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HomeMy WebLinkAbout0080 BELDAN LANE - Health 80 Beldan Lane Centerville P A = 189 031008 No. 42101/3 ®RA 1000 ® O ® p No. I ()�1 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftplitation for MisposaY Opstem ConstCUttion Permit Application for a Permit to Construct( ) Repair V'Upgrade( ) Abandon( ) ❑Complete System individual Components Location Address or Lot No. 1�0 �QOCAN L<�� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel, O�` o o b1/G Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. ��� �l 3 Ut���.�rv.c�,�•2� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) U" gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Re airs 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. Signe Date k l�:>[ Ix 11 y Application Approved by Date Application Disapproved by Date for the following reasons Permit No. o — 0 Date Issued h j r No. � ���( Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplitation for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑Complete System [T�ividual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. *� �C) QOCAN L.CAJ\"C., SQL C o av, Assessor's Map/Parcel o to Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Scoff M ��� �t3 Ucd�4�rh6� 2J Type of Building: 7 / Dwelling No.of Bedrooms f I Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) (/ /�' gpd Design flow provided to// gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) dew 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. a Signed — " Date1�; � �� �( Application Approved by o Date Application Disapproved by Date for the following reasons Permit No. I — yo V Date Issued U 1 /A --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of CDl pliattre THIS IS TO CERRTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired V Upgraded( ) Abandoned( )by `>CO N\ w✓`� at ��, � s „ ( G.y i has been constructed in accordance J with the provisions of Title 5 and the for Disposal System Construction Permit No. 2,0/ dated Q / Installer Designer #bedrooms O I n Approved design flow , ) /1 ( gpd The issuance of this pe it sh 1 not be construed as a guarantee that the system will ctiondesigned. �� f� (�C Date �0 t Inspector i - 7------------------------------------------------------------------------------------------------------------------------------ No. Z — d 7 Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS disposal 6pst>e, Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at 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:Construct;/07 ust be completed within three years of the date of this permit. Date 7 Approved by �Ini 10/18/2019 ShowAsbui It(1700x 2200) -G G x L0CATION � "�SEWAGE t RMI N0. YILLA6E - ---n F:T-- IMP r) l �� I N S T A LLERn'S NAME & ADDRESS I UIIDEIII OR pwNER GATE PERMIT ISSUED ;_7V DATE COM►LIANCE ISSUED https:/Tiitsq ldb.town.barnstable.ma.us:8431/H onie/ShowAsbui It?mp=189031008&sq=1 1/1 TOWN OF BARNSTABLE LOCATION ae &ni a . SEWAGE# ( �w, - u VILLAGE-GQ,,) nJ���L ASSESSOR'S MAP&PARCEL' (J' (f INSTALLER'S NAME&PHONE NO. (`rN Vrr_Nk- CiLt 06t��i SEPTIC TANK CAPACITY ����- �L( LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER r �, PERMIT DATE: (0 Q w\1.ei COMPLIANCE DATE: 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 Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY j 131= le New d—box , COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED -Tdb JUN 2 .1 2004 8vt4' TOWN OF BARNSTABLE TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION MAP � PARCEL ®`�`O Property Address:80 Beldan Lane ��� Centerville. MA >_y Owner's Name: Robert & Jean Stone Owner's Address: Date of Inspection: C� Name of Inspector.(please print) W i 11 i am E_ •Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (5081 775-8776 CERTIFICATION STATEMENT I certify that 1 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: i, Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: w 1 Date: `3� The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth 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 seat to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page I Page 2of11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 80 Beldan Lane Centerville, MA Owner. Robert & Jean Stone Date of Inspection:-: cZ_3 G Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste asses: 1 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or reps ed.The system,upon completion of the replacement or repair,as approved by the Board of Health;will pass Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If`not determined"please expl The septic tank is metal and over 20 years old#or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exis g tank is replaced with a complying septic tank as approved by the Board of Health. •A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indi acing that the tank is less than 20 year old,is available. N explain: Observation of sewage backup or break out or high static water level in the distribution box due to-broken or o tructed pipes)or due to a broken,settled or uneven distribution box..System will pass inspection if(with ap roval of Board of Health): broken pipes)are replaced` obstruction is removed dis tribution ution box is leveled or iepiaced ND xplain: The system required pumping more than 4 times a year due to broken or obstrimled .The system will pass inspection if(With