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HomeMy WebLinkAbout0319 MARSTONS LANE - Health 319 MARSTONS LANE, BARNSTABLE A= 349 090 t H o L . 1 COMMONWEALTH OF MASSACHUSETTS .. EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS' " DEPARTMENT OF ENVIRONMENTAL PROTECTION}. A 1,'• y 9 A�A TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS— - ' SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 319 MARSTONS LANE V11W BARNSTABLE,MA 02668 M349 Po90 Owner's Name: SAMUEL BLACK Owner's Address: 6 BEACON ST. BOSTON MA.02108-3808 Date of Inspection: 12/14/00 Name of Inspector: (please print): JOHN GRACI c*s T° oF&R ` EGf w Company Name: ';ASEPTIC INSPECTIONST ysr Mailing Address: ,P:O.BOX 2119 TEATICKET,MA.02536 t E�jOEpT'k6 Telephone Number: 508-564-6813:FAX,508-564-7270 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is ^ true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes 3;u . _ Conditionally Passes _ Needs Furt er.Ev°aluation by the Local Approving Authority Fails — Inspector's Signature: Date: 12/14/00 The system inspector shall subm' a copy of this inspection report to the Approving Authority(Board of Health or DI;P)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 co,p�ies sent to the buyer, if applicable,and the approving authority. u, Notes and Comments { THE SYSTEM PASSES TITLE V�INPECTION. RECOMMEND PUMPING THE SYSTEM NOW AND EVERN' TWO YEARS TO PROLONG THE SYS $M'S USEFULL LIFE. ,1{`l ****This report only describe$conditions at the time of inspection and under the conditions of use at that time.This L inspection does not address how the system will perform in the future under the same or different conditions of use. ,A r vl Titlr- S In-nrrtinn Fnrm A snnnn Page 2 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A <CERTIFICATION (continued); s Property Address: 319 MARSTONS LANE WEST BARNSTABLE,MA 02668 M349 P060 Owner: SAMUEL BLACK Date of Inspection: 12/14/00 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which'indicates that any of the failure criteria described in310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: THE SYSTEM PASSES TITLE V INPECTION.RECOMMEND PUMPING THE SYSTEM NOW AND EVERY TWO YEARS TO PROLONG THE�SYSTEM'S USEFULL LIFE. 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. n/a The septic tank is metal and over 20 yearsold* 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 v,a 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: n/a M 9 ; n/a 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 E � _ obstruction is removed' distribution box is leveled or replaced ND explain: n/a n/a 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 t , _obstruction is removed ,t ND explain: n/a j Page 3 of 1 I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION(continued) Property Address: 319 MARSTONS LANE WEST BARNSTABLE,MA 02668 M349 P090 Owner: SAMUEL BLACK Date of Inspection: 12/14/00 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 feetof�a;surface water r _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t 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. f _ The system has a septic tank and SAS and the SAS is within a Zone I 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 n/a "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: '}fi n/a a f t^ lit M1 i Page 4 of 11 t: y x , f ' OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 319 MARSTONS LANE,WEST BARNSTABLE MA 02668 M349 P090 Owner: SAMUEL BLACK Date of Inspection: 12/14/00 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for alLinspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool s: X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ X Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow _ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped nLa. X Any portion of the SAS,cesspool or privy is below high ground water elevation, X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. _ X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privytis 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 coliforkm,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.] (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 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) Ili 44 yes no X the system is within 400 feet of a surface drinking water supply s.,.. X the system is within 200 feet of a'tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supplywell If you have answered"yes"to