HomeMy WebLinkAbout0312 MIDPINE RD - Health ff Midpinc Road, Barnstable
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No......................... �'9'..Oo2[J r Fes$..........................
THE COMMONWEALTH OF MASSACHUSETTS k
BOARD OF HEALTH
j.v...........O F..... ./...!4.
s� 3la for 9iip.wial 10orkii Cfilmitrurtinn Verna#
Application is hereby made for a Permit to Construct (Z-Tolor Repair ( ) an Individual Sewage Disposal
System at:
....................� .........y....................................•----•--
Location; o
A dream .� t N
� r Lo
----- - - -- ...... ----- ----- ---------------
-- Owner Address
�. ._f. i ..__ Z --------------•------....._... jZGUP�
►'� Installer Address
Type of Building Size Lot.'/a_/�.� ..Sq. feet
U Dwelling—No. of Bedrooms___........ ...........................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons................_........... Showers ( ) — Cafeteria ( )
a Other fixtur s ---------------------------- --- -
Design Flow.......... ...................gallons per person ear dad, Total daily flow..____... • - ---`----------_gall�o
W - L
WSeptic Tank—Liquid capacity/Mallons Length .___:"��._.. Width__-�_--_� Diameter---------------- Depth..,__.-.__.
x Disposal Trench—No_ __________ ____ Width............. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No_____ ___________ iameter��_-jO._ Depth b owl�,""inlet. __. otal leaching area. i ..sq. ft.
z Other Distribution box Dosing tank ( ) ( (mob s
Percolation Test Results Performed by.:2 �715�,�� . _.... A .... Date..-. _. __._.. ?_.. _
as Test Pit No. 1__L.�_minutes per inch Depth of Test Pit.,l'`__r1_. .... Depth to ground water.ti _
(s, Test Pit No. 2_i! . ...minutes per inch Depth of Test Pit_/JIK�_._. Depth to ground water.... k
........... .. .... .-
--__-.
----•---•-_--_
.................................. . ..................................................F ___.. ._....._.._______..
Description of Soil.. . ...:... � .............2- -
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Si ----•--•----------------------•------------•-----•-•--•-•--•------•------- ................................
Date
Application Approved By_
Date
Application Disapproved for the following reasons--------------------------------------------------------------------------------•-•----••--. ---•••-------_..._
Date
Permit No......................................................... Issued..::.'.
...... ... ...... .......... ......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
� ) BOARD OF HEALTH
l..t✓...........OF... ..f��617,19. ................
(Irrtif iratr of fluutpliattrr
THIS 9 S TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
g -----P • y ( -•---•••.P
\ .l.d - fsB_��. �:.`! Inller `yl ._/v �_..�
at_ 6P. -----•---------------------------
has been installed in accordance with the provisions of T 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.7__ ...___. yam_ . _
PP P y/
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
,1.....DATE � — ..i-....--�
.................................................. Inspector =
TOWN OF BARNSTABLE
LOCATION �L � SEWAGE#
VILLAGE,.,,, A �� ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC.TANK CAPACITY
LEACHING FACILITY.(type)s,,-P,-vs o T� (size) .
NO. OF BEDROOMS
OWNER V., ., `
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum.Adjusted Groundwater Table to the Bottom of Leaching Facility a- -
Private Water Supply Well and Leaching Facility(If any wells exist Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Feet
FURNISHED BY
1I '
I
i
� Fims �a
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........OF..... .....................
ApplirFatiou"fur Elhgpvii al Work.5 Tomitrurtiou runfit
Application is hereby made for a Permit to Construct (4-1!;r Repair (' ) an Individual Sewage Disposal
System at:
Y
Location-A res�s or mot N
...... -----------------------
Owner Address
................:....... ...:... �� �fJtJ ff�}..1-/4IIG
•--
U/�.=/
Installer �'`` Address
'Type of Building uLX Size Lot...—"/ 2ZLSq. feet
V Dwelling—No. of Bedrooms........... .. .Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------f------------
W Design Flow........... .........................gallons per personope�day.. Total daily flow---------a.._._.._.�.....-..........ga119 •.
