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0085 STONEHEDGE DRIVE - Health
85 Stonehedge Drive, Barnstable . A= 317 - 060 f i i a ' } a E e N d I { r Commonwealth of Massachusetts u W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Stonehedge Drive Property Address Barbara Booth Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms.may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Robert Paolini , cursor-do not Name of Inspector use the return key. Capewide Enterprises,LLC Company Name rQ P.O.Box 763 Company Address L Centerville Ma. 02632 City/Town State Zip Code (508)428-4028 . Telephone Number License Number B. Certifications F= r I certify that I have personally inspected the sewage disposal system at this address and thaf 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 onsite sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340�6f Title 5 (31.0 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evalua ' n by t1m Local Approving Authority Lao-;' - (� 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. 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M a 85 Stonehedge Drive Property Address Barbara Booth Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 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 proper working order at the present time. IB) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the�Board of Health,will pass. Answer yes, no or not determined (Y, N, ND)in the ❑for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank.(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank 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. ND Explain: ❑ 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 ❑ obstruction is removed 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Stonehedge Drive Property Address Barbara Booth Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than.4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced _w ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, J 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. 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M e'' 85 Stonehedge Drive Property Address Barbara Booth I Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has 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: t **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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow. ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: 1 ❑ ® 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. 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 85 Stonehedge Drive Property Address Barbara Booth Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal 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 a. regional office of the Department.. 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15 ' Commonwealth of Massachusetts 1 ' W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 85 Stonehedge Drive Property Address "Barbara Booth Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 every page. City/Town l 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: l 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 ® El 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. ® 0 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)] % 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 ' Commonwealth of Massachusetts W Title. 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Stonehedge Drive Property Address Barbara Booth Owner Owner's Name information is required for Barnstable Ma:, 02630 4/11/2007 every page. City/Town State Zip Code Date of Inspection I 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 Number of current residents: 3 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 ® No Water meter readings, if available last 2 ears usage (gpd)): unavailable . 9 ( Y 9 Sump pump? ❑ Yes ❑ No Last date of occupancy: Date 007 -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: Last date of occupancy/use: Date Other(describe): 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 ,? ' Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 85 Stonehedge Drive , Property Address Barbara Booth Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 � every page. City/Town State _ Zip Code Date of Inspection D. System Information (cont.) General Information Pumping-Records: Source of information: Capewide Enterprises Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Pumped tank 2 weeks prior to inspection. 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) El maintenance technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank..Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: - 20 years +- Were sewage odors detected when arriving at the site? ❑ Yes ® No 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage,Disposal System•Page 8 of 15 Commonwealth of Massachusetts ' - Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments ,M 85 Stonehedge Drive Property Address Barbara Booth Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 every page. City/Town State Zip Code Date of Inspection r y D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 14"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 101+ 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): 2 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑)polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑. No -� -------------------------------------------------------------------------------------------------------------------------- Dimensions: 8'6"x4'10"x5'7" Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness 0 Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle 1 How were dimensions determined? visual 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Stonehedge Drive Property Address Barbara Booth Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 „...r, ^' 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.): Pump tank every 2-3 years.lnlet and outlet tees are in place.Tank appears structurally sound.No evidence of leakage. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: l ❑ 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 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): 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 i I - Commonwealth of Massachusetts W Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M 85 Stonehedge Drive Property Address Barbara Booth Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons 1 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 Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-Box not present. Pump Chamber(locate on site plan): Pumps in working order: 0 Yes ❑ No Alarms in working order: ❑ Yes ❑ No 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 r t Commonwealth of Massachusetts Title 5 Official 'Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 85 Stonehedge Drive Property Address Barbara Booth 1 Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) < µ. 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: c Type ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology, Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): r Sandy soil.No evidence of hydraulic failure.New pit piped off old pit.Old pit full. New pit water to invert was 20" at time of inspection. 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 85 Stonehedge Drive ° . Property Address Barbara Booth Owner 'Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow, ❑ Yes ❑ No 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.): 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 1 . Commonwealth of Massachusetts w W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 85 Stonehedge1Drive Property Address Barbara Booth Owner Owner's Name information is Barnstable Ma. 02630 4/11/2007 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. i O 85 stonehedge dr.•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 t Commonwealth of Massachusetts Title 5 Official Inspection Form _ - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 85 Stonehedge Drive Property Address Barbara Booth Owner Owner's Name information is required for Barnstable Ma. 02630 4/11/2007 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 ground water: 20 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ❑ 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: Used:gaherty& Miller Model 12/16/94-ground water elevations.Used:USGS Observation well data June 1992.Used:Technical Bulletion 92-000-01 Plate#2 annual ranges of ground water elevations. 85 stonehedge dr.-08/06 Title 5 Official Inspection Form:Subsurface Sewage:Disposal System-Page 15 of 15 G a TOWN OF BARNSTABLE. 0 LOCATION SEWAGE # VILLAGE ASSESSOR' & LO .a�NSF,tCM 4'NAME&PHONE NO. �l p , SEPTIC TANK CAPACITY l LEACHING FACILITY: (type) (size) NO.OF BEDROO BUILDER 0 OWNE PERMIT DATE: CZP1 IANCE 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 `9" —� s f C?9�, � � �� �I J /�/�� N� �'.. s. c�j_ �j� � � i I GARAGE "' to,M1 9 DECK i A---1 PATIO �1x21 �17c�1 �MaUw,M (y�OGt'u'C°1�� ''�~ � �,����•�� Nna�1 i wc+rr`tJCa:�/ . jt �-�-rF�. ° � yr• 1�+cn�n'd i PATIO WX77) n l POOL �► r 1 � tb _ 100 d I coo .- 96 011Vd p° OliVd �f ►?/O V Ao X-a G -t-. PLAN 33� 4V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpplitation for Misposal *pstrm Construction Permit Application for a Permit to Construct( ) Repair(d) Upgrade(V Abandon( ) 4atornplete System ❑Individual Components Location Address or Lot No. 8 r, a F p f"Ve Owner's Name,Address,and Tel.No. Assessor's Map/Parcel a 11 he, N via I ( Installe`'s Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. k +�r'S r XcavG a do— - ccO, n f SAS 602 /S�j Type of Building: at), Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(/ i Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) S�� gpd Design flow provided gpd Plan Date lP;,'1 q j f-) Number of sheets i Revision Date Title Size of Septic Tank /Sim Type of S.A.S. o Ct+^�f r+_C,kt ., Description of Soil L�&- S;I}/tcac.r. �M��O� (' Nature of Repairs or Alterations(Answer when applicable) i Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B f lth. II Sig ed Date U f�V Application Approved by Date l Application Disapproved by Date for the following reasons Permit No. 3a 1'7-0 7t Date Issued `a� No. � ?--a? � t Fee „r Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS - PUBLIC HEALTH DIVISION'= TT N OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for Misposaf &- pstrut Construction Permit Application for a Permit to Construct Repair �� I�?_rade; Abandon om lete System Individual Components PP ( ) p ( ) pg (� ( ) P Y p " Location Address or Lot No. 8 1 Ve- Owner's Name,Address,and Tel.No. Assessor'sMap/Parcel 3y-) 71.6 &r"S�ble DG."iA iCCcrC -1 L] Installl/err's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. UCt�:�rs �YCCVCJwl -11 R _-1'A dowr\ Cr Q7 Cnz;ne ( ;n Type of Building: Dwelling No.of Bedrooms Lot Size t3;"j j sq.ft. Garbage Grinder(Alo6 F Other Type of Building �"I AA G k A II J No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) S jj gpd Design flow provided <1C 6 gpd Plan Date 0 Z 14 j 0 Number of sheets l Revision Date Title Size of Septic Tank Type of S.A.S. � w 4l A26 dC er's Description of Soil Lp_th/<<S 4;1 }!t c. Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. 