anyquestion in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system his 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. a t , i.f Page 5 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B } " CHECKLIST Property Address: 319 MARSTONS LANE WEST BARNSTABLE,MA 02668 M349 P090 Owner: SAMUEL BLACK Date of Inspection: 12/14/00 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: 1 P, Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health X Were any of the system components pumped out in the previous two weeks? X _ Has the system received normal flows in the previous two week period? X Have large volumes of water been introduced to the system recently or as part of this inspection? X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) X _ Was the facility or dwelling inspected for signs of sewage back up? �• t . X _ Was the site inspected for signs of break out? X _ Were all system components,excluding the SAS,located on site? X _ 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? X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems R k The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _ X Existing information.For example;a plan at the Board of Health. r X _ 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 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ' SYSTEM INFORMATION Property Address: 319 MARSTONS LANE WEST BARNSTABLE,MA 02668 M349 P090 Owner: SAMUEL BLACK Date of Inspection: 12/14/00 ' FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 1 Does residence have a garbage grinder(yes or no): NO Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] Laundry system inspected(yes or no.). N0 Seasonal use: (yes or no): NO Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO Last date of occupancy: n/a COMMERCIAL/INDUSTRIAL Type of establishment: n/a 4' Design flow(based on 310 CMR 15.203)'sn/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO C Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title`5 system(yes or no): NO k Water meter readings, if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a , GENERAL INFORMATION Pumping Records Source of information: n/a Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped: n/agallons.--How was quantity pumped determined?n/a Reason for pumping: n/a �\ i4 TYPE OF SYSTEM X Septic:tank,distribution box,soil abkirption 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 rrom system owner) _Tight tank Attach a copy of the DEP approval Other(describe): n/a Approximate age of all components,date installed(if known)and source of information: 1984 WITH A NEW PIT IN 95 Were sewage odors detected when arriving at the site(yes or no): NO x Page 7 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 319 MARSTONS LANE WEST BARNSTABLE,MA 02668 M349 P090 Owner: SAMUEL BLACK Date of Inspection: 12/14/00 BUILDING SEWER(locate on site plan) Depth below grade:30" _ Materials of construction:_cast iron X40?PVC_other(explain): n/a Distance from private water supply well or.suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) Depth below grade:24" Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) Dimensions: 1000G L 8' 6"H 5' 7"W 4' 10"" Sludge depth:4" Distance from top of sludge to bottom of outlet tee or baffle:30" Scum thickness: 1" 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: n/a How were dimensions determined: MEASURED Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural_integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND.RECOMMEND PUMPING NOW AND EVERY TWO YEARS TOpPROLONG THE SYSTEM'S USEFULL LIFE GREASE TRAP:_(locate on site plan),T Depth below grade: n/a Material of construction:_concrete_metal l_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Y F Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a Distance from bottom of scum to bottom of outlet tee or baffle: n/a Date of last pumping: n/a Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): n/a, .s x Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) E Property Address: 319 MARSTONS LANE WEST BARNSTABLE,MA 02668 M349 P090 Owner: SAMUEL BLACK Date of Inspection: 12/14/00 Ve: TIGHT or HOLDING TANK: (tank must 6e"�pumped at time of inspection)(locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day P 1 Alarm present(yes or no): N/A Alarm level:N/A Alarm in working order(yes or no): NO Date of last pumping: n/a Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:jn/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.): DID NOT EXPOSE lip PUMP CHAMBER:_(locate on site plan)-,,. , Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): n/a ftI , ;rli€i a n, R ' Page 9ofII . 