System Passes: I have not found an information which indicates that an of the failure criteria described in 310 CMR Y Y 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 faiha+e 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 breakout 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 Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY-ASSESSMENTS f SUBSURFACE SEWAGE DISPOSAL_SYSTEM INSPECTION FORM PART X CERTIFICATION;(continued) Property Address: ':�y y1�r as i'a �I octal Owner: yyoh m-t ✓/ac 19o."4 Id Date of Idspection: 9— 2 0--0 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: s ' 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 L.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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALL'SYSTEM MPECTION_FORI 4,;- PART A CERTIFICATION(continued) Property Address: y Marc's 11 Rut ar a /YI T� Owner: ve;1h�e pG n�a Date of Ins ection: 9,-- 20- 09 D. System Failure Criteria applicable to all systems:. You must indicate"yes"or"no"to each of the following for all inspections Yes No V Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool t, Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool d/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow v 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 feetfrom a-private water supply well with no acceptable water quality analysis. [This system passes if iltewQ 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 ppni;provided that no other faihue criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)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 tocouect 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) 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. 4 r Page 5 of 11 ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: .1Y 41a",s lio �cvrh S yid 0 Owner: vch„t We yha Date of nspection: Check if the following have been done.You must indicate`des"or"no"as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health' , ✓/ Were any of the system components pumped out in the previous two weeks? Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ _ .Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? _ Were all system components,excluding the SAS,located on site _✓ _ Were the-septic tank manholes uncovered,opened,ind 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? _Ix _ 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: 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 CMR 15.302(3)(b)] 5 Page 6 of 1 I ` OFFICIAL INSPECTION FORM—NOT FOROLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEIVIINFORMATION rr " Property Address: y /waywo rry s tR /1 Owner: IvGhH,o Date of I pection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3_ Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): "330 Number of current residents: / Does residence have a garbage grinder(yes or no): *0 Is laundry on a separate sewage system(yes or no):40f�! f if yes separate inspection required] Laundry system inspected(yes or no):� � \ yd Seasonal use:(yes or no):� g 9 Water meter readings,if available(last 2 years usage(gpd)): P ire Sump pump(yes or no): No Last date of occupancy: gez L i COMMERCIALIINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ . Industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Mo.t , e d s H e 9 9 9 6 air h or Was system pumped as part of tde tnsp tion(yes or no):_v If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM V Septic tank,distpibattarrbox,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _hmovative/Alternative technology.Attach's 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: $— S- 9/ as hN.I tc.,d Were sewage odors detected when arriving at the site(yes or no): /No 6 ti Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: 20 44a s,o,r IPy�r� h s ygy b Ir Owner:--Yvonne uc ,hmti.-Il n Date of I spection: —2a-04 BUILDING SEWER(locate on site plan) e/ Depth below grade: 30 Materials of construction:_cast iron 40 PV other(explain): Distance from private water supply well or suction line: Comments of joints,on condition oints,venting,evidence of leakage,etc. ( J :g g ) SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction: concrete_metal_fiberglass polyethylene " _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of . certificate) Dimensions: S "X Sludge depth: y" Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness: 3'� Distance from top of scum to top of outlet tee or baffle:- 6 ' Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Rod Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related�to outlet invert,evidence of.leakage,etc.): /an/t hos Aaa4erelo oe4 fe1 fee, a"j hc) faAlr� CJujot hZ ,arrvhoa<et iiz nems,v ,e GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:. concrete metal_fiberglass_polyethylene_other (explain): Dimensions: . Scum thickness: Distance from top of 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 integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): L_ 7 Page 8 of I 1 w •� s OFFICIAL INSPECTION FORM—NOT:MV0LUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM: PARS'C. : r SYSTEM INFORMATION(continued) Property Address: �y /��►Y�S rh I�e�� Owner: vo"h P erc. vy,a Date of I pection: q— TIGHT or HOLDING TANK: (tank must be pumped at time of ittspe=- akiwate an site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): 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.): 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.): 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.k Page9ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: volh a ,*C pyp/ ` Date of pection: 9--��-tlb SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explainwhy: �. . TYPe q � leaching pits,number.'it leaching chambers,number. - leaching galleries,number leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovat1ve/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition'of vegetation, etc.): 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 of ponding,condition of vegetation,etc.): t PRIVY: (locate on site plan) ; Materials of construction: Dimensions: i Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 0 Page 10 of 1 l ° OFFICIAL INSPECTION FORM NOf FOR yVbLVNTX1Y ASSESSMENTS SUBSURFACE SEWAGE DISPOSAY:`SYSTEM INSPECTION FORM PART•C . • SYSTEM INFORMATION(continued) Property Address: /114r4 s iv, '64 • Aq hitabil Owner: V nt A44c e*u i " Date of pection: 9•-1y-0,6 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate'all wells within.100 feet.Locate where_public water supply enters the building. .� I� . 2 C� /2"To ca✓or i , �yv¢.iF�►�"y 3 6 3 y10 Pt ° ° 2 `r�v �.- 1 Qr Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: y /v ea's >" Ada urns • Owner: 1"Ot9 kye Mo c Ned 1 Date of pection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water `/1 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked.with local Board of Health-explain: Checked with local excavators,installers-'(attach documentation) _// Accessed USGS database-explain: You must describe h w you a ttA�bljshed the high ground water elevation: ��rr►S1„L and criFle C0Ai 014,P JYIc s $�owvr+ �O Cy t PAY yt r+Q( AIA 10 r A f _ 4$ j"Tf 11 _ I V • .iy, +. - COMMONWEALTH OF MASSACHUSETTS '� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTIO ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 < Y Col "�FO { S ARGEO PAUL CELLUCCI Governor ; issioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION S Property Address: 24 Maraspin Road, Barnstable, MA ;Name of Owner: Jessie duMont Address of Owner: Same Date of Inspection: June 10, 1999 Name of Inspector: (Please Print) James M. Ford I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: James M. Ford Mailing Address: P.O. Box 49, Osterville, MA 0265S-0049 Telephone Number: (508)862-9400 Map:299 Parcel: 74 CERTIFICATION STATEMENT . I certify that I have personally inspected the sewage disposal system'at'this"address and that the information reported below is tiue,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 f' ✓ Passes Conditionally Passes Needs Further Evalua io By the Local Approving Authority Fails Inspector's Signature: Dates June 14, 1999 The System Inspector shall sub 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 the system owner and copies sent to the buyer,,if applicable, and the approving authority. NOTES AND COMMENTS .' . .4 revised 9/2/98 - + . Page e I of II s t Primed on Recycled Paper i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued)'' Property Address: 24 Maraspin Road, Barnstable, MA' Owner: Jessie duMont Date of Inspection: June 10, 1999 INSPECTION SUMMARY: Check A, B,nC, or D A. SYSTEM PASSES: A ✓ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15,.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 ND). 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 bok is levelled or replaced ` The system required pumping more'than four,times a year dueto 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 t revised 9/2/.98 Page 2oftt r SUBSURFACE{SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued). Property Address: 24 Maraspin Road, Barnstable,tMA Owner: Jessie d uMont Date of Inspection: June 10, 1999 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. 3 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.THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy is within 50 feet of a surface water ." Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)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 to 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 1 of a public water supply well. e 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 wafer 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 revised ,9/2/98 Page 3oflt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ~' CERTIFICATION (continued) Property Address: 24 Maraspin Road, Bainslable,"MA" Owner: Jessie duMora Date of Inspection: June 10, 1999 D. SYSTEM FAILS: - . You must indicate either "Yes" or "No" as 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 facility or system component due 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 YZ 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 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 than50 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".as-to each of thefollowing: 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 s 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'tnapped Zone II of a public water supply well The owner.or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department foi further information. revised'' 9/2/98 Page 4ofII f + t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC I_QN FORM. PART B CHECKLIST Property Address: 24 Maraspin Road, Barnstable, MA „ Owner: Jessie duMont Date of Inspection: June 10, 1999 Check if the following have been done.;You must indicate either•"Yes"'or"No as to each of the-following:' ,r Yes No k - ✓ _ Pumping information was provided by the owner,occupant,or Board of Health. ✓ None of the system components have been pumped for at least 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. ✓ a 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. ✓ _ The site was inspected for signs of breakout. ✓ All system components, excluding the Soil Absorption System,have been located on the site. , y ✓ The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for conditions 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, Plan at B.O.H. 3 ✓ Detern ined 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)l• ✓ _ The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Subsurface Disposal Systems. ° revised 9/2/98 Page 5oftt t f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Y SYSTEM INFORMATION a Property Address: 24 Maraspin Road, Barnstable, MA , Owner: Jessie duMont Date of Inspection: June 10, 1999 FLOW CONDITIONS RESIDENTIAL: Design flow: 110' g.p.d./bedroom. Number of bedrooms(design): n/a Number of bedrooms(actual): ' 3 a Total DESIGN flow n1a — Number of current residents: 2 Garbage grinder(yes or no): No Laundry(separate system)(yes or no): No If yes, separate inspection required Laundry system inspected(yes or no): Yes ; Seasonal use(yes or no): No Water meter readings, if available(last two yearg,usage(gpd): 1998- 7/1000 jeals.; 1997-85°000 Pals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: Qnd(Based on 15.203) Basis of design flow Grease trap present: (yes or no) _ Industrial Waste Holding Tank present: (yes or no) Non-sanitary waste discharged to the Title 5 system: (yes or no) Water meter readings, if available: . Last date of occupancy: x OTHER: (Describe) t Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: None on file-per treatment plant ti System pumped as part of inspection(yes or no): No If yes, volume pumped: gallons 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) 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(if known)and source of information: " 815191 - per as built card . Sewage odors detected when arriving at the site: (yes or no) No ` revised 9/2/98 Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Maraspin Road,Barnstable, MA Owner: Jessie duMont Date of Inspection: June 10, 1999 °c 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) Depth below grade: 16" Material of construction: ✓concrete _metal _Fiberglass _Polyethylene _other(explain) , If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No) Dimensions: 8'6" x 4'10" x 5' (1000 gal.) Sludge depth: 3" k Distance from top of sludge to bottom of outlet tee or baffle:, 30 Scum thickness: ' S" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 13" +' How dimensions were determined: Measuring stick. 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.) The baffles were present. The liquid level was even with the outlet invert. There were no signs of leakage. Recommend pumping. GREASE TRAP: None (locate on site plan) _ v 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: (reconmiendation 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.) revised .9/2/.98 Page 7oflt i SUBSURFACE•SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Maraspin Road, Barnstable, MA. Owner: Jessie duMont Date of Inspection: June 10, 1999 ; TIGHT OR HOLDING TANK: None (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) w 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: .None (locate on site plan) µ 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.) PUMP CHAMBER: None (locate on site plan) t 