WSeptic Tank—Liquid capacity/t�Y! allons Length_C�'.'P. Width__15/.__ Diameter................ Depth.._ ........
x Disposal-Trench—No. .................... Width.................... Total Length...........I....... Total leaching area....................sq. ft.
Seepage Pit.'No.___../----------- Diameter.,/l.2.-.4V. Depth below inlet__ k6,
' Total leaching area.,57_ +.-_---_sq. ft.
Z Other Distribution box ( Dosing tank ( )
Percolarion Test Results Performed by-_� ._�y �.; �_._...__5 - �� ��!'
F. g. cr
Date
aTest Pit No. l...�2-.minut per inch Depth of Test Pit.../ ..... Depth to ground water__'' C�f_.._--_--
(i, Test Pit No. 2_.G-`a"_._min des per inch Depth of Test Pit../-�,-�- _... Depth to ground water----- .....
Description of Soil .:_ 2................J!:p.............
W ••-•••-------------------•----------------........------------------------...__.....-----------------------------------------------------------------------------------------------------...--•-.----•-
UNature of Repairs or Alterations=Answer when applicable_______________________________________________________________________________________________
---------------------------------- •--••-•---------•-••--•----------------••--•---•---.._.._.-•••••--------•-•••••-•-------------•-----------•------------------•----......--•-•----•--.....-•--...-
Agreement: „
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with _
the provisions of i T." 5 df"the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sigd-----------•-----
n Date
Application Approved By.....- t = i .............................
.... .----
Date
Application Disapproved for the following reasons------------------- ---------------------•--------------------------------------•--.....---••--•---......_.._
----------•------•-----------------------••-------••----------------------•-•--•-------------------..-------------•---•--------------------------------------------------------- ------•--•-•--•-•-••--
Date
PermitNo........................................•-:..-----•---- Issued.............................="----------..............
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH,}
` 1.��`.1.. ........OF.... �/ �,�7`........L:�r...............
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( 4)-15'r Repaired ( )
by............!„ 'G� �= ,�9 .C 1, ".................................................................:=------------- -----------------------------------
/ Instal er rC
at
has been installed in accordance with the provisions of m : t;:� 5 of The State Sanitary Code as des�ibed in the
application for Disposal Works Construction Permit No.-MU �1 _'�.` ____... :Z_.__...__. dated__.._ ." .�................
TIDE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
! —
DATE._._.. ��� Inspector......_ Gli -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
s.
7 )
No.......... .
� �rk� C �n rruti�
Permission is hereby granted... -- ,� -------- ----••-------------------•--------........_.........------------...-•--••---••---
to Construct ( &.efRepair ) an Individ 1 Sewage Di posal S stem t
atNo...... ---- rl .......//.?/0__-..... ......................................................
Street t,
as shown on the application for Disposal Works Construction Pe t No..- __. _. Dated-____j'` �_- /..............
idBoard of Health
DATE = .......................................... --------------- J
FORM 1255 HOSES & WARREN, INC.. PUBLISHER 1
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05/15/2009 15:29 FAX 12038342037 THEUPSSTORE 11002
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I certify that this property is
located in Flood Hazard Zone C (out-
side the 500 year flood) as identified
by* the Department of Housing and Urban
Development (HUD) .
Date 45w-V L 3 zoo CERTIFIED PLOT PLAN l
LACA ON 9......... ..y,(CL!lrsgwia)
SCALE DATE FM-ZS�
Regz, Surveyor PLAN REFERENCE .4VE7A!4, /37
e v.. Sao rv�v .G.!�! . !4!►!,./!.sl.E�
I certify to its title insurance company .
�7tiSTlvC DZiCtr/iv
that there are no visible encroachments I CERTIFY THAT THE .. ... .. . . .. . .. ...� .
or easements except as shown and that this
SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
plan was prepared under my immediate AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETBACK REQUIREMENTS OF THE TOWN OF
supervision. WHEN CONSTRUCTED.