5 _ OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) ' Property Address: 319 MARSTONS LANE WEST BARNSTABLE,MA 02668 M349 P090 Owner: SAMUEL BLACK Date of Inspection: 12/14/00 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) V c If SAS not located explain why: n/a Type 1000 GAL 6'X 6' W/3'OF STONE leaching pits, number. 1 n/a leaching chambers, number: n/a n/a leaching galleries, number: n/a n/a leaching trenches, number, length: n/a n/a leaching fields, number: n/a n/a overflow cesspool, number: nla « n/a innosyative/alternative system Type/name of technology: n/a Comments(note condition of soil,°signs of hydraulic'failure, level of ponding,damp soil,condition of vegetation,etc.): THE LEACH PIT APPEARS TO BE FUNCTIONING PROPERLY.THE PIT SHOWS NO SIGNS OF FAILUE.SOIL PROBED DRY IN LEACH AREA. CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: n/a Dimensions of cesspool: n/a Materials of construction: n/a 3' Indication of groundwater inflow(yes or nko):NO Comments(note condition of soil,signs of=hydraulic failure,level of ponding,condition of vegetation,etc.): n/a PRIVY: (locate on site plan) Materials of construction: n/a Dimensions: n/a Depth of solids: n/a Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): n/a t s T ; � I I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 319 MARSTONS LANE WEST BARNSTABLE,MA 02668 M349 P090 Owner: SAMUEL BLACK Date of Inspection: 12/14/00 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. }e D e 0 D 5+ t!t �� I Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 319 MARSTONS LANE WEST BARNSTABLE,MA 02668 M349 P090 Owner: SAMUEL BLACK Date of Inspection: 12/14/00 SITE EXAM _Slope _Surface water _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high ground water elevation: NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a NO Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain: n/a NO Checked with local excavators,'installers-(attach documentation) YES Accessed USGS database-explain: n/a You must describe how you established the high ground water elevation: USGS MAPS AND CHARTS- 12+FEET TOWN OF BARNSTABLE LOCATION r y "<<`�� T �0` 4A) SEWAGE #9xr"71�,7 VILLAGE :JGt� ASSESSOR'S MAP & LOT7,09-®`f INSTALLER'S NAME & PHONE NO. - 3ys'Sl u SEPTIC TANK CAPACITY I �s LEACHING FACILITY:(type) C b 6"4- -3 -S b_w(size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER _ DATE PERMIT ISSUED: ,._ DATE COMPLIANCE ISSUED; r VARIANCE GRANTED: Yes No y a, e�� PA . 33 FEB ...�... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphratiun for Uir.,Vuitt1 Wurku Tunutrnrtiun f rrm t Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal 's System at: iK _- I� � j ...................... _____ _____._._.. ... .. - ........................................................ Lo tion-Address or Lot No. ......................61.�.,.�z,....��`�' c- Ow r �n A mk?' Installer Address UType of Building �/ Size Lot...............:............Sq. feet ►-t Dwelling— No. of Bedrooms.__._._____r________________________________Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capa6ty/400..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. 4 Z Other Distribution box ( ) Dosing tank ( ) '~ Percolation Test Results Performed b Date........................................ a Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water...................... fs, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water................... ----------------------------------------------------------- •---------------- •---•-•-------------------------------•-------------- --•------------ 0 Description of Soil........................................................................................................................................................................ x1 x --------------------------------------------------------------------------------------------------- -------------------- -------- V Nature of Repairs or Alterations— n per when ap icable._._.��s �ril--_- . rv� ...� __��.