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 8oftt SUBSURFACE SEWAGE r DISPOSAL SYSTEM INSPECTION FOR Ai PART C { SYSTEM INFORMATION (coirtinued) Property Address: 24 Maraspin Road, Barnstable, MA Owner: Jessie duMont. Date or Inspection: June 10, 1999 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: F leaching pits, number: 2-6'x 6' leaching chambers, number: ' leaching galleries,number: leaching trenches,number, length: ` leaching fields,number,dimensions: overflow cesspool,number: ' Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.) The first pit was full up to the outlet pipe. The second pit was full Bottom to grade''uws 9' i CESSPOOLS: None (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: *3' 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: None .. A (locate on site plan) Materials of construction: 4 Dimensions: Depth of solids Cottmients: ' (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.) .. ,, a .- . n s - •. I - - .. .A a revised 9/2/98 Page 9oftt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION 'FORM PART C SYSTEM INFORMATION (continued) Property Address: 24 Maras in Road rn f. Ba sable MA, Pe Y P Owner:' Jessie duMonl - Date of Inspection: June 10, 1999 Map:299 Parcel: 74 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) sitdw, , Al 41 ' A a" 3(o� . AH revised 9/2/98 Page 10 oflt SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C t SYSTEM INFORMATION (continued) x .Property Address:' 24 Maraspin Road, Barnstable, MA ; Owner: Jessie duMont Date of Inspection: June 10, 1,W9 NRCS Report name' y Soil Type Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate peep SITE EXAM Slope c� Surface water Check Cellar Shallow wells Estimated Depth to Groundwater _Feet Please indicate all the methods used to detemune High Groundwater Elevation: Obtained from Design Plans on record , Observed Site(Abutting property,observation hole,basements sump etc.) ✓ Determined from local conditions Checked with local Board of Health Checked FEMA Maps a Checked pumping records Check local excavators,installers ✓ Used USGS Data Describe how you established the High Groundwater Elevation: Must be completed) Using Barnstable Topographic and water table contours maps, the maps were showing approximately 40' +/- to groundwater at this site. This report has been prepared and the system inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed,. written or implied, relating to'the system, the inspection and/or this report. revised 9/2/98 Page I of tt TOWN.-0 BARNSTABLE a Ml�r/a SP�� Rd.. SEWAGE LOCATION � VILLAGE aArAS�4�� ASSESSOR'S MAP & LOT a°►q_1� INSTALLER'S NAME&PHONE NO. 4,rrn)011 SEPTIC' TANK CAPACITY OTfO I ,TS a'LEACHING FACILTPY:,,,(type) (size) SOX to NO.OF BEDROOMS 3 ` BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: F15 g I Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom df 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 withid 300 feet of leaching facility) Feet Furnished by ii .. h ti •h£! LC -ht+ he OL -I V O � i q _ TOWNOF BARNSTABLE �. LOCATION au i llMA, 5*121v% R8.. SEWAGE # VILLAGE BAMr��'� ASSESSOR'S MAP & LOTa1 I01- �r ` INSTALLER'S NAME&PHONE NO. 2>0 jb I o Ch SEPTIC TANK'.CAPACITY IOOO LEACHING FACILITY: (type) (size) _off' �oXln NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: COMPLIANCE DATE: F 1 S 9 1 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 - - 4 A ► f3 I Al- AO €. A9, ay. As— 3� F> y 3 S3 .- 34 , A4- D-) Q4• y . y 4 TOWN OF BARNSTABLE LOCATION SEWAGE # a'ILLAGE �6v2wCS% L� ASSESSOR'S MAP & LOTc;P, 7� INSTALLER'S NAME & PHONE NO.&O�e7e-,-FZOW SEPTIC TANK CAPACITY /IJOa � LEACHING FACILITY:(type) '17- (size) aC/Q f .NO. OF BEDROOMS PRIVATE WELL O BLIC WATER BUILDER OR OWNER I&A-) (�i42C�lf� DATE PERMIT ISSUED: l �/ps DATE COMPLIANCE ISSUED: o . VARIANCE GRANTED: Yes LNo— 3 F No. �.... .... Fes$.Q3Q............ THE COMMONWEALTH OF MASSAC14USETTS BOAR® OF HEALTH TOWN OF BARNSTABLE ♦ ppliratiuu for Dhipusal Works D Application is hereby made for a Permit to Construct ( ) or Repai dual Se vW isposal System at: i sSjo n ......0 .r�.': ��. Pi ......-•�-----•............. .•-----•--•...!��.��..i..!..�........r...`�........... orym Location-Address or Lot o. EAj ----------------------•-- -- --------- ----- Owner Address -_ W ........11`.7DCO �'9�JSS'i::.............................. W `.�._�� ..............�, /!LS a Installer � Address Type of Building Size Lot -----------------Sq. feet U Dwelling—No. of Bedrooms....................Q..... .Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building No. of persons............................ Showers Q, yP g ---------------------------- P ( ) — Cafeteria ( ) 04 Other fixtures -----------------------••----- . W Design Flow........................ 4._._.......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 (>4-) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.....................--. Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water.--.................---. a' ---------------------------------------------------------•-------------...........-----------..................................... ..... .--•--.-•------------- 0 Description of Soil........................................................................................................................................................................ x V ................•--••-•••----••••-----•------------......----------------------------..........--------•-••--•-•-------•----•----•-•-----••--••-••-------•-••••-••-••--------------.............•---•---- W UNature of Repairs or Alterations—Answer.when applicable---_�-.....1.l�DD ... �`7.___............... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complianc as een issu by the board of health. Signed-...-- ---------- ..... ..--- .. ._ ...... .. .�/.:� Application Approved By . . ------0/ ... .- .. .. .. ..........1...NIqi - App lication Disapproved for the following reasons: ......................... ti ................----........I--- Date...--------------- Permit No. ...... ------- Issued -- e ........ ......-....... . ; - „!l f THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE , ppliration for Elhip vial Works Cnumitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (_^>,")�Individual Sewage Disposal System at: !` / L4/745 P 1.J ................__..... ..................................................- _---•-......_..... .............. 1�F!v ST! ----• - �- �� Location-Address t o ° •----- -� 0' 'n 2/ v� �� �3�..r' or Lot N ,..3/ ....120A)...... -...:.. ...: --. -D 's = --......C;EnJT Ji -9/ Owner W SL2dCcT�C�C77....._lZ ..............................................eJ ,�J.¢/Li' / Addr!ess ,-a ---........................ � 1.... .. 2 c , . 1� s............... Installer Address Type of Building Size Lot_ ..Q ..Sq. feet DwellingNo. of Bedrooms_______________________ _______s_ ' — �-_ )_.'�ExpansioF�ttic ( ,)�J ��� w Garbage GrinderOther—Type of Building ____________________________ No. of�persons_______..:� _.__ _...._. Sowers ( ) —'Cafeteria. ( ) Other fixtures --------------•••-•• ------......--- f= ------------ Design rA r,l sal ___.... ... W rP� � {ggallons per p os n per ``y. Total•daily w ��* _____ �. __._gallons. WSeptic Tank—Liquid cal alert _ allons Length______________�)Wi dth_...___.._._..__ Diameter ............. Dep#th................ x Disposal Trf nch—No._._ _.�__ _�A. Wldtfi. ._..Total Length J_______________ ...........area. Depth below inlet................... Total leaching.area____.__.__. ...sq. ft. Seepage Pit No __�_ _. Diam z �` s suits �) �Perf Dos-9 tank( ) �5 f Date--'.: t,� Percolation*Test Re , ormed bY'-......................•----.....-------------•••••---•--......•. _.._••••..-............... Nest N No. 1________________minutes per inch Depth of Test Pit.................... Depth-to ground water......................... 44 Test Pit No. 2................minutes per inch h Depth ofj Test Pit____________________ Depth to ground water-_-__ _._____..___.___. I U ODescription'of Soil--•••-•--•••--_`-•••••-•--- ------------------••-••-•------•-----•-------------•------------------------ -------------------------------------•-•-----•--••-••--- U11 _ r W !��._-•--••------ -------- „�------••----.f.'---•------•-•---------•----------•-------------•-------------___--------------------•-----•---------•------------------•---------••-- -...----- V Nature of Repairs or Alterations—Answer when applicable_-__: 1�____.•_ !'x ___ � r' � ___...___... .................. r Agreement:,L_` -The under'siglned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. � :> � — Signed (/ Application Approved BY :_- .........�I X-(,�.------------ --------------- I Da`f te V/.�.. I Application Disapproved for the following reasons- ------------------------- ------------------------------------------------------ ----- r.----...-----........................ - ----------------- ---- --- D Permit No. --� .. .......... Issued -1-- ate THE MONWEALTIH OF MASSACHUSETTS �� t ` BOARD,OF HEALTH.' TOWN'OF BARNSTABLE ✓� i � Te r#tftrate of C amplinure ' ! THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( x ) by----- ---------------------------------------------------------s Q ­7 ------------------1,5 r4.�1.\S x...--------------- ---- Installer at ----------------------------------------------------- has PP p h the provisions of TITLE 5 of The StatU7, Eionmental Code A described in he application tionlforlD Disposal WorksConstruction Permit No. .... 1... dated ..... 7/......... . �. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE 60NSTRUED AS A GUARANTEE THAT/THE SYSTEM WILL FUNCTION SATISFACTORY. DATE............... f r1 - I Inspector r . .. _i.. - ' n THE COMMONWEALTH OF MASSACHUSETTS v BOARD OF HEALTH C� TOWN OF BARNSTABLE No...!........ -.......... FEE... 3�......... Uhip asa1 Works (9nni#rnr#ilart ranfit Permission is hereby granted.................-- �� G D. I------------ C P�s�2��/OA •••--•-•--•--••-•-• .................. . to Construct ( ) or Repair (! ) an Individual Sewage Disposal System atNo......................................I-- ........ !LJ.S ------- Street f �......... (� �f, 7/ as shown on the application,for Disposal Works Construction Permit No.__ T/�?d6a_ted_____ '1..Rl/l/../-- .... DATE------------ a f - ----------------------------------- Board'of Health . FORM 36508 HOBBS Q WARREN,INC.,PUBLISHERS R.. Flc$...... ...................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HE T ��- Appliratinn -for liiipniittl Workii Cnnnitrnrtion Prrnitt Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemt -•--• ----- - ---••- •-------------•----••----•--....------..- L o��ss r� or Lot No. Own Address W � Installer Address Q Type of Buildin Size Lot____________________ ______Sq. feet Dwelling lNo. of Bedrooms-----.'Z' -----------------------------Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures --------------------------- W Design Flow................_1-',0................gal -ns gr_person per day. Total daily flow_____�O__ .......................gallons. WSeptic Tank—Liquid capacityJ®9 _-gal ort Length.............:.. Width---------....... Diameter---------------- Depth---------------- x Disposal Trench—No_ ____________________ Width___._________. ___ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...............I.... Diameter._fpQ�_�J: pth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed b'y------------- -------------------------------------------------------- Date........................................ Test Pit No. I _______________minutes per inch Depth of Test Pit-------------------- Depth to ground water_..__---_----.--__.-_._- (_, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water-_.-..-.-_-.---____--__- -•-•--•--------------------•----------•--___..-•-------•----•--•-•-------.._.-.----•----------------......................................................... 0 Description of Soil- - ---------- ........... ---------------------------------------------------------------------------------------------------------------- U ----------------------------------------------. ...." .......------------------•--------------------------------------------..---------------- -------------------------------------------------- W -------------------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable.---......................................................................................._--. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of;Compliance hMbDeened by t o d of health.Sig --- -- ----------- 2,�-DV- 7 Application Approved By------ ----- _ -- -------------------- •--... .... 'bae ---- Application Disapproved for the following reasons:--------- ----------- ------------------------------------------------------------------•------------------- ---••--•-•---•--••-•------•-•-----•••---------------------------•-----------------------------•--•------------....-•---------------------••-----•. ------------------------------------ Date PermitNo.--------••-•.---••--•--•-•-•---•----------•-----•...... Issued.---•-- -------- •---- ---••--- Dat FEs. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH .-_....- Appliration -for Utsp ial Workii Tomitrurtion Vrrotit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systemiat § /�' .� ,.,. g ° l +c��t ter..— t'"f # ---- _ " ..........------ d ,,,,,,. s ��� or Lot No................................................... L atfon ABdres �jp ✓ ' AGE.. _• .+dnrsc..' �l ----------------------------•-----..._.._.._...---••-•---••-------•---•---•---••---...---•- W AN Owned Address Installer ] Address d Type of Building Y Size Lot............................Sq. feet U Dwelling�`No. of Bedrooms-_..___`' -.______________________________Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures -------------------------------- •_ - W Design Flow................. �perperson per day. Total daily flow__.__�^'�_.�_._._-.._....-.....-__gallons. WSeptic Tank—Liquid capacity/P __gal ori�s —Length---------------- Width................ Diameter-----.---------- Depth_---____-_-_--- x Disposal Trench—No_ ____________________ Width_____:____ __ Total Length.................... Total leaching area___-_-______---_____sq. ft. 3 Seepage Pit No......_________�---- Diameter._ ©�9_..