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HomeMy WebLinkAbout0060 OAKMONT ROAD - Health G I OAKMONT RD., BARNSTABL]E A=349.054 D Commonwealth of Massachusetts 4 9_ ��� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments -rr< 60 Oakmont Rd. NJ Property Address Donna and William French Owner Owner's Name information is - required for every Cummaquid ✓Magrh2bf Q, MA 02637 . 7/10/2017 , page. City/Town State Zip Code Date of InspectidrD Inspection results must be submitted on this form. Inspection'forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information 3 filling out forms S/ 1 2`11 ,- on the computer, I 'l(! use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return key. Name of Inspector, Cape Cod Septic Services Company Name 350 Main St Company Address . W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 Telephone Number_ License Number B. Certification ` 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 ❑ Needs Further Evaluation by the Local Approving Authority 7/17/2017 _ Inspector's Signature Date The system inspector shall submit-a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the. report to the appropriate regional office of the DEP..The original should be.sent to the system owner and copies sent to the buyer, if applicable, and the,approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 �� VS I . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments •�" 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name information is required for every Cummaguid MA 02637 7/10/2017 page. City/Town 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: System in working condition. B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system,.upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", 1.no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name information is required for every Cummaquid MA 02637 7/10/2017 page. City/Town State. Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational.'System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ' ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System.will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ •�` 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name information is required for every Cummaquid MA 02637, 7/10/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, .if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or Clogged SAS or cesspool El z Discharge or ponding of effluent to the surface of the ground or surface waters due town 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 ❑ z Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form -Not for Voluntary Assessments- °` 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name information is required for every Cummaquid MA 02637 _ 7/10/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable wa ter quality analyses. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this.form.] ❑ ® ' The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a_surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in*a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,•�" 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name required fo is Cummaquid MA 02637 7/10/2017 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected,for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)'provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the,failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x4= 440gpd t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M , 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name information is Cumma uid _ MA 02637 7/10/2017 required for every q _ page. CityrTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 6 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection Yes, ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2015=271gpd2016=342gpd Detail: Sump pump? []'Yes ® No Last date of occupancy: Current- Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.); — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name information is required for every Cummaquid MA 02637 7/10/2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No Records 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. I ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 8 or 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , 60 Oakmont Rd. Property Address Donna and William French _ Owner Owner's Name information is required for every Cummaguid MA 02637 7/10/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1998 Per BOH records. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'feet Material of construction: [],cast iron ®40 PVC• El-other(explain): +10 Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank(locate on site plan): Depth below grade: 16"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 l Dimensions: 1500Ga - Sludge depth: 8-10" t5ins•3/13 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage(Disposal System Form - Not for Voluntary Assessments ••' 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name information is Cummaquid MA 02637 7/10/2017. required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.). Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 6-8 11 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1500Gal tank in good structural condition. PVC tees in place. Tank at normal operating level. Covers 16" below grade. Recommend service of tank. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete. ❑ metal, ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness -- Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts a Title 5 Official Inspection Form, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name information is required for every Cummaquid MA 02637 7/10/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as.related to outlet invert, evidence of leakage,.etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: -- Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): i *Attach-copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 I Commonwealth of Massachusetts u Title 5 official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,••'' 60 Oakmont Rd. _ Property Address Donna and William French - Owner Owner's Name information is required for every Cumma quid MA 02637 7/10/2017 page, Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0„ - - Comments (note if box is level'and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): H-10 DB-3 with 1 Line in and 2 lines out in good condition. Box is clean and level with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 16" below grade. Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No* Alarms in working order: ❑ .Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name information is Cummaquid MA 02637 7/10/2017 required for every ` page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500ga1 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 2-500gal leach chambers with stone. Chambers found dry at time of inspection. No sign of overloading or hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration — Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts 9-3 . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M a'" 60 Oakmont Rd. _ Property Address Donna and William French Owner Owner's Name A information is G required for every Cumma uid. MA 02637 7/10/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions -- --- Depth of solids - .Comments (note condition of soil,-signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts IBM, Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Oakmont Rd. Property Address Donna and William French Owner Owners Name information is Cummaguid _ required for every MA- 02637 7/10/2017 page. Citylrown State Zip Code Date of Inspection D. System Information (cost.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name information is required for every Cummaguid MA 02637 7/10/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: feet feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 1991 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Test hole data per records on file at BOH. i -- Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments `( 60 Oakmont Rd. Property Address Donna and William French Owner Owner's Name information is required for every Cummaguid MA 02637 ' 7/10/2017 page. Cityrrown State Zip Code Date of inspection E. Report Completeness,Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r !o d TOWN OF BARNSTABLE }n LOCATION OPI-l®e1r SEWAGE# 71_ yos to VILLAGE 64,1Z,#Qaz/1.4 GQQ� ASSSEESSOIVS MAP&LOT 2u . INSTALLER'S NAME&PHONE N0. /JO/'&Z011I ZAV0,,` 77/-9� SEPTIC TANK CAPACITY / 09oI LEACHING FACILITY:(type) `SGt9 4dI 4 )04(size) NO.OF BEDROOMS^ BUILDER O WNER PERMTTDA�Q"0 7 —I COMPLIANCE DATE: Separation Distance Between the: ' Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet. Furnished by 61 - Jf , 33 Reap of l vfe r _ S t Commonwealth & Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �^M 60 Oakmont Rd. Property Address William French Owner Owner's Name information is required for Cummiq uid Ma. 02637 9/18/2008 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. Please see completeness checklist at the end of the form. Important: When filling out A. General Information When / forms on the G� l computer,use 1. Inspector: / only the tab key d5 41 to move your Robert Paolini. cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC. Company Name r� P.O.Box 763 - Company Address Centerville � Ma. 02632 City/Town State Zip Code (508)428-4028 S14454 . 