Loading...
HomeMy WebLinkAbout0183 SALT ROCK ROAD - Health 183 SALT ROCK RD., BARNSTABLE A = ♦ - a ; a z sy a w • t{ µ i x , d }ti n ♦ a a a W ., a e r Commonwealth of Massachusetts _ Title 5 Official-Y al-Inspection Form I dt Ii� t I�. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments. 183 Salt Rock rd Property Address Joanne Robichaud -- Cwncr Ovmer's Name -- Inforrnation Is Lo 30 required for every Barnstable_Y.-_- Ma 026----- pa3c C tyiTown State Zip Cock; 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 forms General Information S� �Q0�on the computer, if use on:y the tab 1. Inspector. ` key to mo,:,your .cursor-do not Mlchaei DiBuonu use the return - ------ --- ---.. -- - —._. - - --: ----- --....— -- =-— --------- -- ---- key. Name of Inspector DiBuono Sewer and Drain troy raa_ Company Name o -------..--- 8 Johns path_ - -- ---- Company Address S_Yarmouth-------- ----- --- ---- --- . •MA -- ---- -- 02664 ---- -- City!Town - State Zip Code 508-364-9587 S113522 Telephone Number License Number B. Certification -1 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 -0 Conditionally Passes 0 Fails Needs Further Evaluation'by the h cal Approving.Authority 11/4/1i • Inspector's Signature Date I The system inspector shall submit'a copy'of fhis inspection report to the Approving Authority (Board of F-Iealth 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 f, report to the appropriate regional office of the DEP The original should be sent to the system owner k. 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 iri the future under r the sameor different conditions of use. 15ins•3/13 Title 5 Officiai Inspection Form Subsurface Sewage Disposal System•Page 1 of 17 1 Commonwealth of Massachusetts f - W Title 5 Official Inspection Form Subsurface Sewage:Disposal System Form - Not for Voluntary Assessments 183 Salt Rock_rd Property Address Joanne Robichaud Cwner _ Owner's Name information is required for every Barnstable Ma 02630 11/3/15 - --- ------- --- -- .— page. City/Town M_ State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310<CMR 15.303 or irr:310 CNIR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1000 gallon tank as well as a concrete Distribution box. All tees and baffles are,in place.The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels__—__ 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 wil! pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tankswill 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 ' 183 Salt Rock rd ' Property Address -- -- Joanne Robichaud_ ` Owner Owner's Name — ------ --- -- information is required for every Barnstable _ Na . 02630 11/3/15. page. City/Town k 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.); qpbservation,of sewage backup_orbreak out or high static water level in the distribution box due to broken or obstructed pipets) or due to a broken, settled or!uneven distribution box. System will pass inspection if(with approval of Board'of Health): broken pipets) are replaced ❑ -Y ❑ N :❑ ND (Explain.below): ❑ obstruction is removed ❑ Y ❑ N ❑' ND (Explain below): ❑ distribution box i.s leveled or replaced ❑ Y 0 N ❑ ND (Explain below): ❑ The'system required pumping more than 4 times ayear'due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): F ❑ broken pipe(s) are replaced 0, Y R N, ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND°(Explain below): C) Further Evaluation is Required by the Board of Health:4 ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment: 1. System will pass unless Board of Health determines im,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: ❑ C6 spool 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•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 Salt Rock rd Property Address Joanne Robichaud Owner .. - —==------------ -- Owner's Name information is required for every Barnstable Ma 02630 11/3/15 - ---------------------------- -- ---- ---- 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 putillic 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 E ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow _ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 " - Commonwealth of Massachusetts Title 5 Official Inspection , Form I Subsurface Sewage Disposal System Form Not for Voluntary Assessments " 183 Salt Rock rd Property Address Joanne Robichaud Owner Owner's Name - - - -- - _ information is Barnstable Ma 02630 11/3/15 required for every — ---- _ s 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. ' El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary a to surface water supply._ ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. " ❑ N Any portion of a cesspool or privy is within 50 feet of a private water supply well. El ® Any portion of a cesspool or privy is less than 1'OO 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- ❑ ® : 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 li.bf`a public water supply well. If you have answered "yes" to any question in Section Effie 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 Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments 183 Salt Rock rd Property Address Joanne Robichaud Owner -- ------------- ------ Owner's Name information is Barnstable Ma 02630 11/3/15 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? El ® 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 CM 15.302(5)] D. System Information Residential Flow_Conditions: Number of bedrooms (design): 3 --- Number of bedrooms.(actual): 3 - — DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 Salt Rock rd -- -------- - - -------- - =----- Property Address — Joanne Robichaud Owner ..Owner's Name ------- --- -------�— _. . ------ information is Barnstable Ma _02630 11/3%15 required for every —.-- — = page. CftylTown State. ' Zip code. Date of Inspection D. System Information Description: The system contains a 1000 gallon tank as well as a concrete Distribution box.,All tees and baffles - are in place.The leaching is made up of several leaching chambers and at time of inspection levels appeared to never have been at abnormal levels. Number of current residents; Unoccupied Does residence have a garbage grinder? ❑ 'Yes E No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) El Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal.use? ❑ Yes ❑ No Water meter readin s, if available last 2. `ears usage d Approximately 29 9 ( Y 9 (gP ))� GPD Detail: _ ------------- - Sump pump? ❑ Yes ® No Last date of occupancy: pate . Commercial/Industrial Flow Conditions: r _ < Type of Establishment: --- --- ----- Design flow (based.on 31.0 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: — l5ins•3113 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 Salt Rock rd Property Address Joanne Robichaud Cwner Owner's Name ------- ----- ` — . - _ information is Barnstable Ma 02630 11/3/15 required for every --___ — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Unknown Date Other(describe below): j General Information Pumping Records: Source of information: None provided___ _ 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): 15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 • Commonwealth mmon ealth of Massachusetts Title 5 official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 183 Salt Rock rd R Property Address ------ ------ -------+-------------------_ --- --- --- Joanne Robichaud Owner ------- -----------------=-------------------- .-- ----�- Owner's Name information is Barnstable Ma 02630 11/3/15 required for every --__ _.._. _ __- page. CityrTown , State Zip Code Date ofJnspection D. System Information (cont.) Approximate age of all components, date instailed,(if known) and source of information: 16 years Were sewage odors detected when arriving at the site?. ❑ Yes ❑ No Building Sewer(locate on site plan): . Depth below grade: 28"feet ----------- Material of construction: 0 cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: fe--- -== -- ---=-------— ' et Comments (on condition of joints, venting, evidence of leakage, etc.): System its vented throught the roof_ Septic Tank (locate on site plan); .3 ft Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) _1000 gallon, —- 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: l51ns•3/1 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form . Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments c, 183 Salt Rock rd _ Property Address Joanne Robichaud Owner Owner's Name information is Barnstable Ma 02630 11/3/15 required for every —_— — page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) Septic Tank (cont.) 24" Distance from top of sludge to bottom of outlet tee or baffle ---- --- -- Scum thickness 3"----- --- --- --- 42" Distance from top of scum to top of outlet tee or baffle — . ---- Distance from bottom of scum to bottom of.outlet tee or baffle . 1" Sludge stick .How were dimensions determined? Tape Measure_ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of leaking Tees and or baffles in�lace at time of inspection_ Grease Trap (locate on site plan): Depth below grade- NA _-- —_ 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.'' . Title 5 Official Inspection -Fora Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 183 Salt Rock rd Property Address ------ - ---------- — --. ----- Joanne Robichaud Owner Owner's Name -- ---; ------- ------ --- information is Barnstable a Ma 02630 _ 11/3/15 required for every ---- - ---- -- - --- -- -- ---- page. Clty(Town State Zip Code 'Date of Inspection D. System Information-(cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle'condition, structural in liquid levels as related to'outlet invert, evidence of leakage,,etc.):..`- Tees are in place and levels are normal. 