__�`►� �' / -- . :. Agreement: - s The undersigned agrees to install the aforedescribed In -uidual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental kode The undersigned furth^agrees not to place the system in operation until a Certificate of Complian ee i, '`d'by the board of e It Signed ------------ - .. . Application Approved By ...... .... .. .. ..L- -- ------- -- Date J. Application Disapproved for the following ream • -------------------------------------------------------------------- ........................................................ � Date - -" r ..................... OY Permit No. .............. ... - Issued /. ... .. r: ,• *, 1 - 3 q No.. ... ... ... FEB k�.............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Divi-Vniittl Workii Toustrnrtiun ramit Application is hereby made for a Permit to.Construct ( ) or Repair ( ) an Individual Sewage Disposal System at -----------------31..----/����. ..w...---...^'- ----.•-•--••..---•-••--- -- Locptimf i-Address or Lot No. .....................�... ............................. ------•----•------............................ ._...:.----•----•---------------------..-.-...- ��/ t Ow,nre T �r ( i--1�. Apddd`rcf a ................................................../`'. - � �/ Installer Address UType of Building 4 Size Lot............................Sq. feet �. Dwelling—No. of Bedrooms.........._!-------------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............. No. of ersons--------_--_____-.-_--_---_- Showers a yp g --------------- P ( ) — Cafeteria ( ) Otherfixtures --------------------------------------------------------------------------------------- ------------------------------------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/00_.galIons Length................ Width---------------- Diameter--- ............ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------- ---- ------ Diameter....................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... 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........................ P4 ....--•--...-----•--•--•..............••--••----•-•-•-•--•-•-•--- •-•-----•--..•..-•-----••---.........---•------------•---...-•----•---.............-. ODescription of Soil....................................................................................................................................................................... W V ....'-'••------•--••...----••-•••••--•----••---•••-••--•-•-----•-•••-•••--•-••-----•-•--•-•"---------•-•-•-•--------••-•••••-•----'--•-----...•--•-----•----•--•-•----•---••-•----.....-•••------------ ---------•------------------------------------------------------•----•.......-----•-----------•--'----------------------:------------ ------ .---....... U Nature of Repairs or Alterations—Answer when applicable__;Tl' �t��_ �c__ s� � cl✓v r- P f fQ 0)-/u _ .................................... �} Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code: The undersigned further,agrees not to place the system in operation until a Certificate of Compliance"has bbeen isju•d by the board of health - , n� � Signed ............ � . ......................'�'.....n _1/......-.. ...... ..................:.. � r / / Datf Application Approved By ....._ ... ':. . ���---- ' n---�d��� •..._:� �------------------------------- Dae Application Disapproved for the following reasons.. ..... ....... ....... . ..................... ..._.------------------------------------------- �/--------------------------------------------............................................. --------y ----- --------------*......... �--------------� < Dare �- r Permit No. -----------! ------------------- Issued ..... —1- -- '. ............. ....... Date' THE COMMONWEALTH OF MASSACHUSETTS o BOARD OF HEALTH TOWN OF BARNSTABLE Ter#ifi a e of Tontylianre THIS!hS,-T0-CER ZFYi That the Ind-ivi•ual Sewa.e Disposal System constructed ( ) or Repaired ( ) by ............ `l i.`_1...: .f(T... '` r.:.� 1 <A-- . em, at ..................... .. ....� �� �`T(ZI . . �r�:�. -�', 1- :. .�.ll.tl ...--_----------------------- 1 has been installed in accordance with the provisions o TITLE 5 of The State.Env'ronmental Code as described in the application for Disposal Works Construction Permit No-. dated dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 9E CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �`i��, DATE-- -- ....... 1 . /. ----------------------- ------------------------- ------------- ---------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH i-1 -3 TOWN OF BARNSTABLE �� No..................... FEE----.................... Bisposa1 Workii Tomitrudion(Prrnttt Permission is hereby granted--•---- ��, -i ; '_v�/��� j�C.