approval of the Board of Health): p (s) broken pipe(s),arc replaced s obstruction is nmvod .F ND a in: Page'3 of 11 y OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 80 Beldan Lane Centerville, MA Owner..Robert & .Jean Stone Date of Inspection: — 0 O ` 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 fling to protect public health,safety or the environment. System will pass unless Board of Health determines in accordance with 310 CM11.15.303(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 System will fail unless the Board of Health(and Public Water Supplier,if-any)determines that the ystem 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.l of a public.water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply,well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well** Method used to determine distance ••This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 80 Beldan Lane - Centerville, MA _ Owner: Robert & Jean Stone Date of Inspection: 7 CA—6 L D. S stem Failure Criteria applicable to all systems: You m st indicate"yes"or"no"to each of the following for all inspections: Yes Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface'of the ground or surface waters due to an overloaded'or clogged-SAS or cesspool _ Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or cesspool - Liquid depth in cesspool is less than'6"below invert oc available volume is less thanV day Clow _ Required pumping more than 4 times in the last year,NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within i00.feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool orprivy 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.IThis system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free.from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E Large Systems: T be considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 g d. Y u must indicate either"yes"or"no"to each of the following: e following criteria apply to large systems in addition to the criteria above) no lye _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet ora tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim We Protection Area—I WPA)or a mapped Zone 11 of a public water supply well If ou have answered"yes"to any question in Section E the system is considered a significant threat,or answered es"in Section D above the large system has fined.The o%mcr or operator of arty large system considered a s gm iicant threat under Section E or failed under Section D shall upgrade the system in accordance with 3 10 CMR lK 304.The system ovwr should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 80 Beldan Lane Centerville, MA Owner:Robert & Jean Stone Date of Inspection: c7'-3 o—o 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? l,/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? 411 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:, Yes no _t/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 CUR 15.302(3)(b)J a 5 Page 6 of I I T OFFICIAL INSPECTION FORM-;NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTION FORM PART C` . SYSTEM'INFORMATION Property Address: 80 Beldan Lane Cen ervi e, ma Owner: Robert & Jean Stone . Date of Inspection: f/-3 G—0 FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design):.3 Number of bedrooms(actual):_ DESIGN flow based on 310 CiIRf`)5.203(for example: 110 gpd x#of bedrooms):,7G O Number of current residents: `7 Does residence have a garbage grin er(yes or.no):: !> Is laundry on a separate sewage system(yes or no) [if yes separate inspection required] Laundry system inspected(yes or no)._" Seasonal use:(yes or no):/lr Water meter readings,if available(last 2 years`usage(gpd)): 2 0 0.3 = 7 5,ll0 0 Sump pump(yes or no): 2UU2 - 192,000 Last date of occupancy. 51-j oa-a COMMERCIA USTRIAL Type of establishme Design flow(based n 310 CMR 15.203): 0d Basis of design flo (seatslpersons/sgft,etc.): Grease trap presen (yes or no):_ Industrial waste h ding tank present(yes or no):_ Non•sanitary wa a discharged to the Title 5 system(yes or no): Water meter rea ings,if available: Last date of oc pancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: d Was system,pumped as part of the inspection(yes or no): !J If yes,volume`pumped:__gallons-How was quantity pumped determined? Reason for pumping: TYl' F SYSTEM peptic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _lnnovative/Altemative 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: ei�� Were sewage odors detected when arriving at the site(yes or no):,Arf/_) 6 Pagc 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued)' Property Address: 80 Beldan Lane Centerville, ma Owner:Robert & Jean Stone Date of Inspection: c/-3&--b 4/ BUILDING SEW (locate on site plan) Depth below grade: Materials of cons ction:_cast iron _40 PVC_other(explain): Distance from priv to water supply well,or suction line: Comments(on co dition of joutts,'vening,evidence of leakage,etc.): SEPTIC TANK:Zvocate on site plan) Depth below grade: �- Material of construction: ✓concrete_metal_fiberglass_polyethylene _other explain) . If tank is metal list age:_ Is age confirme&by a Certificate of Compliance certificate) P (yes or no): (attach a copy of l Dimensions: 4 Sludge depth:_ �/:f ►' Distance from top of sludge to bottom of outlet ice or baffle: ;L zf Scum thickness: � Distance from top of sc m to top of outlet tee or baffle: �. Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): _ GREASE TRAP: (locate on site plan) Depth below grad :_ Material of cons ction:_concrete._metal fiberglass__polyethylene____other (explain): Dimensions: Scum thickness Distance from op of scum to top of outlet tee or baffle: Distance fro ottom of scum to bottom of outlet tee or baffle: Date of last p mping: Comments n pumping reconunendations,inlet and outlet ice or baffle condition,structural integrity,liquid levels as related t outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM:-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Beldan Lane Centerville, Ma Owner: Robert & Jean Stone Date or Inspection:_[`3U-a�t TIGHT or H WING TANK: (tank must be pumped at time of inspec(ion)(locate on site plan) Depth below ade: Material of co sttvction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity. I gallons Design Flow gallons/day Alarm prese t(yes or no): Alarm level: Alarm in working order(yes or no): Date of last umping: Comments ondition of alarm and float swi(ches,etc.): DISTRIBUTION BOX: t--�(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: d 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.): PUMP CHAMBER (locate on site plan) Pumps in working o er(yes or no): Alarms in working rder(yes or no): Comments(note c dition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C y. SYSTEM INFORMATION(continued) Property Address: 80 Beldan Lane Centerville, Ma Owner:Robert & Jean Stone - Date of Inspection: /—SO—cs L/ SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation'notrequired) If SAS not located explain why: Typeleaching pits,number: J leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): .� i % Ao// CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and config tion: Depth—top of liquid o inlet invert: Depth of solids layer. Depth of scum layer: Dimensions of cessp ol: Materials of constru ion: Indication of groun ater inflow.(yes or no): Comments(note co dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of constructi Dimensions: Depth of solids: Comments(note con ition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I l OFFICIAL INSPECTION.FORM=NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Beldan . Lane Centerville, Ma Owner: Robert & Jean Stone Date of inspection: `/-36,a L-1 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. L61 �1 3 � 10 Pagel I of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 80 Beldan Lane Centerville, MA Owner.Robert & Jean Stone Date_of Inspection: z-/—T? ,,G �/ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 7 3 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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: 6 U Flcs.... .......... THE COMMONWEALTH OF MASSACHUSETTS � 50pe R D F �—I E �T I—� �. ................ ......OF..Y"' � / J .. �� /17to 63/oo, Appliratilan for Uhipas al Works Tnnitrurtion ramit Application is hereby ade fqj Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: � Location-A dress or Lot 1.�1.. 15� fd �'.---------••-•-•---....... Lw er Address a � .s ..••----`:. 'NC.................................... Installer Address�f p-� � Type of Building Size Lo _f. .. .... ........Sq. feet Dwelling—No. of Bedrooms.............. ...........................Expansion Attic ( ) Garbage 'Grinder ( ) 0.4 Other—T e of Buildin p, yp g ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a � Other fixtures ..._..... - -- - --- ----- ---------.-----------•---•-------•---------•--------.......-----.........-------- -...................... Design Flow............. _ ,CJ.___ gallons per person per day. Total daily flow____-7�41..........................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.....................Total leaching area... sq. ft. Seepage Pit No---_-_------------- Diameter.................... Depth below inlet.................... Total leaching area .. ......sq. ft. Z Other Distribution box,(�Cr) Dosing tank a Percolation Test Results Performed by..__._.r� __.. .................. Date....�5 -------- Test Pit No. 1LLF ____.minutes per inch Depth of Test Pit.......1 ...... Depth to ground water.__ .. ..... . 44 Test Pit No.,2I ......minutes per inch Depth of Test Pit................:... Depth to ground water... __. ---- ------..w4v......................... Descri tion of Soil_...... ---------•--------- ------ ............................................................-........................................................................................................................................... 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 TITIE 5 of the State Sanitary Code—The undersi ned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by th bo d of health. Signed ------• •----••• ----=. . ••-- •.....................•-•-•-•----------• . ' //AD to Application Approved BY .. z%%%� .. 13A. Date Application Disapproved for the following reasons:----•---------•-----------------------------------------------•-----------------------------------••.........._ ........-•--•-••-•--••.......................•------------....------------••-----•--------...-------••---••----•-----•-------••--•---------............................................................ Date Permit No.... -- Issued_- ..--- -- ----------- �l�J'e�i�t�� �d'•�2.7^�e� Date a Fss. THE COMMONWEALTHPF MASSACHUSETTS BOARD OF HEALTH ............................OF.:/...................