DATE Z.009
.S7TE7.--%1.1E-7V [7iq A
N f9, C,e%�y/-/SET. ��ArtpC
R GISTEREO LAND SURV OR
L
TOWN OF BARNSTABLE
' sOCATION o� �G,p`w 2 YN&I SEWAGE#�� 'M
TILLAGE Ce�w.w�ag ASSESSOR'S MAP&PARCEL 3 S_
INSTALLERS NAME&PHONE NO. sow' co-5
SEPTIC TANK CAPACITY
11. qy C;
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER- V .�,,Z .o« -e—
• PERMIT DATE: COMPLIANCE DATE: D
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) t/ Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
-within'300 feet of leaching facility) /t' Feet
FURNISHED BY
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rAoivr.. .,
q'��
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A `VO
, .= :10_'
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No. 00 Fee �� r
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01ppliLatlon for Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair 04 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3`� ;cDw',AtZ Owner's Name,Address,and Tel.No. 6-0$—,3
���
Assessor's Map/Parcel yg Oa S Pr^)T'" ( 31c1 v 0603
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
�•�. 53ox 3'7/
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( ).
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this B and of Health.
i d Date
Application Approved by AuDate
Application Disapproved by Date
for the following reasons
Permit No.A Q Date Issued a G
------------- -------- -
a.---.^r sy'•.'SP-,5+.ter. -,+.. , •-�� -
No. 1JU `( Fee /va '
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplitation for ]Disposal Opstem Construction Vermit
Application for a Permit to Construct( ) Repair(4 Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 3`� �',cD ,,ne- Owner's Name,Address,and Tel.No. Szig-37-7-o
Assessor's Map/Parcel 3 y� C���` G(P tr Q -?,tia n� e� �C23
Installer's Name,Address,and Tel.No. ,�� Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 7 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
` Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) .-?
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
S'ignedd _1. _ �� /� —^ Date_�j
ApplicationApprovedby �(') Ant �� Q), / Date
v
Application Disapproved by�J Date
for the following reasons
Permit No. U 1_C, 3 Date Issued / j 716 Cj
-- --.____~h_�----------------------
.- .-.--.--._._..._-. - -- -- --.--.-----.-.--.-------- .
` (� y THE COMMONWEALTH OF MASSACHUSETTS
I BARNSTABLE,MASSACHUSETTS
n1� Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by
at a j-, {� u has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. � "6��dated 2/; 74 Cr
Installer ,--,QA 7.�,o� )- , L,,c : Designer 1 'r
#bedrooms `rh l[A- Approved design flow �� /� gpd �
The issuance of this permit shall not be construed as a guarantee that the system will-.fimction as designed.
Date , Inspector
17-------- -----------------_--
No. "J, Q 3 Fee /M "
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstent Construction i9ermit
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )
System located at
V
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permil.
Date t= pi er.� 1-2 Approved by `•j ,��/` �/V� i f��
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is required for Barnstable MA .. 02673 February 18, 2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important
When filling out A. General Information
forms the
computer,
r,use 1. Inspector: _I
only the tab key
to move your Patrick T. Sullivan
cursor-do not Name of Inspector
use the return
key. Ready Rooter, Inc.
Company Name
Q PO Box 371 -17 Jan Sebastian Dr.
Company Address
Sandwich MA 02563
Cityrrown State Zip Code
508-888-2805 S112843
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails ; M
❑ Needs Further Evaluation by the Local Approving Authority —�►
ems: M r-'
February 19,2009
Inspector's Signature Date f,
�y
The system inspector shall submit a copy of this inspection report to the Approvi g Auth my(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a hared Stem�,r
has a design flow of 10,000 gpd or greater, the inspector and the system owner hall submit the
report to the appropriate regional office of the DEP. The original should be sent t 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.
Lea zl b�
3i2midpinedr•03/08 Title 5 Official Inspection Form:Subsurface Sew ge Disposal System•Page 1 of 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is Barnstable MA 02673. February 18, 2009
required for ry
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
D-Box was found to be rotted and leaking during unofficial inspection. Replaced on February 17,
2009 prior to inspection. Recommend removal of garbage disposal. System not designed to handle
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, ,ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and ver 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhi ' s substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspe on if the existing tank is replaced with a complying septic tank as
approved by the Boar of Health.