- •-•---------••---••----••-•--- t�1�C to Construct ( l ) Rep atr ( �) an Individual Sewage Disposal System , at No............... - !. ;- w: -- '✓ /� `•� t street ...f as shown on the application for Disposal Works ConstructiotPermit No._Z__�'�... " !n ` ' � ._- - Dated•.-...---- ) •.... .. ..........,,......... of Health � DATE...........................1.�..�.../ y (/ FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) m A LI DATA N 3� s THE COMMONWEALTH OF MASSACHUSETTS BOAWD PF HEALTH ..................OF........ r/ ....................................... Appliration for 11isposal Works Tonstrurtion rlermit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Sy at: , ) _— Ow Address W �ns�ru rr'ze�rrrairrssna... iw �........... .. ..........� VF......... . J7/� ......----•---•-------------------- Installer Address T i ing ,� `,Size Lot..>"1.�P�.{moo Sq. feet U D�er— No. of Bedrooms.._.. Expansion Attic K �-�a Garbage Grinder 04 Type of Building No. of persons............................ Showers — Cafeteria a' Other fixtures W ~— gallons per person per day. Total daily flow...............Design Flow..................... WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No//.................... Width.... f:........... Total Length.._............. Total leaching area...,.I- -sq. ft. Seepage Pit No.........,1 .. D' ter.... ...... Depth below inlet...-.......... Total leaching area.................sq. ft. Z Other Distribution box ( � Dosing 0.4 Percolation Test Results Pe 91 .. . ,�,b ......... . ....... ... ............ Date.......�1°.. .:. Test Pit No. 1.....9.....min`"��r inch Depth of Test Pit......���..... Depth to ground watetU�r J.�... rzq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x ' --...... ¢.... - ............................................................ Description of Soil.. - 3 �J��1.� �J �.............. .... ... ..... . ......... V ..........................................................• -----••-----.........------..................----------... ............ ... .E........................................ W ....................................................................................•--•----.......----........---------•-------.......------------ •••-• ............................................ U Nature of Repairs or Alterations—Answer when applicable..........................................: ................................................. .................................................••-•---•-----..................----•-----•----•--•---..........-•-------------------...----•---...........------....................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage D posa System in accordance with the provisions of iITIU S of the State Sanitary Co e— he dersigned further s not to place th operation until a Certificate of Compliance has been sub b t bo d of health. lgned. ..... --- ........ --- -- Application Approved By............ ` Application Disapprove or t e f oll ........................................ Permit N No._Z.3'.1�3 THE COMMONWEALTH OF MASSACHUSETTS , - BOARD F HEALTH %(.,t"/ .................OF........:,1/l......I ' . --..................................._... Appliratiun for Disposal Works Tonstrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Systent at .......-_d":.. Locan=Address --• t No. - ---�-- ��� ...... l r r :�.c�=.-..... ...1.:: .�............... - ....................' �! .... ,�`r... .�� Own dregs W .. .. .............. �.... ��� r-4sL Installer •-- Address --••-•---------•• T uil ing Size Lot. ,. .6.,62Sq. feet D�er—Type —No. of Bedrooms___.. ..............................Expansion Attic Garbage Grinder (XJj) j 04 of Buildin .............. No. of ersons.................._......... Showers — Cafeteriaag .............. P ( ) ( ) 04 Other fixtures_ _ WDesign Flow.....................% _......._._gallons per person per day. Total daily flow............... �.:r?.............gallons. Septic Tank—Liquid capacity.._..._ ..gallons Length................ Width................ Diameter................ Depth................ Disposal Trench—NO. .................... Width.._.: ...._.... Total Length.........:_..j:.... Total leaching area...". ?L�.sq. ft. 3 Seepage Pit No......... ......Diameter......__...... Depth„below inlet.... ...........Total leaching area.................sq. ft. Z Other Distribution box O Dosing tank ( ' r- Percolation Test Results Performed lby._.._.. ��` _.lLl`........._- C: ?