7 Signed~� ,�� ' �.;- Date Application Approved by `� _� �� Datee Application Disapproved by Date for the following reasons Permit No. c��-1�l- -f 7�-{ Date Issued �` <': l f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( v)� . Abandoned( )by f'�� 1 V1 /C��� �?� S �Y • ' ( Lt •, at t`f Y has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No O/7 c%y dated (� i Installer !,,,i I E r\yl X&I�����1)/1 Designer h_i Al f/1 l� i ()A�,�e Wk NNI "k-\ ,w.. _ J._ r #bedrooms Approved design flow", ( gpd The issuance of th's permit shall not be construed as a guarantee that the system w�function as des'gned. Date { Inspector ` � , I No. kl l:� Q2 LI Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade(�r)� Abandon( ) System located at. _�j J and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. , Provided:Construction must be completed within three years of the date of this/permit. Date �'�2:: / Approve y ��—�, 1 TOWN OF BARNSTABLE _LOCATION 86� Sl onehe ck p SEWAGE# /��C`7y VILLAGE ASSESSOR'S MAP&PARCEL 3/7 �(O� INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) SDO as I ttV cl,nbe(c (size) y2)e J;•8,? NO.OF BEDROOMS S OWNER-bow A k;CoXcli/ PERMIT DATE: a/�//-) COMPLIANCE DATE: 7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility ='Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and hing Facility y wetlands exist within 300 feet of le n acility) Feet FURNISHED B g(�3NL jka= i J.q t A3:23•9 AH=.9710 6q= 344V R s=5-1 �s_3y-g '"=y8.6 4*7` 31 Pr0=i-toa), (38`3`.,3 38 3 �J L v 7- 4A 67'oA,,E H�F f��SrA�GE 6�� 4,F.2 ) USE roil mo ,diZ o s .-Xia/c U A'49E4 ) /!jA c A9,E,6 '4 5 S U 7- � _ ono C / r loa° Sromc PgcrfQ 5 0 �I 3S C 2' ,Ofz i u No... ......... ........... THE COMMONWEALTH OF MASSACHUSETTS, BOARD H�EL ...................iOF........ ......................... Apphration Ur M' ' sat Works Tanstrurtion Prrutit Application is hereby made for Perrni to Construct or Repair an Individual Sewage Disposal it 'noyst t ................. ..... fa on- ress- # 1. .77 �dC i �o4 No. .......... .. . . . 1.: ... ... .... ............................................ . er Address ........................... 4a..... ta"Ier —V........................... ............................................. .Address................. Type of Bulldilj& Size Lot............................Sq. feet U Dwelling NO. of Bedrooms............. .....................Expansion Attic Garbage Grinder 4 P-4 Other—Type of Building ............................ No. of persons-........................... Showers Cafeteria 1:14 Other fixtures .................................................................................................................. ........ v................... 4i W Design Flow__ .......................:-372P..,,,,gallons per person per day. Total daily flow..............Z... -------gallons. P4 Septic Tank t Liquid capacity/pOlk"allons Length................ Width ---- Diameter___.____________ Depth.___._._......_. Disposal Trench—,No..................... Widtl .... ....... 1alL th. . Total leaching area....................sq. f t. .. ...... -iingarea. en Seepage Pit No----1�------I-------- Diameter..-. Dep 01 �e�......C.p.... Total leaching sj. ft. --- le til Other Distribution box D?os i g Percolation Test Results Performed by.......ilkvj Date-------------.......................... Test Pit No. I................minutes per inch Depth of Test Pit.._....._.____._.___ Depth to ground water___-___-__________-_-_ Test Pit No. 2................minutes per inch Depth of Test Pit.__.__.__._.__.__... Depth to ground water._.._....__._._..______. .............. -------- ----------------------------------------------------------------------------------------------------------- 0 Description of Soil.......!=r::........... ------------------------------------- -------4-------------------------------------------------------- �4 U ......................................................................................................................................................................................................... ........................................................................................................................................................................................................ U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------........................ .......... ............................................................................................................................................................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is el e ar of health. igned ----------- ............ Date ........................................ Application Approved By...... U,44, --------- Date . .................... Application Disapproved for the following reasons:................... ...... 7 -------------------*...........*....**... .....................................................m................................................................................................. ................................................ Date Permit No......................................................... Issued.. .. ................. X ------------------------------------------------------------------------------------------------------------------------------- 3 �I No. ......... Fx$.. ��::..... THE COMMONWEALTH OF MASSACHUSETTS n BOARD 9F HEALT �. ,f 7 .... . ..... OF.........t �4 � c .................. Applirativit for :43hiposal Workii Toutitrur#iott Vinmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal system paKit .................. 1. .. r sLn• 1� d yaeN M ......„..§ .t .�_ o . .0...n.......................... —• a er ddress ...... ........................ ....................................... .. .............................................