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:`. - - ----------- - Alarrrr in working order: ❑ Yes ❑ No Date of last pumping: --- -- -- =— - ---- Date Comments (condition of alarm and float switches, etc.): v Attach copy of current pumping contract(required). Is copy attached? ❑. Yes ❑, No (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts _ Title Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments , 183 Salt Rock rd Property Address — - Joanne Robichaud _ Owner Owner's Name information is Barnstable __ _ _ Ma _02630 11/3/15 required for 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 outlet invert At normal level 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.): Distribution Box is levei and at normal level with no signs of carryover or decay. Pump Chamber (locate'on site plan): Pumps in working order: ❑ Yes ❑ No` Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 Salt Rock rd s Property Address Joanne Robichaud Owner --- --------- ------ __.-= -- _ Owner's Name _ information is Barnstable _Ma 02630 11015 required for every _ _ ._- page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) ' Type: ❑ leaching pits number:' ----- 10x34x1.5 leaching chambers number: — ❑ leaching galleries number` - — ❑ leaching trenches number, length: - leaching fields number, dimensions:' = -= ❑ overflow cesspool number: --= El 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.): No signs of carry over and no signs of 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 15,ns•3/13 >. w Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 `. Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments 183 Salt Rock rd. Property Address — ------------------------- -- ---- Jbanne Robichaud ' Owned Own ersNa _ me :;. - =--. — --- — --. ------ t Irt�form,a ton is requi:redforevery Barnstable Ma _ 02630 11/3/.15 C.if(Town':. — — — — ---- State Zi e. Code a Date of Inspection Y P D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): No ssiqns of pondinq or hydraulic failure. i i 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.): x. F t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 ..::,f_:U;."',,�� �_F,h, 1 'S NAME c FkION NO \f x"� - - F, T5 £ xr- ✓ 1 s SFTXC TANK CAFA�CITY �' �'' m, T. I FACILE (tY ) �� �< �s�z -`�� r s:. *, r rt r t 1,74 4°4J�. t'� $4F"UsEi­11, 3 r4` F,. ..� 3 1!! ux a" j \/�. 1� k'hI' 3 'zf }y x z z YC A i 11 of ''yL."# <t�'`a"°r t -. ,yam. r j E '` '::r s � /� k z s t. - I M T ATE J s CG DA �� ( {Zm, .v�` •a' s^' :­77777h. Ss.77777 s.�4,s n ' ,n t �. .t 4 x v.} Pt s} My-yonalm � W ��R���x�1sta',nce�13.r6jw� tAl�i� t 5 s s ., � k 3yf1.1. � � ` s� c i Ym a�+�t �t J� p xFeet Y Ns � � Adjusted Groundwater Table and Bottom`o.'L ach1ng3Fac�l�ty1. 11 t wilt �;�°`o`r u?, s �s�f'v tss: s ? �` 5. e ¢ s E.:i "' s x tz a s.-d �'10 � z ��� ,y well's eusx �n � � ; f °va ``Watecuply We�l,and'Leactu�ng WRY-pFac�Ut w ­pwai. y ! G � Feet wn g ' �'ur'tlin 2eugqw,Q0 feet aF leacEung faciLMAMMty)g` i'i --------- n:_ ` " 1'1rkitltsl' k 4c�'illtia. r�9.rM,s�fc (Tf and+ Lvetlands e�sk y } d -� 3� /gvq-"M1�� i K F: l T'"P:�t 4'S F,ra.+.N�y s ,� v t v `nos. -v 7 (' � �tk � t f �t 0 lea:t ng act ry)J xF O F X <a �', %� q � k . a> z'.,Y�`p11 �CrCc''{£�,.Aq.ay+ ...�5 ?rA r c'�t.7 E-`'a"r"•s•'" '` 1.% t' ` '.k k �`r > , '�.� -t5 z .z x' r .�,a `� `iiii � sz;.. �x 'a�r7Ai1r D, 65 ? iiiii z ,a t :r 3 - .n �" �'r , 'a t .r,a,I" r t_ �h a s 3 t{�" Tp.. zx� a1 $ ;� �• -. 