` Date.........f:.. .. a --.........j Test Pit No. 1.._.. ._...mmutes`'perInch Depth of Test Pit._.._...2.7�.___. Depth to ground watereV f:~� Lt. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth tto' ground water........................ O Description of Soil.. ._f_.. ....... f'.r.'F?... ... J,,.:, ':' .a ..._... ':f 4'..`.�+jl� .. f ..._.. ....... -•--••••----•••-••••------•-----••--••...... .......... ___------ __------•------- c"rr�=�-- �� ...............---••---� --..._ W U Nature of Repairs or Alterations—Answer when applicable........................................... Y ...............................................................................•-•----•---...............-•-•-------------------•-•--•----...---....-----....................__••••-•---................ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Di osal ystem in accordance with the provisions of TITLE 5 of the State Sanitary Co — e u rsigned further a not to place the system in operation until a Certificate of Compliance has been i sue b th boa of health. - ' Igned_ ...... .. _ /A/ .... DA Application Approved By.....`...!::...f rr.:............ ter?. ,c�� 2 " Date Application Disapproved�fo t. a following reasons:............................................•----------•--....------------••---•-------•---•Date---•-•------ ---•-•............................................................................•----........-•---- .................----.._.....-•-----•------.........------•-•--..........--------......_....._.._ Date PermitNo...................................................-.... Issued......................................................- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF................ f9rrtifirtar of:Compliana THIS IS TO° ERTIFY hat the Indivi al Sewage a oral stem construct ,� { g Posal S..............................................................( � °r Repaired ( ) ed b .., .. ___...._ Installer f .3 h s been installed in accordance with the provisions of TITLE j of The State Sanitary Cod c Code,/as Ibed in the application for Disposal Works Construction 1Permit No.. __ _.. .. 3............. dated._/..,� ` THE ISSU NCE OF THIS CERTIFICATE SHALL NOT BE>CONSTRU AS A GUARANTEE THAT THE SYSTEM�1 FU �ON SATISFACTORY. .... ...... ............... DATE...: --- ......------•---.....-•---•----......--•-•--........ Inspecto ---•- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .. . ........................OF.................................................................................. No... J. F>a>t.......................... 3�i n tt ,lurks f;unstr iun f rr it,,.,�. Permission is eb anted.,: ( Y gr -- .!1� ............................. to Construct or R .`, an Ivx3ual Wage Di (((sal Syi atNo......................... .:!� = ........ / {1 c-( r.. .. --- -------.......----------•-----•-------_..__..... ................... Street as shown on the application for Disposal Works Construction Permit No... ... ........... Dated.......................................... ......................... ---•-•---••- ---...---•--------....•---•........--•-•----••---••---....._ Board of Health DATE.........2!_a: 7=f...- FORM C-1255 CITY& TOWN FORMS, INC.369-9708 �:' Wo GARgAG GQJL1DEsR. Ft-OW x 110 X 3 = 330G.Po _ I5EPT1G TAWK a a3oxl5o% UStr 100o GAL. � � ', t v o 0 6AL. VL" L_c�T 195 D15POSAL.. PIT VICE7 . 3 G j1DGWAL.� A2.EA =ZG � �� 2 4 X j.Z S =33D GPI. , ooTM A•CoeGA, = 1514 S F. El�G � . v '° E"ASE�IE�/T 7Z� 91.0`X t7 toG co91• TvTAL j PE(ZC"ATIOW MA?E t 1"IN $'MIN:= :QESiGN �1 toy, l �..S Gg� IQ Q I -,ems sr, I - N 10' h�.►c. a PLC !i 94 G? ! HSE.• tlwl i 5; RSr9C� jN OF MgS,sgc\ it 2— � 2•Iv�ToZ,� , �Ig W1LLI•AM u'a O� ALAN I Ioq 17/ k C. ;1 N Y E JONES No.. 19334 No. 7 5 110 U °1 G m Z 9G 9 ''11 UM ii Noy 9171,93 1 G' o D15T. Q INS• Si`VT G 9`3.8 I 3 ' loon IrJ� 9o7c y3 to TANK �, LErscu �r3-o . INV. PIT q t� { oC/rs/e"r 4441d WIT" 9.3 93 7 6Taµr Hi CERTIt~It'yp PLoT PLA1J PR.p�ILG 1,.ocA710W GuNAMAQ L11U 8Z.© No 'sCALE �jGALE l ...VP.TE RED E>z.Elu 1 R6�ON GOMP Y5 Y�Tt�TH� S�L1N�4YN P.W D S s-me►GK R.6Q V 12 EM�N'1'� O F"f H P�- •3��35 P6.►yc� 'TvWN of T3AQ IJ5TA131 AND 1� t�1of K 1 I-oCp.TGO MIT 1w T %-OCPD L DATE 31 BA.KTEtZe fJYE INC. REG 1 tort F_-7.6.'D'IJ\W D 5 u eY rc li T4115 PLQN Ili K10'T at%.5Ep 1d AN o*,rG9_V1LLE • Ss• II• lu,s-t-R,uMEN1' Su2vG-Y -rH o�r_'5 r5 suouo , ►1oT t3G- u�l ��TGti C�CTt:•c'-MI�lC l.r.-t VIIIC�� APP�.IGA►.