•..... alley Address Q Type of BuildinLT Size Lot............................Sq. feet U�-, Dwelling No. of Bedrooms.............. ". ............._...__..Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------................... Showers ( ) — Cafeteria ( ) Otherfixtures •. ---- •--•----•••--••-••................ •-•------••---•-•--- ................................................. �f , Design Flow.................... : e,�' _.gallons per person per day. Total daily flow............. �--____-_-___gallons. WSeptic Tank 4 Liquid capacity/4teAk>lloi>s. Length................ Width_____ ... Diameter------------------ Depth................ x Disposal Trench—l�To...::......... .... Width x s otal L th ...._._ Total leaching area...................sq. ft. Seepage Pit No .:.....:..... Diameter_ /� ..__ 'D e o et ....... Total leaching area—,'i."_�s ft. Z Other Distribution boy: ( ) Dosing tank - } Percolation Test Results _ ..... Date...................................... . W .Performed by-- °p t -- -- . Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-------------:__:______- f14 . Test Pit No. 2................minutes per inch Depth of Test Pit......................Depth to ground water-_______.__..._---...... a' •••. -----------------------------------------•-----•------•--------------------•---------------------- Description of Soil........:, ...............� ;H, a ........: c) .``. --•- --------------•----•-•--•-••••••----------------••••-••••••------•----•-•-----••-••-•-•••---•-••--•••- W . UNature of Repairs or Alterations--Answer when applicable.................................................. _.______.._.................... •---•-------------------------•--------------•----••••.....----•--•-------...__._...............••-•--------•------------------- --- -------------- .................................................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article X.I of tl�e State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been is ed ,�,`; t e ar f healtl�l "i . igned ��..... 'Date ApplicatNon Approved BY ...... - Date. Application Disapproved for the following reasons:-------------- .................. ----•--------•------•-•----••--•---...........--•-•-••••.......--•........... --....---•--------•----------••--••--•-•-------•----•............................•.•••- Date Permit ............................................ ;, Issued.................................... Date - ;:`.,fig•:, THE COMMONWEALTH OF MASSACHUSETTS BOARD OF- HEALTH .. 19. f�riirp ,afaa�tItttrp T ERTIFY t the.Indivviidual Sewage Disposal System constructed I; or Repaired ( ) b }^ -PfArti�le Met `- , � has been installed in accordance with the rowXs ions of 1he State Sa.nitar C de as described in the PY application-:for Disposal Works°.Construction Permit No_________ ____ _1_........._._....... dated__.__. . ...`.._3.-"_7_ ._...... r ? " THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY, DATE................................................................................. Inspector--t.....•.._.......................----------•------.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH OF........ '� Y' ............ .. •- No....1 ... ......... . . .......... '. FEE.. ..:. ......... it Vrrmit Permission :is reby granted..s....1''�r . :_. - - 4 ...�'""'......................................................... to Constr ct �,orq e air ( ) an li All gav�e Di,posal Systat N ~Stree ,� / . ,as shown on the application for Disposal «Vorks:.Construction Pei ipn' No.�: y..._�" Dated....1. •-:-f- :. : . of Health DATE •--• •• --`--- -------- -----'------ FORM 1255 HOBBS & WARREN. INC.. PUSLISHERS / '��M '� /► (( I 'own of Barnstable P Department of Health,Safety,and Environmental Services � %. Public Health Division Date117 3.67 Main Street,Hyannis MA 02601$ �y� Y M>gAaTtBi jj� • '.. rn �1 Date Scheduled Time L hr- Fee Pd. T w.9 Soil Suitability Assessment for Sew e I)'sp�sat r„}ry +" .o Performed By: Re5,0q.. tf¢�.;,s�'(,f,is � Witnessed By: isd}%�ist''!isi'r' Et:;iE<:ii;;;i(:iiSii?:i?'r'';: ?<:'::i:.:..;•;`;•:::.:..,;.,::•:•s:'s'•'i:;::::..:.:..::.:::.::..,;..y,,, ...,:,:::,:;:•:.•:::;:.;y:;;.,:.::.,...•.�:;::.;rs::::::::::<:::::iS:ii:xi<:;::rf:r:'s3di$i:ii:ifi2'• � . :...F... Location Address S leh C J„e y Owner's Nome ►' Address Assessor's Map/Parcel: I / En incer's Name lb0 4 �. NEW CONSTRUCTION /I REPAIR Telephone# 08 c�6ol ` �J Land Use . N� Slopes(%) 6 "` Surface Stones Wfj1` " Distances from: Open Watcr Body R Possible Wet Area 3W+ It Drinking Water Well ('R Drainage Way + It Property Line (t . Other Q SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locale wetlands in proximity to holes) a , Parent material(geologic) t ��;` sfit> Depth to Bedrocktf,: Depth to Groundwater: Standing Water In hole:- k Weeping from Pit Pace Estimated Seasonal High Groundwater Method Used: Depth Observed standing-in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment Index Well H_ _ -Reading Date: ; Index Well level._-- Adj.factor Adj.Groundwater Level {i�i;ii'# '�;:? �:i!#>i>,' i`2ii5<%Si:t•,•.:::'•iii: i<� ii:::i::<ifi:?: � a Observation �) Hole 9 Time at 9" .- Depth of Perc J I g?_ Time at 6" k Start Pre-soak Time© Time(9"-6") End Pre-soak Rate Min./inch Site Suitability Assessment: Site Passed Site railed: Additional Testing Needed(Y/N) _ Original: Public Health Division Observation Hole Data To Be Completed on Back Copy: Applicant ..... ........... ............... ... ........... C Depth from Soil IIorizon Soil Texture 1 00 Color 1 soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. lisislona.,%Gravel) JOZ loll VIA G . -ro ........... ........ .. ... .. .. . ... .............. ....... . ........ .................. ............ ....... .. ..... .. .......... up W Soil Color Soil 8oil 7citurc Other .. ........ . .... Depth from soil Horizon Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. 7. Depth from" ........ ... Soil Horizon '§oj1 Color Soil Texture Soil Gtlter Surface(in.) (JSDA) (Munsoll) Mottling (Structure,Stones,Boulderes. of i i r 0/.Graypl) ......... L.. ........41:111 ............ Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes, Consistency,1%Gravel) Flood Insurance Rate Map-, Above 500 year flood boundary No— yes Within 500 year boundary No X, Yes Within 100 year flood boundary No Yes Depth O[Ngtura11yQ99jjL Does at least four feet of naturally occurring pery oLL. material exist in all areas observed throughout the area proposed for the soil absorption System? If not,what is the depth of naturally occurring pervious material? Certification I certify that on (date)I have passed the soil evaluator examination approved by the Department of Environtbental Protection and that the above analysis was performed by me consistent with the required trai ing,expertise and experience described in 310 CMR 15.017. Date Signature -.0 4 5 Town ®f Barnstable Regulatory Services Thomas F. Geiler,Director Public Health Division ApE01NA'�69 'Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer&Desigger Certification Forma Dater 1 Sewage Pergnit#,c�0i7-07'g Assessor's Map\Parcel Designer: �0 W, Q `q I i'a*i Installer: wi ✓1►✓W Address: Address: gag ,'Lcl i5,i - Gt�✓Hilo ]' ��S�22 /%��— 0 i���"� On was issued a permit to install a (date) (installer) '1 septic system at � based on a design drawn by (address Gc h► 4, o-14 fE 0 LJ dated I �7 We-signer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I' certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or c ifled as-b ' by designer to follow. --� M10F PAgs�c DANIEL A. o OJAUA (Installer's Signature) civil_ N No.46502 •�J+ :� -� D��S ANAL ��rF,� (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form 3-26-04.doc f FAX Ae Ertvtronmentat PO BOX 929 NORTHBORO, MA 01532 greg@aerotecasbestosremoval.com PHONE: 978-375-9534 FAX: 508-393-3365' ----------------—--------------------------- -- ------------------- - --------------- ATTN: BOH -Fax : 508-.790-6304 FROM: Greg Harding DATE: 1/17/2017 PAGES: 4 RE: Asbestos Abatement -. a6ed 99£££66809 nloJay Wd 69.'ti0 L lOZ L6 `uer Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) looassos> -, Asbestos Project# ! Asbestos Notification Form l- Project Revision r Project Cancellation A. Asbestos Abatement Description 1.Facility Location: HOUSE 8581C}N9�DGE IUD Instructions f.All a ity b.Street Address sections of this form BARNSTABLE must be oomplaW in MA 02532 7742801642 order to comply with rtYlrown d.Stale ®.Le. f Telephone NlassDEP notification requirements of 310 DAVID RICARDI OVVNE 2' ' CMR 7.15 and• g•Facility Contact Person Name h.Faality Contact Person Title Department of Labor Worksite Location: BATI-IRDpp/I Standards(BLS) notification i.Building Nme.Wng,Floor,.Room,etc. requirements of 4w 2. Is the facility occupied? CMR 6.12 Fla."es r b No 3.Is this a fee exempt notfication(city,town, district, municjpal.housing authoritlr, state facility,or a MassDEP use Only owner-occupied residential property of four units or less)?F a.yes r b.No 4.Blanket Permit Project Approval;if applicable: Date Received Approval ID,* 5.Non-Traditional Asbestos Abatement Work Practice Approval, 2.Submit Ori&al i°applicable: Form Tor Approval to it Commonwealth of Massachusetts . 6.Asbestos Contractor: PA.Box 4062 Boston,MA02211 AERO TECH ENMRONMENTAL 1E3RICEAVE a Name In.Address NORMBOR+000 I MA 01532 9783759E34, c.City Town d,State e.Zp Code f.Telephone ACWMI h.Contract Type:Pr 1.Written r 2.Verbal ` g.DLS License# 7 GILEERTOHUERTA A8901837 a.Name of Contractor's on-Site Supervisor/Foreman b.CLS Certification# 8 RAY BRESNAHAN AM900294 a.Narreof Project Monitor b.DLS Certification# 9. ewIRONMeIYrALCOMPLIANCEsER%ncES,WC AA000225 a.Name of Asbestos Anslyt cal Laa b,DLS Certfication# e 10. 111118017 1/1812017. a.Project Start Date(M,PADDNYYY) b.End Date(MM/DD/YYYY) SAWIPM 6AAA7PM a%York Hours-Monda Through Fries Y 9 Y d.Work Hours-Saturday&Sunday . 11.What type of project is this?, r a.Demolition Pr b:Renovations" c.Repair r d,Other-Please Specify: Revised: 11/13,7013 Page 1 of 4 Z abed 996MES05 0140- d Wd 69"VO L lOZ L 6 Uer Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) - loaas$osl Asbestos Project# Asbestos Notification Form r project Revision ► � r Project Cancellation A.Asbestos Abatement Description:(coot.) T 12.Abatement procedures(check all that apply): r a.Glove Bag r b.Encapsulation r c.Enclosure r d.Disposal Only r e.Cleanup Ir f.Full Containment r g.Other-Please Specify: 13.Job is being conducted: rr a.Indoors r b.Outdoors 14 a.Total amount of each type of asbestos Containing materials(ACM)to be removed;enclosed,or encapsulated: 32 1.Linear Feet(Lin.Ft) , 2.Square Feet(Sq.FL) b.Boiler,Breaching,Duct, c.Transite Pipe Tank Surface Coatings 1.Lin.Ft 2.Sq.Ft 1.Lin.Ft 2.8%Ft. d.Pipe Insulation e.Transite Shingles 1.Lin,Ft 2.Sq.Ft. 1.Lin.Ft. 2.Sq.Ft f,Spray-On Fireproofing g.Transite Panels 1.Lin.Ft 2.Sq.Ft 1.Lin.Ft. 2.8%Ft h.Cloths,Woven Fabrics i.Other-Please Specify: 1.Lin.Ft 2.Sq.Ft j.Insulating Cement LwpLUgw 32 1.Lin.Ft 2.'Sq.Ft. 1.Lin.Ft. 2 Sq.Ft 15.Describe the decontamination system(s)to be used: x 3 CRMSER RASH BW*-7 16.Describe the containerization/disposal methods to comply with 310 ChIR 7.15 and 453 CMR 6.14(2) 6 MLLL DOUBLE BAG 17.For Emergency Asbestos Operations,the MassDEP and*DLS officials who evaluated the emergency: CYNTHA BARON INSPECTOR a.Nar»ed MlassDEPOITcial