1-11 ^§-F,�.a l r ^,d''fd ° :. hf r Zt�i r f _: ; !t m ,,ta. t ,. 7 ',Y'Y x sv > z '3'�$: ^3` ,.4 F z s fr,Y ? _YY�t * A, M ,:a,•v �,-x ti 1 c r t' s r� �" � . " e ' �y'� L F� fx.z j4m�4e�? n'>dCc"`rt & '>d-- STY r'�S t :. g p 3 s ,x +. s� 5ri. Lzn "°K f L -fir <"'; ,>y. } q'z"k'f rhst ' z' trl nt e` ,a; ,« `St �fr� ,,,,�..�......_,,,, Ev t ,�^`','l.3 YN?^irF 3 t _,k e s{, s ,x ztP ,F4 s*t z, � t �.F a., a -; ;':.� k ii' J c �,' ��, TAX a P•m:'✓„ ,st .# h x "x; s� 4 x, _ P 4 :M x r _. t$W < dx. �+ks.a M !"'x),N ES � a s.�S,;_" ;r f r fir : ..#T - Ss �, ;'!" t '. K Y x,,,+cyvA:. 5`•r,.✓'a'rrj,.F r '', ''; � ,7 S- � ; ,i v. ri ,, ?. ANi .w �v. n 'i s. ' .,G ?, .� __ ",F�,�',K`M.I; x ,°'S 25� ', p2 a _. 3C f {. t s r' t r F ? �% °`". 7 s'{Y,. €_ J ` 44 :�r�c. i t#�> Y?' 5ra .,; , 3*4z"'ny3'tx 7":. ,. .. rub,.a k ,- .mg. -�s t IY�` P.ls x -2 tx -,` .: re 25 -'t��+� " x3 �s s3a a#'a s a x r _t'�, s`a ..§' x> j t't r a} �„i,` sp,.�FpE• 'F` "FY'� •rr. ,"gym` "zq&.�js k s'tysz � 5 �Y ;5 x: +� ,. y t5 # got PH! :} ll 4 w,,, z3 .r,.fix, , ' :',-�ulb�` r � '"c... 5.. �Y` c s' ar. < r ��' T�'as a .-.Ys > 1. hr r 2" z ."s`' z 3 .. t''tn5 .k- P xY,.. �'a r�xFh.`rm' d'z .r;,, dr sfiH {::s,: ,.,afif` A. P 'a i Ss i � •`x,� c > 7. ��'� 7 -'S. ,rtJ i ,, z '''` z-'�aJ> `xs"'•r a4''e -'x n .d z's,� "'$ y t _ } s :.t11 y �,kA s 4 �,;* _� z'yN{? s r�i x"1a rs` I''..,3- 7P' `' i' '.t4x. rx`p".:f v u. { xy%c ,r. '' - St a t i Y, s.e sy �a # s ,ram u.y tar rv.{�,.' s r�'sia'z^ie �#z.� i *t- .rt .x. ` v '„n' s '*�s r F• .`•,'e .u.,-1-,a .p 3`k Y!'- .z �. ?''�Jam^ s e r z' z :K * :rr 't s r z rAr: - r t S "i c ,i P.. •' '.ye f ®r 1 rE ''vil „ 'E�.'�_:y ✓..yT*ss;+.,r' r§ fwf > 6� ..,xn `'` a.t. y:s f 'a A ' a�'6.e .e f > ty}.. vie rR Y:. IV N £S y.,_ L t xt k R-`h /,Ag'1 L t Alt/` b ,.:$ �S f I vY i e Y-:Y '� i 't C.. £' . ,�,'`: n d nth., �`�, ":e a 3 �,a+ s,r s v' sm si,sr aC. S ?''*m - +. .� �. Y'?; 11 t "%i7 s�'k .,t '}.5,. ,'J£. x' "A�`' t e r v z`.) y ,f Z 3 E« ',.` i w 4 >'.8> P -x '� s 111 t9 I f 'nrr Sa efA� - �r -s UK,Y rya 4� YC 13..xs Y 3� l', &• s SI �, t fP s x.Yes -:.y -+ qK Y $ t i n ! u * 3 ?s F r �. w "s T _ s I "�5't :A^r` ,•`t x , e,3'n� -. 4 ::x rm a s s v - s sr°z' �, a a> E ti i ma` s �o,Sa y ��� `� �n t x"; 'd X.Y t*7. tt .a' 3 E s' I tlz­ b �x 3 C as r: s<�' S a rs 2 ,a1'x.^ 3xk,`t `� s Y 5 2s ` � a 3 r '`., 5 a Y a y: 3 ar`?.r! .i. r v 4�G 3 E ,s."Z' a s •sz x ` y g A x a£'-zs r *, " '` '�'`'� r '3 fz^ .,.� %r'``A7 3 �ua " ��v i s,r ,_5a a.a,�,, t,ti z§fi�5 x'1 t »:F�g€ .r y. d '� '� s '.. y 'r --`,,, ", 11`", xfi,,g„:x 'v; 1 "f 1' �,'. •,b t ,� d 3 > :,;z ,�, i�.'8^ ys. f q r I u .. '� L u. ,�' :r ,11 s R� 3 . vrz ' I - '� 1 ",rx�g -`' .nS,`'m¢y,"`, �1s f F rtF 7- R i z. ,°s s,...,a� 5 _ ^Yt i �&+ eR ,v` ;;`, r r r ( ; r J §w e�ps a�f tr: ,'ref � n�` ':a MW - t.7{x,as-sx Ra4' @�tT+`Ny# a 'T+'s �v .x "y`t a r s ti +. §r :' ,s 9 =3' $;�, E, H.._1.� a'`v''� `; <' y,.vM 9 .,,;i.� 'z s P: a".zu. _vz,As' �yw' "^ PS p u ,n ,v^� :.Yr^,.�A b i%f dm fv,Srt, "z:n..r`3`�' st>fx n.i F" _R t ... xs„"x"n`F�t � :s �t,c , �.y �r a k..{ � .sx x s?. :,Y * ,� s fit• 3xS :S x x '__ m d 7 r 1 £ -V ?.� �.. 'tt9 � §;F'}p *€i �tsy�b -r y shs,' '" r°? ? _"€ a a K Y$'z s' s `� <"vt, ' f ; f .y:n .y€ t'3,%` s¢r t -,;s f t s r ^`'E"_rmP�,, a s �„r X Et `',.,a, * >, •.A >Y R �' r ,i"` m. ..., >� � r. '�! x.r.:t. S,x,�_ as vt. -gg�.4 ' #*g 3-,� ri; :k vE�',$ •mn`` 'z.. 