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 ElConditionally Passes El Fail s r� EO co ❑ Needs Further Evaluation by the Local Approving Authority v e ro L0 9/18/2008 Inspector's Signature Date The system inspector shall submit a copy of this inspection report.to the Approvi g Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in.the future under the same or different conditions of use. V" t5ins•09/08. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 2 Commonwealth of Massachusetts - W Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form - Not for Voluntary Assessments 60 Oakmont Rd. Property Address William French Owner Owner's Name information is required for Cummiq uid Ma. 02637 9/18/2008 every page. City/Town 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: The septic system is in porper working order at the present time. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits.substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is-structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 60 Oakmont Rd. Property Address William French Owner . Owner's Name information is required for Cummiq uid Ma. 02637 9/18/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)-are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official' Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 60 Oakmont Rd. Property Address William French Owner Owner's Name information is -Cummi uid - Ma. 02637 9/18/2008 required for � q j every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water - supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has aseptic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of,effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than T below invert or available volume is less than Y2 day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not'for Voluntary Assessments M 60 Oakmont Rd. Property Address William French Owner Owner's Name information is required for Cummiq uid Ma. 02637 9/18/2008 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy.is below high groundwater elevation. El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ E Any portion of a cesspool or privy is within a Zone 1 of a.public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑_ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified "laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1"0,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 1.5.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No -❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply El El Area system is located in'a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade'the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate . regional office of the Department. t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 60 Oakmont Rd. Property Address William French Owner Owner's Name information is , Cummi•uid Ma. 02637 9/18/2008 required for q every page. City/Town State Zip Code Date of Ir'spection 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. 11 ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 60 Oakmont Rd. Property Address William French Owner Owner's Name information is.required for Cummiq uid Ma. 02637 9/18/2008 every page. City/Town State Zip Code Date of Inspection D. System Information Description: The septic system consists of a 1500 gallon septic tank,Distribution box,and two 500 gallon leaching chambers with 4'of stone. Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes E :No Water meter readings, if available last 2 ears usage d 2006:80,000 g ( y g (gP ))' 2007:73,000 Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date 008 Date Commercial!lndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203); Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts W Title Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .'' 60 Oakmont Rd. Property Address - William French Owner Owner's Name information is Cummi uid Ma. 02637 9/18/2008 required for q every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Capewide Enterprises,LLC. Was system pumped as part of the inspection? ® Yes ❑ No 1500 If yes,volume pumped: gallons How was quantity pumped determined? Measured _ Reason for pumping: Maintenance Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑. Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract` ❑ Tight tank.Attach a copy of the DEP approval. ❑ " Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 r Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 60 Oakmont Rd. Property Address William French Owner Owner's Name information is required for Cummiq uid Ma. 02637 9/18/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feeetet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10'+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of Ieakage.System vented through the house vents. Septic Tank(locate on site plan): 16" 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: Sludge depth: t5ins•09/08 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 ,M 60 Oakmont Rd. Property Address William French Owner Owner's Name information is required for Cummiq uid Ma. 02637 9/18/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _ Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle NA Scum thickness 0 Distance from top of scum to top of outlet tee or baffle NA Distance from bottom of scum to bottom of outlet tee or baffle NA How were dimensions determined? tank pumped at inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appearsa to be structurally sound. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 60 Oakmont Rd. Property Address William French Owner Owner's Name information is required for Cummiq uid Ma. 02637 9/18/2008 every page. City/Town State Zip-Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping:. Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth..of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 60 Oakmont Rd. Property Address William French Owner Owner's Name information is required for Cummiquid Ma - 02637 9/18/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above cutlet invert No 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.): Box is Ievel.Box has two outlet laterals with equal distribution.No evidence of solids carryover.No evidence of leakage into or out of box. 1 �I Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: El Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 F - i Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 60 Oakmont Rd. Property Address William French Owner Owner's Name information is required for Cummiq uid Ma. 02637 9/18/2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gl. LC ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil,'signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Sandy dry soil.No signs of hydraulic failure.Chambers had 14"of water in them at time of inspection.No stain line observed above water level. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface,Sewage Disposal System•Page 13 of 13 A Commonwealth of Massachusetts. W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments 60 Oakmont Rd. Property Address William French Owner Owner's Name information is Cummi uid Ma. 02637 9/18/2008 required for Q every page. City/Town State Zip Code Date of Inspection ' D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; 1, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 Map http://www.town.barnstable.ma.us/arcims/appgeoapp/map.aspx?prope... Town of Barnstable Geographic Information System Parcel Viewer Custom Map Abutters Map Sae Zoom Out In� y le R T ,. R r� 2 y z x:. Cl 9 :ap •^`_ A 2; Feet Set Scale 1" =20 ; ' Aerial Photos i MAP DISCLAIMER l of 2 9/26/2008 1:47 PM Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 60 Oakmont Rd. Property Address William French Owner Owner's Name information is Cummi uid Ma. 02637 9/18/2008 required for q every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells. Estimated depth to high ground water: bottom of chamber 60 feet feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site.(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: As-Built Card ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: USED:OSGS Observation Well Data.USE D:Technical Bulletin 92-000-01 plate#2 annual ranges of groundwater elevations. s Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 60 Oakmont Rd. Property Address William French Owner Owner's Name information is required for Cummiq uid Ma. 02637 9/18/2008 . every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E.checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn.on page 15 or attached in separate file 1 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 r p TOWN OF BARNSTABLE LOCATION ��9 OPe�®/lT tale SEWAGE #177 VILLAGE G ll/yl/YI /�;°l!/�� ASSESSOR'S MAP& LOT � ;INSTALLER'S NAME&PHONE NO. O O Cohn 77 SEPTIC TANK CAPACITY _ /,7 ,f 1 EAmNG FAciLrry: (type) C,)04(size) .NO:pF BEDROOMS } 'DUELIDER 01 OWNER) f'�j�Ci� ftRmrrDATE: D,5 -C1 1--92 COMPLIANCE DATE: ;Separation Distance Between the: ; Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet .' 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I,. _ -, .r v:. e •t: � ,lam ''t'�i 1� =�_� �':.�` ,�.':_ �, :'�� '`�' 19,7y •+"W •.�� �'�t•�. .yV�:: ,,.'C(•��� r4 C., T •K• -:3: --':t:ry'� �• '�, >:z�i%'�+���v7' �^•. `.:�!.ti b'•Iir �� #1."•.' �. q�^�'•as.,: 'I��` .. • .i:.^...:d:,..�,,�...,.-W .:..r_.,�-� ... ir__..�... ._,. __. .. _ .. ,1:_7:.•SIi4, 'T.. �v.::.iris�errrluv�e,.�� .v:`�i?�Ph`1u�.iS7:u•..d:l++�.::�:�(�'SR_�_t�.c':T.t_.:saz...Ga.;'+I�':"Flfi.r+:...ti�,�.� _� ,,._56:ta 'a�'p. m w . • .• � �.�i ice, e: �- i �•.. w LO co - - m Syr_A m Ln . �L m . i— �.••.�rx.