h Tide afMassDEP Of cia] 111712017 SAYIl-17-021 a Date ofAuttnrization(MWlDD/YYYY) d WAvert BOSTON INSPBOTOR e.Name of OLS Official, f.Title of DLS Official 1/17=17 18291-2017 g.Date of AuftrQation(MWDD/YYYY). h Waiver 18.Do prevailing wage rates as per M.G.L.c. 149,§26,27 or 27A—F apply to this r a Yes F b.No pivject? Revised:1 U13/2013 Page 2 of 4 c abed 99£EE6ES09 3%0Ja W&9:,�O�ZMZ L6 Uef Massachusetts Department of Environmental Protection BWP AQ 04 (ANF-001) 100258051 Asbestos Project#- t 11, Asbestos Notification Form Project Revision r7 Project Cancellation B. Facility Description 1.Current or prior use of facility: HOUSING 2.Is the facility owner-occupied residential with 4'units or.less? 17 a.Yes r-,b,no DAMDRICARDI 85STONEH RD a. _ a.Faci ty Owner Name b.Address BARNSTABLE MA 02532 " 7742BO1643 C.CdyJTown d.Stahe e.Zp Code f.Telephone 4.NA NA a.Name of Facility Owner's o"te Manager. b.Address NA MA_ D000) 0000000000 c.CttyRown d.State e.ap Code f.Telephone S AERO•TEC - 163RICEAVE a.Name of General Contracts b.Address NORTHBOROUGH NIA" 01532 M83759534 a City/Town d.State e.Mp Code f.Telephone ACE 9,Contraolors Workers Compensatlon Insurer 656206 0 7f2017 h.Policy# i.E*mtion Dale(MMlDD/YYYY} 6.What is the size of this facility? 2200 2 a.Square Feet. b.#of Floors C.Asbestos Transportation&Disposal 1.Transporter of asbestos-contairing waste material from site of generation: I a.Directly to Landfill or • ,R b.To Temporary Storage Location/Transfer station AERO TEC ENVIRONMENTAL 163 RICE AVE Mule:Temporary c.Name offTrransporffir d.Address storage of Asbestos NORTMROLIGH RCA 01532 97837595,U Comte lnIng waste e.CityRoym f.State" zip Code h.Telephone material Is only 9• P allowed at the place of licensed Assbes of tosLS 2 if x temporally storage location/transfer station is used,list name of transpwler of asbestos containing contractor or a transfer waste materiai.from temporary sterage locationhransfer station to final disposal site: station that Is permitted by RTL, 173 RCKMG ST MessDEP and a.Nettie of Trarrperter . operated in b.Address compliance with Solid . pTp Waste Regulations CT 06480 8603421022 Cit 310 CMR 19.000 - ylfoWn d.State a.Zip Code "-f.Telephone . Revised: 1 11fIM013 Page 3 of 4 abed g9£££6m oaf Wd l•94b0 L U .L 6 Uer i Massachusetts Department of Environmental Protection .A BWP AQ 04 (ANF-001) toozssos i Asbestos Project# Asbestos Notification Form . Ir ProjectRevision If Project Cancellation C.Asbestos Traosportatlao&Disposal• (coot) 3.Name and address of ternporary storage location/transfer station for the asbestos containing waste; material: NA NA a Temporary storage Location Name b.Address NA MA OD000 DD00000000 a City/Town d.State e.Zip Code f.Telephone 4.Name and location of finEl disrwal site(asbestos landfill); h7NMVABffaWRLSE M NERVAEN TERPRSE a.Final Disposal Site Name b.Final Disp osal Site Owner Name 9000 NNERVA RD c Address VdAYNESSURG OH 44688 3308663435 d.Cdyrrmn S.State f 2ip code g.Telephone A Certification ' GREGORY HARDING GREGORY HARDiNG "I ceftlfy that I have personally 1.Name 2.Authorized Signature examined the foregoing and am O MER familiar with the information 11172017 contained in this document and 3•PosrtcnTdte 4.Dale(MMrDDrYYYY),,na.:Contracts must • sign this tam for DLS all attachments and that,based 9783759534 AERO TEC nodfication purposes on my inquiry of those 5.Telephone 6.Representing Individuals immediately 163 RICE AVE. NORTHBoRoLGH responsible for obtaining the 7.Address 8.Citylrow n information,I believe that the information is true,accurate, and 01532 complete.I am aware that there 9.Mate 10.Zip Code are significant penalties for submitting false information, including possible fines and imprisonment The undersigned r hereby states that I have read tfre Commonwealth of Massachusetts regulations governing asbestos abatement (453 CMR 6.00 promulgated by the Department of Labor Standards and 310 CMR 7.15 promulgated by the Department of Environmental Protection),, and that l am aware that this Permit application or.notifirfon shall not be deemed valid unless payment of the applicable fee s made:" Revised:11/13M]3 Page 4of4 y a6ed 99E£M6M 381DJaf Wd l,93,0 L 60Z Li, UT 3/ _.. ti BORTOLOTTI CONSTRUCTION, INC. 765 WAKEBY ROAD,MARSTONS MILLS, MA 02648 508-771-9399 508-428-8926 FAX: 508-428-9399 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: V� 1 �o Date of Inspection: Inspector' Name: - er's Name and Address: Q l CERTIFICATION STATEMENT: I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-` formed based on my training and experience in the proper function and maintenance of on-site sewage disposal stems. The System: Passes 77 Conditionally Passes 4af Needs Further E Local Aproving Authority Fails Inspector's Signature: Date: TheS stem Inspector shall submit this inspection report to the - Approving `a Zuthorit within —thi r- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,006 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: A)SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. " B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repaired. The system,upon comple- tion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If not determined",explain why not. The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or exhItration,or tank failure is imminent. The system will pass inspection if the existing sep- tic tank is replaced with a conforming septic tank as approved by The Board of Health. k Sewage backkup or breakout or high static water level otiserved in the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of The Board of Health): - 1 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system