�T' f APPLICATION FOR PER LATION TEST AND OBSERVATION PITS LOQATION NO - VILLAGE _ DATE APPLICANT FEE ZJ ADDRESS TELEPHONE NO. (Non-refundable) ENGINEER 0-� TELEPHONE NO. DATE SCHEDULED (Applicant' s signature) • . . . . . . O O . O . . . . . . . . ! . . . . . . . . . . . . O . . . . . . . . O . . . . . . . O . . . . O . . . . . . . . O . O . . . : . O . . O . . . . . . SOIL LOG SUB-DIVISION NAME DATE_ TIME/��d EXPANSION ARE : YES NO� ENGINEER:.",,! TOWN WATER/ PRIVATE WELL BOARD OF HEALTH C_ EXCAVATOR SKETCH: (Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands 'in proximity to test holes) NOTES: r oC' Lam- 9S N PERCOLATION RATE: �- TEST HOLE NO: ELEVATION: TEST HOLE N0: ELEVATION: 2 2 3 -. 3 4 4 5 5 10 10 11 11 12 .12 13 13 14 ^� 14 15 15 .16 16 SUITABLE FOR SUB-SURFACE SEWAGE: " LEACHING FIELD LEACHING PITS( LEACHING TRENCHES- UNSUITABLE FOR SUB-SURFACE SEWAGE. REASONS: NOTE: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PEC ST APPLICATION ( ORIGINAL: COMPLETED IN ENTIRETY BY P. E. AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPLICANT f BORTOLOTTI CONSTRUCTION INC. 3 �B.IIBBURYACE . 8E 7►C3E• DISPOSAL SYSTEM I14SPECTI014 FOR} I Addigss ,otaproperty.. •- -- Ownerts 'name�i Data ot•L Inspection, _-.-- - PART A CHECKLIST Check if. the following have been done: _695 Pumping•.information was requested of the owner, occupant and E,<-�<, : Health-.. -Nona of the system components have been pumped for at least t'_10 -cc and "the. .system..has. been' receiving normal" flow rates durinq that period. �Large. .volumes of water have. not been introduced into th., Sys t4m. rs'centl-y'.or:'as, part of this inspection . ' �Az built •plans have -been obtained and examined . Note if they < < availabhe ,with -N/A. The. fecili.ty '.or. dwelling was inspected for' signs of sewage hacr:-,.;;.; . _L--' �Tha site was. inspected for signs of breakout . , _4z:::f, 1►11 system :components, ' excluding the SAS , have been located, site. t,�Tha se"ptic .tank. manholes. were uncovered, opened , and the inte�- 1 ^., tha .8apt'ic' tank tiers `inspected.: for" condition of baffles or tees , aa.ter.ialr :.of'•construction, dimensions, depth of liquid , depth o: slud_4e-,...dApth. of.� SCUm. The.*. size and: .location of the SAS on the site has been determ., nec:i on . existin" information or approximated by non-intrusive methods . The facility~owner."("and occupants, if differentfrom owner ) we F provided"with `intormation on the proper maintenance of SSDS . et OD Acfry g PR S 199, N . S y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS . If residential number .of bedrooms number of current residents - . garbage grinder, yes or no laundry connected to system, yes or no - seasonal. use, yes or .no If nonresidential, .'calculated flow Water meter readings, if available: = (.A?I Last date of occupancy GENERAL INFORMATION Pumping records and source of information: wv System pumped as part of inspection, yes or no if .yes, volume pumped Reason for pumping: Typ"f system -------... Septic tank/distribution box/soil absorption Single cesspool g p ion system Overflow cesspoolY Privy Shared system (yes or no) (if yes; attach previous inspection records, if any) Other (explain) Approximate age of. all components. Date installed, if known . ntormation:. Source of .Sewag,e odors- detected when arriving at the site es o y r no SUBSURFACE SEWAGE DIBPOBAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK.. �. (loc.ate `o:n -site plan) depth below grade:. material of construction: Y//concre.te metal FRP other (explain) dimensions: /000 C1 r,A -- sludge depth distancel..from .top of sludge to bottom of outlet tee or baffle scum :.thickness distance from .top of scum to top of outlet tee or baffle distance 'fro.m bottom of scum to bottom of outlet tee or baffle .Comments: (recommend'ation for. pumping, condition of inlet and outlet tees or baffles , depth of liquid level ,'in-relation to outlet invert, structural integrity , 'evidence_ of . leakage, recommendations for repairs, etc. ) DISTRIBUTION BOX: (locate .on .site plan) depth of liquid level above outlet invert Comments: (note.-if level and distribution is equal , evidence of solids carryover , evidence of. leakage into or out- of -box, recommendation. for repairs , etc . ; ,,. PUMP CHAMBER*, (locate on si,te. plan) pumps in workings order, yes.