*A metal septic t k will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance ' dicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break ou r high static water level in the distribution box due
to broken or obstructed pipe(s) or due to broken,settled or uneven distribution box. System will
pass inspection if(with approval of Boa of Health):
❑ broken pipe(s) are replace
❑ obstruction is removed
312midpinedr-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
x Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is rY Barnstable MA 02673 February 18 2009
required for ,
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is levele or replaced
ND Explain:
❑ The syYbron
pumping more than 4 times a year due to broken or obstructed pipe(s). The
systemin if(with approval of the Board of Health):
❑ s) are replaced
s removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Boar of Health in order to determine if
the system is failing to protect public health, safety or the a vironment.
1. System will pass unless Board of Health determi es in accordance with 316 CMR
15.303(1)(b)that the system is not functioning in manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a rface water
❑ Cesspool or privy is within 50 feet a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board f Health (and Public Water Supplier, if any)
determines that the system is fun ioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic ank and soil absorption system(SAS) and the SAS is within
100 feet of a surface w ter supply or tributary to a surface water supply.
❑ The system has a se is tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a �eptic tank and SAS and the SAS is within 50 feet of a private water
supply well. "
312midpinedr-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is ry Barnstable MA 02673 Februa 18 2009
required for ,
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has /dan
k and SAS and he SAS is less than 100 feet but 50 feet or
more from a privupply well".
Method used to distance:
`* This system passell w ter analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates ab presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provo other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool ,
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
❑ ® 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.
312midpinedr•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is Barnstable
required for MA 02673 February 18, 2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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 conform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with,a design flow of 2000gpd-
1 0,000g pd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd
For large systems, you must indicate either"yes"or"no" of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 4 feet of a surface drinking water supply
❑ ❑ the system is with' 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is I cated in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWP or a mapped Zone II of a public water supply well
If you have answered "yes"to y question in Section E the system is considered a significant threat,
or answered "yes" in Sectio above the large system has failed. The owner or operator of any large
system considered a signi 'cant threat under Section E or failed under Section D shall upgrade the
system in accordance w 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
312midpinedr-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5
I`
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is ry Barnstable MA 02673 February 18 2009
required for ,
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® 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)]
312midpinedr-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is ry Barnstable MA 02673 February 18 2009
required for ,
every page. City/Town State Zip Code Date of Inspection
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 bedrooms): 330 GPD
Number of current residents:
1
Does residence have a garbage grinder? ® Yes ❑ No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2007= 309 GPD
9 ( Y 9 (gpd)): 2008= 309 GPD
Sump pump? ❑ Yes ® No
Last date of occupancy: CurrentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd) .
Basis of design flow(seats/persons/sq.ft., et
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank presents ❑ Yes ❑ No
Non-sanitary waste discharged to he Title 5 system? ❑ Yes ❑ No
Water meter readings, if avai ble:
Last date of occupancy/u Date
Other(describe):
I
312midpinedr-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is Barnstable MA 02673 February 18, 2009
required for ry
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont:)
General Information
Pumping Records:
Source of information: Owners records: Pumped July 2008
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):
Approximate age of all components, date installed (if,known) and source of information:
Tank installed 1980, new D-Box installed February 17, 2009, SAS installed October 28, 1997. As-built
plans on file with Board of Health.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
312midpinedr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is N Barnstable MA 02673 February 18 2009
required for ,
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 22"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
---------------------------------------------------------------------------------------------------------------------------
Dimensions:
8 X 4.5 X 4.5 1000 gallons
Sludge depth:
1"
Distance from top of sludge to bottom of outlet tee or baffle
33"
Scum thickness 1/2
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape measure and dip tube.