will_pass_inspection if_(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1)SYSTEM WILL PASS UNLESS BOARD,OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY-AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION- ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 Feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public . water supply well. The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but 50 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile oiganic compounds indicates that the well is free from pollution from the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due to an overloaded-or ,clogged SAS or cess p,1. gg . rl aded or clog- ged � due an ove o i ribution box above outlet invert' i .1 el in the d st Static hqu d ev . . . SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A • CERTIFICATION (continued) 1 r privy is below the high groundwater m cesspool 0 Absorption System, g g ion of the Soil Abso p Y An portion rp Y P Y po elevation. Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia.nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: . The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant,: threat to public health and safety and the environment because one or more of the following conditions exist: The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of a tributary to n 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: The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART B +� CfIECKLIST. Check if the following have been done: t/Pumping information was requested of the owner,occupant, and Board of Health. None of the system components have been pumped for atleast two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As-built plans have been obtained and examined. Note if they are not available with N/A: The facility or dwelling was inspected for signs of sewage back-up.. v The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components,excluding the Soil'Absorptiou System, have been located on site. The'septic tank manholes were uncovered,opened,and the interior of the septic tank was in- Y spected for condition of baffles or tees, material of construction,dimensions,depth of liquid, depth of sludge,depth of scum. Ll The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3- ,y x,` r SUBSURFACE SEWAGE DISPOSAL:SYSTEM.INSPECTION FORM PART B CHECKLIST(continued) _)were P n different from owner re provided with information The facility owner(and occupants, if the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION FLOW CONDITIONS RF.SIDENTLAS: Design Flow:Y-V0 allons Number of Bedrooms: / Number of Current Residents Garbage Grinder: A)0 Laundry Connected'I'o System: Seasonal Use: Water Meter Readings,if ilable: Last Date of Occupancy: COMMERCLAI./INDUSTRIAL•14)6 Type of Establishment: Design Flow: gallons/day Grease Trap Present: (yes or no)" Industrial Waste Holding Tank Present: Non-Sanitary Waste Discharged To The Title V System: Water Meter Readings, If Available: Last Date of Occupancy: OTHER: Describe) Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: o t (,(„ ✓ 3 Z System Pumped as part of inspection:�(?�_ if yes,volume pumped: gallons Reason for pumping: TYPE OF SYSTEM: Septic Tank/Distribution Box/Soil Absorption System • Single Cesspool Overflow Cesspool Privy hared System(I es,attach previous inspection records, if any e Other(explain): / -T'f PROXIMATE AGE of all com onen�site: installed(if known)and source of information: Se age odors detecte hen arriving at t -4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C GENERAL INFORMATION (continued) SEPTIC TANK: Depth below grade: // Material of Construction: `concrete metal FRP_Other (explain) Dimisions: 'Y,51 Sludge Depth:�o'r, Scum Thickness: Distance from fop of sludge to bottom of outlet tee or baffle: .33 1 Distance.from bottom of scum to bottom of outlet tee or baffle: -.den Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in r ation to outlet invert, structural integrity, evidence of leakage,etc.) g,c 0 Q• /UIX� •/ �i . GREASE TRAP:A)o Depth.Below Grade: Material of Construction:—concrete—metal FRP ` Other (explain) — — Dimensions: Scum Thickness: Distance from top of scum to top of outlet tee or baffle: Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) TIGHT OR HOLDING TANK: On { Depth Below Grade: Material of Construction:_concrete metal_FRP Other(explain) Dimensions: Capacity: gallons Design Flow: gallons/day Alarm Level: Comments: (condition of inlet tee,condition of alarm and float switches,etc.) DISTRIBUTION BOX: Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: F Pump is in working order: Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) SOIL ABSORPTION SYSTEM(SAS): (Locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive. methods) If not determined to be present,explain: Type: Leaching pits,number:Leaching chambers, number: Leaching galleries,number: Leaching trenches,number, length: Leaching fields, number,dimensions: Overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failurcAevel of ding,condition of vvetation, e r CESSPOOLS: . Number and configuration: Depth top of liquid to t invert: Depth of solids layer: Depth of scum layer: Dimensions of Cesspool: Materials of construction: Indication of groundwater: Inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of pondiug,condition of vegetation, etc.) PRIVY: Materials of construction: Dimensions: Depth of Solids: Comments: (note condition of soil, signs of hydraulic.failure, level of ponding,condition of vegetation, etc.) -6 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I,AR'I•C SYSTEM. INFORMATION (:con inued) . SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landnmrks'or benchmarks. Locate all wells within 100 Feet. a - , c AP , t DEPTH TO GROUNDWATER: Depth to groundwater: _Feet / Method of Determination or Ap roxi�ation: -7- SYSTEM STEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTE) MARKED WITH MAGNETIC TAPE OR PROVIDE MIN'. 