-or no Comments' (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs, etc. ) 'BUBS.UkFAdE:`SEWAGE . DISPOSAL:. SYSTEM INSPECTION FORM PART. B. SYSTEM INPORXATION continued BOIL ]� SORPTI.ON::;SYSTEM : (SAS)': - (locate ona te',plan;" if possible; excavation not required, but may be approximated` by "non-intrusive. methods) If not determined to ;be present,, explain: Ty pe leaching pits;: and: number leaching "chaitibers and:'`number leaching galleries and -number leaching trenches number, length lea:ch�ing .:fie1`ds; ;.number, dimensions overflow 'cesspool, nuzaber :,. .Comments (note eonditi:on o;f soil , signs, of hydraulic failure, level of ponding , condi`tion. of ve tatf'on, r'ecommendations : for maintenance or repairs , etc . ) s ,c Jh� n �t ( c Y CESSPOOLS` (locate on, site plan) number configuration depth, ;top;; of liquid to inlet invert depth of:'.'.solids layer --.._. . dOpt h`, of scum ';layer dimensions of;-cess POOL. - materialsr of ';construction -- indication ot ;groundwater -- inflow (cesspool,:.must .be pumped :as part: of 'inspect _on):' -Comments.. (:note.; condition of so3l, ; signs of hydraulic failure, level of .ponding , condi'tfon of vegetation, recommendations 'for maintenance or repairs , etc . ) PRIVY; :(locate o.n site plan) r F materials: .of' construction. dimensions _.. �tlepth ,solids Comments: : (note< conditi'on :of so l, ` signs. of. hydraulic failure, level of ponding, condition, of vegetation,. recommendations for maintenance or re a 'irs P e tc . ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF- SEWAGE DISPOSAL SYSTEM: ; include; ties . to at least. two permanent references landmarks or benchmarks locate, all wells within 100 ' SL ' . 36 a3- i DEPTH, TO GROUNDWATER _ depth to groundwater Method of determination . or approximation: r 80B8IIRFACE, SEWA GE.:DI8POSAL SYSTEM INSPECTION FORM PART C FAILURE 'CRITERIA In dicate`..y or not determined.'.(Y, N, or ND) . Describe basis of -,;determination ,in. all...°ins.tances If "not determined" , explain why not) Backup `of sewage` into. faci'l.ity? Discharge or ponding° of effluent to the-surface of the ground or surface .waters? t , N4_ S.tat,ic .liquid level in the distribution box above outlet invert . -Li.Q uid d,e th din' cess, ool <6"' below invert or available volume< 1 2 d� , .. : P P / f l ow? ..1z :Re ired': pumping 4_.times or more in the 4�, P P g. last year. number of: times pumped Zseptic tank is. metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Al Is any. portion .of the SAS, . ce.sspool or privy: /�' below. the high .groundwater" .elevation?' within" So. feet of a surface water? . within. 100 feet of,;a..sur.'face water supply or tributary to a surface ' water suPPlY? within .a Zone I 'of- a public well? within 50. feet of a bordering vegetated wetland .or salt marsh (cesspools and privies only, DQt the SAS) ? within 50-'feet of� 'a private water supply well? less than 100- feet but . greater than. 50 feet from a private water supply..well with.:no, acce table wa p ter quality analysis . If the well has been:.'analyzed to be acceptable, attach copy of well water analys for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. _ c SUBSURFACE.. 8EWAGE 'DISPOSAL SYSTEM INSPECTION FORM PART 'D CERTIFICATION Name of- Ins Inspector P Company Name j� n Company Address *,� '° .Certification Statement I certify. that :I have personallyinspected the sewage disposal system at this ;addresa.:and that .the information reported is true accurate and comp lete :�as 'o'f the -.time of ..inspection. The inspection was performed and any -recommendations regarding upgrade, maintenance and repair are consistent with :my training and experience -in the proper function and manitenance. of on-site sewage disposal systems. Check one.: _j/ I have. not found any information which indicates that the system fails to adequately protect :public health or the environment as defined in 310 CMR 15. 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA .section of this form. . - I have determined. that the system fails to protect public health and the . environment as defined in 310 CMR 15 . 303 . The basis for this determination is .provided in the FAILURE CRITERIA section of this form. Inspector' s SignatureGL�� CG% � Date71R Original to system owner Copies to: Buyer . (If applicable) Approv.ing : authority 3 'U� W LO TI N 9' SE AGE. PERMIT NO. � �IL L AG E G INSTA LLER'S NAME i ADDRESS rye UILDER OR OWNER DATE PERMIT ISSUED 4ez 1�-Zlyl-5 DATE COMPLIANCE ISSUED �� YV7 S � � I r p � 6