312midpinedr-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is Barnstable MA 02673 February 18, 2009
required for rY
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Intet and outlet concrete baffles in lace. Liquid level at outlet invert. N sin f I p q e o o leakage. Risers bring
9 9 9
covers within 6"of grade.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal. ❑ fiberglass., ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thicknes/m.of
Distance from p of outlet tee or baffle
Distance from to bottom of outlet tee or baffle
Date of last pu Date
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 in, ection) (locate on site plan):
Depth below grade:
Material of construction: ,
❑ concrete ❑ metal ❑ frglass; ❑ polyethylene , ❑ other(explain):
312midpinedr-03/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name -
information is
required for Barnstable MA 02673 February 18 2009
4 rY
eve page. City/Town State Zi Code Date of Inspection
every P 9 P P
D. System Information (cont.)
Tight or Holding Tank(cont.)
Dimensions:
Capacity: allons
Design Flow: gallons per day
Alarm present: . El Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm a float switches,etc,): .
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert Oil
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
One inlet, one outlet. New, liquid level at outlet invert. No sign of leakage. Riser brings cover within 6"
of grade.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
312midpinedr-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is ry Barnstable MA 02673 February 18 2009
required for ,
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
® innovative/alternative system
Type/name of technology: Infiltrators-4 hi-capacity units w/4' stone.
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
SAS located and inspected with camera. Liquid level 1"over base. No sign of past hydraulic failure.
312midpinedr-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is ry Barnstable MA 02673 February 18 2009
required for ,
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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 i ow ❑ Yes ❑ No
Comments (note conditi 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 by aulic failure, level of ponding, condition of vegetation,
etc.):
312midpinedr•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13
e ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
Owner Owner's Name
information is ry Barnstable MA 02673 Februa 18 2009
required for ,
every page. CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
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 supp[y enters the building.
1
y �
k3
LDL
3L
I
312midpinedr•03106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
312 Midpine Road
Property Address
Janet Gage
9
Owner Owner's Name
information is
Barnstable ,: MA 02673 February 18 2009
required for ry
every page. Cityrrown State -Zip Code Date of inspection .
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
❑ Check cellar =
❑ Shallow wells
F a
Estimated depth to high ground water- 36.20_
feet
Please indicate all methods used to determine the.high groundwater elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 10/28/97 ,
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS) '
❑ Checked with local Board of Health explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain: i-
ma.water.usgs.gov - terraserver-usa.com
You must describe how you established the high groundwater elevation:
Test hole found no ground water(1997). Ground water separation found to be 36.20 at that time.
Accessed local ground water-contours and topo mapping to confirm data.
312midpinedr•03168 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
r
TOWN OF BARNSTABLE
LOCATION Q_ ���f 2 Or SEWAGE # �� l
VILLAGE �V �'�-� ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO./VC c c-
.T
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) / ''fc ( (size) ( C ?C P
NO.OF BEDROOMS g
BUILDER OR OWNER C)
PERMITDATE: t '-'2-'IF-- 191"ICOMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �"� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachi facili feet
Furnished by /t!�
� Z
No. r _ Fee g�
THE COMMONWEALYH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
application for Migogar bpacm Congtruction permit
Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
c� e
Location Address or Lot No. 1 p` 0� Owner's Name,Address and Tel.No.
,3-49e f %cS� J ne��`eJ *Z
Assessor's Map/Parcel tf
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
/�L °,P, 1, e4r-\
Type of Building:
Dwelling No.of Bedrooms Lot Si7-e f r ( sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title .
Size of Septic Tank Type of S.A.S.
Description of Soil
s
Nature of Repairs or Alterations(Answer when applicable)
r
Date last inspected:
Agreement:' tl 6
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu by t ' Boar ealth.
Sign O Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued 119
IF
x1 Fee�—
e^
THE COMMONWEAL` —OF MASSACHUSETTS Eniered in computer:
PUBLIC`HEALTH DIVISION —TOWN`0 F 6ARNSTABLES MASSACHUSETTS Yes
Application for Otgpogar &p.5tem"Con6tructton Permit r
Application for a Permit to Construct( Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. .? p� Nit f 111 e Owner's Name,Address and Tel.No.