20" DIAM. WATERTIGHT 1. DATUM IS (NOT To SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. NAVQ 88 BQrnstabk Harbor � ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3" GRADE , 2' PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING• � TOP FOUND. EL. 36.4' FILTER FABRIC OVER STONE 35.0' MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYSTEM 35,0' 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. NOTE: 2" MIN. WALL 4. DESIGN LOADING FOR ALL PROPOSED PRECAST PRECAST H-10 THICKNESS REQUIRED BLOCKS OR UNITS TO BE AASHO H-1Q RISERS (TYP.) PRECAST RISERS o� 2'0 4"OSCH40 PVC MORTAR ALL a 6" MIN. suMP PIPES LEVEL 1S1 2' 4' COMPONENTS H-10 5. PIPE JOINTS TO BE MADE WATERTIGHT. `- 12" MIN. INr. DIM, ENDS (TYP') 0 SIDES 32.03' 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE *33.3' 10" 1500 GAL H-10 14" a� ��< n°G �°G NTH TEE SEPTIC TANK TEE 32.38' 2,13 �� ®� ®®®1 ?Uooa 310 CMR 15.000 (TITLE 5.) v �ufe oo°ogcgcoca°o; WATER D'BOX MR �]R �® � �� ® _ GAS BAFFLE.` ,,. FOR LEVELNESS °o°^°�°Q a, b� aGus +_o 0 0 0 0, =�®L171® ®® ®�� ®® o o o p 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND 7 7 p P o O n � U C11 ' > p'o�n�o u°o°n o° 29.2' NOT TO BE USED FOR LOT LINE STAKING OR ANY °qd ''••: 4' LIQ. LEVEL (ACME R EQUAL).,"., 31.53 1.36 n OTHER PURPOSE. 'DOpOOQaOGOaaaaaOCOaaa0o0a0o040a0aOCOCOCOCoa01. fr _ O °,00^0000,°a,°,o,°,a°,o°,000000aooi°,of°of° ° °,o°,o�oQa 0. LH-10 500 GAL LEACHING CHAMBER BY ACME PRECAST OR EQUAL. e 8. PIPE FOR SEPTIC SYSTEM TQ SCH. 40-4 PVC, o Gr 3/4 -T-1/2' DOUBLE WASHER STONE 4 MIN. (4) UNITS' REQUIRED o Noce 4nit� c" ALL AROUND PRECAST STRUCTURES 9. COMPONENTS NOT TO BE BACKFILLED OR �' ? 6 CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 42.00' X 12.83' �e COMPACTION. (15.221 [21) N CONCEALED WITHOUT INSPECTION BY BOARD OF 111 HEALTH AND PERMISSION OBTAINED FROM BOARD ��o4g a OF HEALTH. 10. CONTRACTOR SHALL BE RESPONSIBLE FOR24.0' BOTTOM TH-2 CALLING 1 �nU MAP J % SLOPE 2 % SLOPE) 1 % SLOPE NO GROUNDWATER FOUND VERIFYING iTHE LOCATION OF ALL UNDERGROUND & LOCUS- ( ) ( } OVERHEAD UTILITIES PRIOR TO COMMENCEMENT OF SCALE 1"-200a't FOUNDATION 18' SEPTIC TANK 29' D' B LEACHING woRK.OX 18' ASSESSORS MAP 317 PARCEL 60 FACILITY 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL * VARIANCES FOR SEPTIC SYSTEM REPAIRS WHICH MAY BE REMOVED 5' BENEATH AND AROUND THE THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL PROPOSED LEACHING FACILITY. UTILITIES AND ALL BUILDING SEWER OUTLETS AND ELEVATIONS BE IMMEDIATELY GRANTED BY THE BOARD OF PRIOR TO INSTALLING ANY PORTION OF SEPTIC SYSTEM HEALTH AGENT OR BY HEALTH INSPECTOR 12. EXISTING LEACHING FACILITY SHALL BE PUMPED LEGEND I D PAPERWORK AND HEARING REDUCTION PROPOSALS AND REMOVED OR PUMPED AND FILLED WITH CLEAN APPROVED BY THE BOARD OF HEALTH REVISED SAND. DURING A PUBLIC HEARING HELD ON DEC. 10, 2013 99 - EXISTING CONTOUR X 99 r EXIST. SPOT ELEV. �+�p ,� �� 1) ALL SYSTEMS THAT HAVE NO INCREASE IN FLOW - SEPTIC STEM R COURT SETBACK (NO MORE THAN N 50% REDUCTION IN FOUNDATIONENT TO —[9s]— PROPOSED CONTOUR _ REQUIRED SEPARATION DISTANCE) (10' TO 19.2') SYSTEM DESIGN: 1s$.4] PROPOSED SPOT EL. --- — — -- GARBAGE DISPOSER IS NOT ALLOWED TH 1 TEST HOLE rJ 27.40-.._.. - - -- - _r .,,. � +_-^�.. { EXISTING 5 BEDROOM DWELLING -' 2 sLOPE of cRouND STONE / f ,. �..-__r ` "� �~~n} DESIGN FLOW: 5 BEDROOMS 0 110 GPD 550 GPD DRIVE �, ( ■ ' i j BENCHMARK: USE A 550 GPD DESIGN FLOW UTILITY POLE h' _,N LOT 6A CEMENT BOUND R HYDRANT - FIE 20,009 SF i -33.7 NAVD88 ;_.. -- .- + �. �- �., _.` SEPTIC TANK: 550 GPD (2) 1100 NOTE: NOT ALL SYM13OLS MAY APPEAR IN DRA4YING USE A 1500 GAL. SEPTIC TANK -PAVED :I f • E DRIV _.' ! ,--' LEACHING: TEST HALE LOGS I -- - . _ - I f -- � SIDES• 2 (42 + 12.83) 2 (.74 -- 162 GPD BOTTOM 42 x 12.83 (.74) = 398 GPD CRAIG J. FERRARI, SE 13871 ENGINEER: # ��. TOTAL: 756 S.F. 560 GPD iD W. STANTON RS WITNESS: _ \` , DAV �--c -` USE (4) 500 GAL. LEACHING CHAMBERS (ACME OR EQUAL) DATE: 2/8/2017 � , c _ < 2 MIN INCH ,a ; J + GARAGE ON ..-I `�--c ---_ - WITH 4' STONE ALL AROUND PERC. RATE - - / - a } I, -t-- -,,� CLASS I SOILS P# 15261 EXISTINGj [.,�� ELEV. ELEV. i� iJ DECK J DWELLING i ~� 1 ^ MA E�pCT 00 �n 1 t x raF 3s.4 I APPROVED DATE BOARD OF HEALTH o PATIO p t' 4 � 1 I --- ,, -W A f1 I INV , --W W --_W __ c 1 LS f� 1 PATIO 8 10YR 3/2 ,!f __ -- - ( W TITLE 5 SITE PLAN B FILL t, ��, POOL _>1 `}� ��x TH 1 '�ri N TH2 ( OF LS �t r� r I 10YR 5/4 33.5' ;, v _., , -jr_. '-� t 22.o � o —. N ,�, #85 STOINEHEDGiE DRIVE 18 84 28 l I r BARNSTABLE MA 02 SL I f PREPARED FOR CN 1OYR 6/6 CAPE COD SEPTIC / LEDFORD MS Q0 DATE: FEB. 14. 2017 C2 ` 5' REMOVAL OF UNSUITABLE SOIL REQUIREDA -,6 of Mq SIEVE ------ AROUND PERIMETER OF LEACHING FACT-ITY, �'''-_ - - t..^-,, a � ?c�` ,, tt ?t >�, �� oFnr 10YR 7 4 DOWN TO S -TABLE-SOIL LAYER. REP ACE - .1. off 508-362-4541 ev. J:_ D6�NI `. �_ _.. a. < fax 508-362-9880 -1hI�TH�.OLEA MED. SAND, TO MEET / -�� \,. c> A. �; r DAPalLL- u, U.. SPECIFICATIONS OF 310 CMR 15.255(3) i -- I« GJ,�t.A 9.Ii•-; CJA "' downca e.com MS N- �1Ov80 (p (LWI( I CIVIL n l� P NO �'�?6�02 . m No.465 � Cape eerrng Inc. „ 1 OYR 7/4 , n , { �; "<5 �»r t t.". ��S S1�' �r\S"�'t� 120 25 132 24 _ _:+ r(�NAI_ t sfoNAL CIV%/ G�'I7C�'%�eE?/'S Scale: 1"= z0' land surveyors NO GROUNDWATER ENCOUNTERED �- L'i-1`D 939 Moin Street ( Rte 6A) YARMOUTHPOR7' MA 02675 0 50 FEE DATE DANIEL A. OJALA, P.E., P.L.S. 17-a25