'r3. >, ri k }.vak 1 S - �s.✓N ?.*" r«�5.,�$, .1 s :.: x.e } -a $r , gr .;, ex k a>zsd wa "�r z :xr ''rc_a T' f x Y 'z ,„yx ".",, , r -t . I .,..s'"�.a` `C.'a 4 rt ` - by4 :..ry r s1`I'l"fi' .,e..s 'm Yr .3 Y t..p, ? x zr t tit •4-_: $ E':€y �4 s} 3 '? a.: , .; r -+ €3 �9 `f. 4S1 'zsr,kt q r arl. Cv r .. x u z •t i' g -..<^•n ;;7 m?... f.: r€� -;' 'n,a �i' ,, d w 5y 2,r' Lv '"3 f'Sk .,5. x, �:, i '^-.y: �' 5 w'F A c - as II z.x r.. �€ -x -i �,4 a'Y :? i -" -- "sl 3a�. •„ i v er* €. z ,an>'I ,t fi ,Ul r,� 4^ �. �, �y > 1 . tR .,ry �} > `7 "' sJ i--- �. Psr .y Y ."` ''� �r���16 r,".I f�'+ iL,r am ,,,f1€ 7� ,- t'� ` t: q ' r {''"� t' ,z 3 '' k.., 11 k.dt f L r*Z�' �v i'^q ) S.M ., "x` ,_. �.�?.'aa� r �,• �'�rvyt '� Y3 � x 't•.J , ,,�'' to g rt� {'k.,rt T^rt i6 5 .S R ?^' ,�� 5 4 C # 5 �fl ..i' .� r' y v 4 •r' F,� `�i�z +^, € ry�,q Y F x x g�, S x3a yr 3:� y ,.r a �„ _ .,'k 4r �,s `a ' f 1 ,a I p.f J Y :�bk 3f Y s�' \, } S.L .G �.Kak^i +e.,^ ';Y ✓fs w:;. s"3 5�xxd "X.p a Y�°`r^I ..2xs £ rk5'3 s 1 �3+ti-'fi .`' 4 .,� F ss Xe, "+5 Li ��;-`.,ts :.g $•` :a' g�.;/ '1_1.JyJ1 '�.`�- 3a _ y a. .t 'vs fi -°r'n' '4 ..fe^ Xiz: s rY" -:x h fix•e �s .._ .P f '; s '" O v',k4'ra+.y p' Yryt'{"`� 5 °. x.i t� 1 t t( .A i +r' 4 v .f F� r ..�S 3F S. �:.z v,.,. a 4- `k'y.: Ilt � ss u F f t�`w'•L 4 1�6IT�s d W p-- W r Eet Y t f }4 4, -3e s a 5f '� ,.ax:: i§L 4•y.7d 3't a".r,` a }ga%Ii � � < :aY cs'.. ""#' ,: .3 , -az v x s 5. s sx r rm s' a "°Rr;_ `k"i r Jsac r, i.�,._� (/ r, _ ;e z , :FS lsb, � Iri :k U�;x 52r T �l a ,��,: ''•,e } '�Si„ a"' �.i Fs 9s,cs y b,.�t.�'f4 i �'' h$+'r S:. :. e .ors�r:f .. �+y�., y.rs_ 2:. 4 ^y -�.. "srf, ; s °'"iM ,' ,' .•` t ; � 3���s-.,..V x sS .�` �' sa r^ f 4s�.r a �, x i .� ,x:. -ra a€' ?s�¢ f --x� ! K x E t a :. q ,.. Ys ,;, ra ,...s5'^,<, ::'. v 4 N a F 'fF ., t �iE 4 x z,e 5 s ' r ,z.s r' y:. � �"... 4 s€ :. ,1�'.." �, ,e +t t§s%rx, �z tF l r .� r .+. �� -i• aa+ *i ^ E.t°--' a dr JX<4 'a E.'! 'b' ` 9 y,.a`z r 2 k s �n ti,i "'--w, . � s'$ s T�i � � Y� >�.isI't`a',zv 1 P i i r 1 e s 3 „ z, ss f. a § 9. 4 2 tm c P Key., ,� ,.£ t4 f ,.! .� t P `° ,' > _..�Ya' `:C. 4 kI r hk �.: ;t v § x y ?.' t -' °' 'r`,',� 4 -,: I" t•a"', �°a z�^ :r�-,.'? ""s�S ""-get a r.`sr3Y s..zr, ntr'. � t r;•"'" :: <H. .�' c� 'p;trk v'e . ';,-fE a :fit £k`r 5 mY .Yb RA- �y z"3 * xa } 73° ! .a r of '' z St h z1 s t,..a is tg :n� -& .¢. s.s v : T. #i9�� `E s 3 t a s; R�` t 7. 7» "' {�'� :T t�{ _<�� I �' ' •,�w" Ptc .S'x 1 s;v-x ", 1 r:xIa h `: <4. 3 c, ,5 „,Y,, y..., -, 2 ` ��• ��' s� s...s° xs zx t ,, y a Y t"f: mph.. s4.t�'r"'t• M ,C s y'"- ;?- eli r<d. n e 4s '��< ..=Y ra,ri., v .>',h 'If,r�'x2 t tarfq^?ca+' 'x � n � 'i 3 ,��^• sv- .f r'S..F+ a t•`F -'t '� + s '? :Yx' .. - d,:. .-'!. ldr'°!' fir' ' t i e ._` f ,` ' ✓ 4� ,`,,.Fa;. v'u+'"�€^` 3,U? ?i -v r t� �, �.. �:, , f0ly I. dry. a r a k'� _ls s "T ? l,>. t F 5x -•^ '� st €'''i el, �, r 3 g 7.:: t °''" T -'.r .t e' 3., k. Mt' >: by?fL E IX h k q �s,(- ' "'� �"�'by s7tiv r� ��?� �`�'yu�?..e"� ;�'d# r>F.1 � ,�.•sr'��€ Arm �1€ �� ate 9 r ti i - qx ;6A°�°R yiF'.N i ups�t,�•'"' a �* t{ � . gi. .b�-; �*0` ,4 ���3` ���5ss�%yi2 �`i lx'�;YB^. 4 �'r4 � "Ts «$'ti�.E ., v>n. J r is s'- r d ti• H.v 5tt a.