-...__........ ` Appliratiun for Diupuuttl Works Tonutrur#iun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �!� ................_. ............................................... .......---•---------•----.....----•_.....•---------_.............................................. Location ddress ? (,,.; or Lot_No. �.._.... ...........�.. q� r.................... I!Y f '1..• AwMer Address ..................................•••••........-•-••-•-----•-----------. -------• -•...-•-••--•-•-•••--------------•-•- :- �"� Installer Address d Type of Building M Size Lot'_._}_.?`. ....Sq. feet" U Dwelling—No. of Bedrooms_-_.....•...73...........................Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria a' Other fixtures ........ . W Design Flow.............._ . ...._.. ---..gallons per person per day. Total daily flow..._-�_.__4...........................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width..............t..... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching are �......�'�--....sq. ft.a- Z Other Distribution box (k ) Dosing tank (, ) t ` � :, t a Percolation Test Results Performed by........ �_'�`=!.'.. ........_.. Date........ ....� v minutes per inch Depth of Test Pit__j ✓Test Pit No. l.t P3J /� f ►-1 P P ------- -------- Depth to ground water.__. +!�..�....__. (i Test Pit No. 2XA' _..._nunutes per inch Depth of Test Pit.................... Depth to ground water..' .i;; �+ ........................................................ -r-------•---- ---•---•- ..........[........................ ............... O Description of Soil------.4%.. " .......Af/'...........................-f....�--------�-- ��../fr I/w�a'( X 1��_�'�_�. ........ V .......................... 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 TITLZ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beenyissued by the-boafd of health. '/X Signedcf:< .... •L• . ...............•••••........... ' �/ Date Application Approved ........................=�.-•�f "' ----•--•-•-----•---------------•--------- bn c ------------- Application Disapproved for the following reasons-------------------------------------------------------------------------------------------•••--•-•--------•---- ................•••••---•--•••-•.....•--•---•-•-----•------•••••-•••••••••----••----•---•....-••••---•---I--•-----------•-----••--•--•-•---•-•--••••--••--------......----------•-•••--••..............-- Date PermitNo......................................................... Issued---•--•---•-----•-- ............................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _Z<11 /"-,/ .................................... .............................................................. (Intifiratr of Toutplittnrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (Y) or Repaired ( ) by--------------------`'.n ._I../ `._. r-------' -------- --Installer------•---•-----------------------------------•- --•--._...-------------------._ /f r 4 / at-•••--•-•--Z-&••-••••f.-........./!�/�.__...f............... 7--------------�r-�-------_--................................. has been installed in accordance with the provisions of TITIE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit N�'�..- ..................... dated--------------------------_..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SAT4SFACTORY. C.1 nDATE....._l �5._ _ - -------------• ��- •-- .....---._......---•----------.. Inspector-•------ -..__.. ... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0......................... FEE.../................. �iu�u��l urk�/�unu�riun �Crrnti� , Permission is hereby granted... r._ ....._�' -.°/� to Construct .( ) or Repair.,( ),an Individual Sewage Disposal System at No....................... it3`' .---•• G� . .. .... �..•• ' Street as shown on the application for Disposal Works Constru ermitjNo..................... Dated.......................................... y ' DATE........../Q/Z. 1.�1)........ .......................... oard of Health FORM 1255 HOBBS & WARREN. INC., PUBLISHERS \ .ECG 4L�.� r 1 N( ) SEWAGE P R M I NO. VILLAGE I N S T A LLER'S NAME i ADDRESS oQ 3 U I L D E R OR MINER DATE PERMIT ISSUED � � 2 DATE COMPLIANCE ISSUED �d a7. �D �\ � ... �� s. t,D �/ �s S AlG3 z3 ty �. n AIF_ _ + - r AP pA Y � ���a �;` 1..-' p� 1 � � .y�y \ 1-,Q P�'� �,�-____-�• � V x ,a r �46 S,F. W� " 3=O' •F yr' A) 2 �o ROBERT . F P. ^ rn '- ' / � p NO.22162 Q /STEP �< k: z� \� r Z F FSS1pNAL E r ,., r f LEGEND' ISTING SPOT ELEVATION 0,0 CERTIFIED PLAT PLAN 1' EXISTING3, CONTOUR _— ;:FINLSHED•.SPOT' ELEVATION �0. 0� G vT 8 rE�_l%.4 n,/ L.glve ' FINISHE-D-', CONTOUR 0 APPROVED = BOARD OF HEALTH I N 9„=F S TA 13 LA A DAT E �` E. AGENT ; fi _ SCAT E / � 47�� DATE DREDGE- ENGINEERING CO ,INd CLIENT.__.. I CERTIFY . THAT THE PROPOSED ' EGISTERE "REGISTEREb) 7 � JOB N0. _9 O (, `-> BUILDING SHOWN ON THIS :PLAN ...-CIVIL LAND r l OR, BY • "�. CONFORMS TO THE ZONING • LAWS _ ENGINEER41 I,SURVEYQR� - OF BARNSTA LE MASS. y33 NC' MAIN S' 72 MAIN S; CH. BY R__�.._ __' /fG 50.E fARMOCTN, MASS. HYANNIS, Mai; SHEET l_ OF ._�__ DAYE REG. LAND SURVEY R � •� • my � � yc� Zc � c2Z v, yy o � ,. 4 - -'a — o-: ,•:.�� , r r tl m 0 y r Il D yy o h � y , I �l r ffi1 ` v' I xr 1 o T n 2 r d CCIy� Z � � rl Rt C1 Z .. M o� I- � "ice•.\`i` �/J`/r1L l fn I� �•W W II, f� 1 I'� _I� • � � � ! 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