* � � � 1!'ti � �,,, No, Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 5 PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ` (pplicatiou for iq gat *paem Congtruction Perron Application for a Permit to Construct(' Repair( )Upgrade( )Abandon( ) , ❑Complete System ❑Individual Components Location Address or'Lot No. O D��O'� (D�� Ow is Name,Address and Tel..No. .�j/L G ���iVCf1 Assessor's Map/Parcel ✓G* e4u i) _ Installer's Name,Address,and Tel.No. Designer's(/Name,Address and Tel.No. rev Type of Building: y ���� Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow D 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- r' , F 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 Certifi- cate of Compliance has been issue t rd OHealth. Signed Date Application Approved by Date Application Disapproved f rM- 1, wing reasons Permit No. Date Issued —————---—————————————————————— 3,_ ;„ Fee 5— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication ")Repair i�poml *p�tem Con-4truction Permit Application for a Permit to Construct( ( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. &0 � K/k(041)>T 29 Ow is Name,A sand Tel. 7 L G�)>fi e✓iVC> Assessor'sMap/Parcel Installer's Name,Address,and Tel.No. / Designer's Name,Address and Tel.No. 1 �45_ � 77 Type of Building: /' Dwelling No.`of Bedrooms Lot Size ' V�L/7_7/sq. ft. ; Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow a gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. p Description of Soil ,i Nature of Repairs or Alterations(Answer when applicable) Date last inspected: • 't Agreement: J 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 hS gned ii been issued,issued,b t 37d. . Health. — Date ,r Application Approved by `, g , Date Application Disapproved forthe following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CER Y th�f t�}e�On-�SeDisposal System Constructed( )Repaired( )Upgraded-( ) Abandoned( )by at 08 K M MG constructed in accordance r -„ with the provisions of.Title 5 and the for Disposal System/Construction Construction Permit No. ated Installer Designer Y The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No.q Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Oigoaf pitem Construction Permit Permission is hereby g antes t )Repai ( U gra )Aban n System located at .and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to- ccmply-with Title 5 and the followinglocal.provisions orspecial conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by r" �� EL 7B; G G. No rE - A[c c..v TAdL E /kIA rr/cZ rt ,A, - - T0P of rOUN;:*- ,a"'D s't3&Y�' p 7a cor,cREl_ cOvcR, ., -'�71 •4' OR SCHEDULE 40 � "" rl 4"SCHEDULE 40 P.V.C. (ONLY) 9�MIN . LEACHING TRENCH (L )REO �•�IPV.C. PIPE MIN. PIPE_ MIN 1/8' - 1/2" WASHED STONE 36" MAX. r ?ITCH PITCH .• _. a 1 I I � —_J t1 O CJ� d i C7 Cl I' •J_ .T DIST. INVERT �= ,q�=ram n�t� c�,'CI' �' Ci b' 24" SEPTIC TANK =,- 7Z-� EL7�-!? o o INVERT o� �a� - .. eox '�"Q -� '�' �����? — -� 6y.Q,a iL.7¢ INVE, EL.............. ------------__1 EL.7Z:.3.¢ II:`�_ T Precast 500 Gal.Leach 3/4"-II/2"-� L..7./. (Z-) REQ alamber WASHED STONE • u6'�CRUSHED STONE Cl�1V7 G�.vQ, oFEgS�yewT /s {- �• - v -�--/G I H----- 19 11/ ---____ P- -G S �'AGE DISPOSAL 51�'S T E11 GROUND wATcR TAZLE E� SOIL LOG T Y?1C L C?CS-3 SECTION -_ abc /y /�9� ; ,,� /o:ov A!'1 N0 SC'L_ LEACH I NG T BENCH ,.. ^ t H TEST HOL ?s Wiz. 7a.�7 =LSv. .v� =.�.?�s =-=v. .��.8 DESIGN DATA : } �. 1 9 AfN. �,. -_D f/ 36"MAX ^,S JivliG �f'�/�//�./ f � /� �! .' Z4„r 'Ea. Y _ r [-/oA,•�,n,.r C�' Cna r.o �4°� AREA Ir _ 28, � .[ sn.�o:TT7 TC-AL ESTIMATED FLOW . . .'� GALLONS/DAY „yR 2 Z a' C 44 0 AR A SQ.PT TRENCH yemBJTTOM L=ACPirG Y, S/ „ 24" 30 -- nrj : c SIDE LEAC4ING AREA . . . .��/.•. �j► . 30.,T./TnE CI 74,4.r naw Ewa ( �' h6il. 10Y414 G8' ,oY" % GARBAGE- DISPOSAL .eYOf-�4--(50°o AREA INCREASE) - - G \ L i, / C ev f r+w C Co-o'�cr �, - '}G. C�7 — C ��+IY (oA,f✓SAW GsA»y Sbs.D 1O 84 3 A►`` , 70 /s . _RCOLAI ION Ra-= �5. Tf�/n0N��iiv r =R. IriCa ,s // ;, sn.rY• __ __ Z. - Gq-�G�y M4L /3Z �.__ c4 f. 4--y LEACHING AREA =ER P_RC0LAT10N P.=,±c SO.FT�G.IRA, Y �I►N u .46" 43 o �G �TIlNC1 CS Irr...rk"�+CD GRCIiND 'N w.I CR 7i.2-L— J7*0s,fr*,n / 43 ,s e•.O APPROvcD . . . . . . . . . . . . . .. BOARD OF HEALTH /_Vo. ..Y AT_R ENCOU?iT-cRED � DATE AG_N'T 0R INSP TO R tN Or {� \ '` r•� FiG�a D W i T N E-_S)5 F D BY ��p� 5,s, �H OF --•` ofvn'.�+ /�'J/o2,gNZJ'/ 07 / o EDWARD 1 HEALTH � � ��f S . . . ..... -�. ENGINEER i.�1Cfv�17` � ,r3 1 LLEY e" � 0. ► GNO. 26100 CO b. r&VVC� L�a�,c,v LL5i47eI� GLy PETITIONER -�'��•/!/9( l/Ii+ . . . e`ss/9fCISTE� �pQe r . Y �aAL L AH® S� 9 SANS Q a srR��r r. ;►° /viLC o vvv Joy o o _ EVAAILU Ales, L- -- - a -- 77�I .; �„ - - 71- 7o611 / I?' _. I �• r _ 1 7G ' oho \ \ 7B �........ ---- ' 1 _ '78 1 _ �-y f) /L�/5/_R2 7- 7> _ f 78 z 78 // /997 _: , C-X'is'n.vG" C,e�vt rO DY H No. 26100 AL LAMS Pv��