>x,x' it : . N Commonwealth of Massachusetts u Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments 183 Salt Rock rd Property Address Joanne Robichaud _ Owner — — -- --------------_ ------------- ----- -------- Owner's Name information is Barnstable Ma 02630 11/3/15 required for every — page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks.-Locate all wells within 100 feet. Locate where public.water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ®;!-drawing attached separately ' f . t5,ns 3/13 - - - Tille 5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 15 of 17 - i Commonwealth of Massachusetts Title 5 official Inspection Form (: — 8 Subsurface Sewage Disposal_System Form - Not for Voluntary Assessments 183 Salt Rock rd Property Address Joanne Robichaud Owner Owner's Name --------------- ---._..-- —__.--- information is Barnstable Ma 02630 11/3/15 required for 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: 10 + ft 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: 12/4/99 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 on plan dated 12/4/99 indicates NGE at 128 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 a=, Title 5 Official Inspection 'Form �P,(= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 183 Salt Rock rd. Property Address ------ — —.-----'--- Joanne Robichaud Owner Owner's Name —-- —-- ----- ------—=----- " - - — --- information is Barnstable Ma `02630 11/3/15. . required for every —_— _—_ — — page. City/Town 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 orattached.in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 S� 3 _ a f j r � j; N 5 3 �J f 1 7� 5 a ' 1. s J` Qv SAWN RAW- fly OUT go "blot No to�c - � t 1 lot 6 10 °= 3 4 C S As Aa d C i MAI MINE ME ZEE its v { S s� y Z Y L / Y { r f 1 j a S y £ 1 4 i L �M y TOWN OF BARNSTABLE P LOCATION P, S SEWAGE # gy " r VILLAGE Z ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. �" "L�•f SEPTIC TANK CAPACITY c'v © Y t LEACHING FACILITY: (type) 1� C'�siz�- NO.OF BEDROOMS 3 BUILDER OR OWNER S PERMITDATE: COMPLIANCE DATE: 4L11LZ i 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 TOWN OF BARNSTABLE 6L-- t LOCATION 192 J a 1 k SEWAGE # " VILLAGE 6tn4tii�� ASSESSOR'S MAP & LOT V-3/- -O , INSTALLER'S NAME&PHONE NO. !"L SEPTIC TANK CAPACITY v �' LEACHING FACILITY: (type) il!: si NO.OF BEDROOMS BUILDER OR OWNER S V PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility :Sd 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 ,�l within 300 feet of leaching facility) G - Feet Furnished by .y �, �, �� � _ �. N_ _.� �. -� - �. � � + r , � �� _ .._) � � �,� ��' ;� �� t`. `� ����� r � �� � � FeeC/. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS � Zippfication for 0i0po5al *p5tem Cougtruction permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No.jG 5 -t � Owner's Name,Address and Tel.No. Asse>'sor's Ma� -j U. 7 Uli Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. j-0 MC-L41A Type of Building: S C Dwelling No.of Bedrooms J Lot Size ! 