+, C%2�/� ca
Assessor's Map/Parcel 3 Y ( 0 o1_
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
,
.,.,-Type of Building: -y
' Dwelling No.of Bedrooms .5 Lot Size sq.ft. Garbage Gander( )
' Other Type of Building No. of Persons Showers yp g ( Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tarik Type of S.A.S.
Description of Soil
Nature'of Repairs or Alterations(Answer when applicable) +A I
v
�—
✓ v Vt/ V
Date;last inspected:'
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
i in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by t ' Boaz ealth. M..
Sign O Date
Application Approved by Date, ,
Application Disapproved for the following reasons
Permit No. Date Issued
-- -------------------------------THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
i Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded'( )
Abandoned( )by
at p!e baspyen constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector ram,
r
----------------------------
No.a Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Digogaf *pgte Cons�tructton Permit �
Permission is hereby gran d, o Constru jt(o Re 'r Upgrade( bband ( )
System located
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/he,duty to
comply with Title 5 and the following local provisions or special conditions.
G
Provided:Construe 'ontmu om feted within three years of the date of thi perml .
Date: Approved by O j
1
1,0/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
,hereby certify that the application for disposal works
construction permit signed by me dated 1 9' 7, concerning the
property located at � Al\, ILO 1� c kt ct- meets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will=be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) U
B)Observed Groundwater Table Elevation(according to Health Division well map)
/X ^
SIGNED--. DATE:
LICENSED SEPTIC SYSTEM INSTALLER THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
I
TOWN OF BARNSTA,.BLE
LOCATION / ` ' �� f e �r SEWAGE # 7 w�
��
VILLAGE`CV c•-t-� j ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO/�t ��►^� �4 d .2SS�
SEPTIC TANK CAPACITY d
LEACH1lG FACILITY: (type) / 'Ii (size) ?C
NO.OF.BEDROOMS
� d L
BUILDER.OR OWNER
PERMI'I':DATE: I COMPLIANCE DATE:.-( d
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �" n t Feet
• Private.Water.Supply Well and Leaching Facility (If any wells exist �� e
on sit.'or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within:300 feet of eachi facili feet
Furnished by
we
_I
J
1 7T
G ` >
'.\ i� � � 1 t ! � !f�r`9✓" s'S` r �+'�' 1 f t f t �`
\�, • w+.. ..a_. ,/�` .7 +w.. ram. !��` - .....r. r" ye
altzk
l .��.....�..
t { Copt fop
, . f ,
L i•�i�s � �i�AO� ter.-_ -- 1 . �i�v ca7os%o,oe�
Bow •�v f /s� -
�
.!:?,e /r�
/00
4 r/Q W.
"'" „ � �Q B'q(ft+ - `_' •t ?: EG E!/ Ae
` ,o '� �O �,/al. �' 6=0 DMA•-.'�2� _ ��Q T --.._
. : PROFILE OF
SANITARY Di SPOSAL SYSTEM `" �' �'�`� = 9 '• '
NOT TO SCALE DESIGN DATA
BEDROOMS
CONSTRUCTION OF SANITARY DISPOSAL DESIGN FLOW 33C-2 GAL ./DAY
SYSTEM SHALL. C'ONF+OR.M TO MASS . LEACH RATE - - MINJINCH
ENVIRONMENTAL CODE TITLES
AND THE TOWN OF PROPOSED LEACH CAPACtT,1Y :
) 77L C-17- -�5 1
HEALTH REGULATIONS.
GAL ./DAY
f
SITE PLAN SHOWING PROPOSED CONSTRUCTION
LOCATION : _ . ._. .. 5. �.
FOR
APPROVED 19
SCALE: ,� � DATE y= BOARD OF HEALTH
R E F E R E N C E 0?"
T E A G E N T
Ck
MA
J. M. MONAHAN, JR. & ASSOCIATES
REGISTERED LAND SURVEYORS & ENGINEERS
65f MAIN $T' REET (!? ENNISPORT, MASS. 02639