-____ _epth below inlet.................... Total leaching area______-__________sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date__--•----------------------------------- ,� Test Pit No. I----------------minutes per inch Depth of Test Pit.................... Depth-to ground water-_-____-_______-__-_---. f� Test Pit No. 2....._----------minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ -----------------------------------------------------------------------------------------------------------------------------------------------------------------------•---•------•-------------------------•--•-----------•-•---------•-------------------_----- D Description of Soil--_-______--_ - _____0 � ------ ------------------------------------------------------------------------------------- --------------- ----------------- x --_ ------ --------C'-----------fit W ---------------- ------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- UNature of Repairs or Alterations—Answer when applicable._-___---------------------------------------------------------------------_____---------- -------------------------------------- ...-----------------_-------------------•....---••-•-------••-..-._-._...----------------...-•--•-•_..-•----.-..._..._........................... -----•------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Comphance has been i ed by t oa fd of health. }{ !. 1571 Signed f�If s'r'"" 7 .»-.., - ------- --•---•--- Date/ Application Approved By..--- ,./- �.f =-. / 1'`,�' �' � j! �� ate Application Disapproved for the following reasons--------------_-------- ------•-----------------------------•-•--------.__._.._-.----------------------------- --------------------------------- - - - --- -- --------------------------- Date PermitNo......................................................... Issued--- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH * ..................OF..... a ................................. (Irrtifiratr of Toutplialtrr THIS'IS TO CERT F , Th the Individual Sewage Disposal System constructed ( or Repaired ( ) by....... %1A .................................. f st ler has been installed in accordance with the ?"'ovisions of Article XI of The State Sanitary Code as descr• ed in the application for Disposal Works Construction Permit No-_____-____fir "'__-___________ dated_-r-___ _-_ .. -_./ __.____.._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOTtBE CONSTR ED AS A G RANTEE THAT THE SYSTEM W LL 11NCT N SATISFACTORY. O DATE. �Va F""---""- --- Inspector - ------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.... ........ ...................................... No..... ....... ( FEE- --- ..... �rk� �ott�trurttott �rrtttit Permission is hereby granted......... # .-------------------------------------------- ---------------------------------------------------------------------- ............ to Construct ) or Repair ( ) an Individual_Sewage�sDisposal System atNo....................................., ..�+ 1-- ---------tr=�:•---•-------- - - -- --------------------------------- --•--- 6# street ` . as shown on the application for Disposal Works Construction `Permit s1-__._____._ Dated.... -- °�' ` �� Board of Health DATE---------- --- ---- --------- -------------•••----------•• FORM 1255 HOBBS & ARREN. INC.. PUBLISHERS t tppl��++ t r s t SEPTIC�SYSTEM MUST BE ig NSTALLED 7 xt IN COMPLIANCEw'��� WITH ARTICLE II STATE'. CODE AND TOWN f �OfTMETO R GftQ TOWN OF I2AI�.NSTr i SAUSTABLE, i Q e BUILDING tt aka. APPLICATION FOR PERMITFt O � . .�'�:.;' !Y ' � ��; .�. t kq k TYPE OF CONSTRUCTION /krrr. b gT� 1 4 . - ; kk • .k lit .F. �#) • :x +" '' ���. E}{ ,! TO.THE:.INSPECTOR OF BUILDINGS: fir, t ,r The .undersigned ,hereby applies,,for a permit according to the following information:. • ; fi .wit g Location D. .. ... .',..1. .�nt% .P.L! .......................... ,ett� �'I f Proposed .Use ...:... ? .'' .. .... f "� •„ r :... . Zoning.SDiatnct .... Fire Districta'�`y"' k ,Name of Owner .. .. (��: Address . . ..... ..4i : t Name of .Builder . ...........................................r ......... .. ..Address ......... ........................................................... � Name ofArchitect Address vn as /. ' Num erg of Rooms a... .... /,�!/2 /> r .Foundation .......... N ! r - Nr. ./....F ' Roofing '..::. .xi ExieGi1.o� �• `� G f„ ��i9 �ai91Z I Floors / �D �''' �.. .... Interior ....... I{ (LDGI �r Heating �j. s ..... )�. !? ?�'�......:.". ,-.....Plumbing ...... //J(�/ .4)e s, ' ....... !replace .5 .. .:. .. .Approximate Cost ............ P . r. .Q/. 1; Definitive Flan Approved by Planning,Board. _'�_:, ---19�_ - r' Diagram of'_Lot and Building''with Dimensions E fs Ue kaow,s '1 SUBJECT,TO APPROVAL.OF BOARD OF .HEALTH f b C, f ql _. a ' Do 0 G"7 L t441 r A TL v Af V. ,MMyy ,ry'{31 > ar *t hereby agree to conform'to all the Rules and Regulations of the Town of Barnstable regarding the aboveY. construction. -. s Name ..............� .... t} "�v ham'u e a ' a;nq ,a, 1'hY>r ;.'fia _. _-._. ,.�,...�.,.h—T-u s '"' 'r,.'' T� t N t•`¢-. t }°� Fw , ,:r ;'ias e �c' xh'iy k 4ik+ Ptr tia3eA �7+^!