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. UX 3 - 2- Description of Soil Nature of Repairs or Alterations(Answer when applic L Nth :� t- 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 t 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued thi Bo d of a Signed = Date Application Approved by Date Application Disapproved for the following reasons Permit No. `��" �✓ 1� Date Issued Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLES MASSACHUSETTS Ye✓ ZIpprication for 30iopogaY *peum Construction 13ermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.Ig - Owner's Name,Address and Tel.No. Asses'or's Map/Parcel t4� Installer's Name,Address,and Tel.No. � �'�• Designer's Name,Address and Tel.No. 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /God Type of S.A.S. /OX 3,� t_)( /. Z Description of Soil _ 1 y .,r Nature of Repairs or Alterations(Answer-when applic 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 i`f1 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued this B d of alt q Signed Date /�' C� / Application Approved by a. Date Application Disapproved for the following reasons Permit No. Date Issued Z 3 ------------------------------------ ---- THE COMMONWEALTH OF MASSACHUSETTS 3 f G —0 0 BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT IEY A at the On-site Sewage Disposal System Constructed( )Repaired (�' )Upgraded( ) Abandoned( )by rM at I S G- 1- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. !9 /— ? —dated- 12 —1`9 7 Installer ► f Designer h !t V The issuance of this permit-shall-pot/bye stern /Gonstrued as a guarantee that the -will function as/design/', Date � /K I �I Inspector A �� d • �'' --------------------------------------- s� No. 's Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Oigogal *potem Conotruction Permit Permission is hereby granted to Construct( )Repair(k)Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes 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 e t. Date: Z / ( Approved by 1/6i99 NOTICE:.,This Farm Is To Be Used For the Repair, Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) hereby certify that the application.for disposal works construction permit sizned by me dated jo - L(- concernins the property located at �g 5 ,t�'�Cf�L . �a.�,�� meets all of the f0owins criteria: • The failed system is conner ed to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch_ • There are no wetlands within 100 feet of the proposed seutic system • 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 • The bottom of the proposed leaching facility will not be located less than five feet above the ma..dmum adjusted groundwater table elevauon. (Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S. will be located with 250 feet of anv vegetated wetlands, the bottom of the proposed leaching facility will not be located less than founeen(14) feet above the ma:-dmu.m adjusted groundwater table e!evatiorL Please complete the following: A) Too of Ground Surface Elevation(using GIS information) 7�' B) G.W. Elevation -the Fligh G.W. Adjustment .' �S DT E-RENCE BETWEEN a,and B �y SIGNED : GI/v1ic�:s �--'" 1)ATE. -1 L (Sketch proposed p an of system on bac!cJ. a:!czkh,alder,c-t Aw Y G „ p t � 4 I N CP ` Ln t- U, 01 Ul tp N - N I� V1 �N W I� (� U, is l 0 'T i tp N� o 0 cp Uri J U Ul 1 i �rn f i N IT\ N m o ' I < LID m rb Li N I� �w s L. o - -� N N fJD N . L z8�Z 25 sz. Gj j T� i p � cp TO 0 Ir s -Tj -v J ! Icp II r i� T , - L 5N1�61 L�' ,� ►v� z' x TO \ X �v SILL C T J LC� o � E3 TH-1 CON ,--- -___ ----- - Po u/?-ei) 7 0s �1C