HomeMy WebLinkAbout0060 CAP'N JAC'S ROAD - Health 60 CAWN JAC'S, CENTERVILLE
A=194-057
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UPC 12534
No.2-153LOR
HASTINOS,MN
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 60 Captain Jac's Road
Centerville, MA 02632
Owner's Name: Tony Carafone
Owner's Address: Same
Date of Inspection: June 27, 2001
Name of Inspector:(Please Print) James M. Ford
RECEIVED
Company Name: - James M. Ford
Mailing Address: P.O. Boz 49 Map -194
Osterville,MA 02655-0049 Parcel: 0 7 J U L 0 6 2001
Telephone Number:., (508) 862-9400
TOWN OF BARNSTABLE
HEALTH DEPT.
CERTIFICATION STATEMENT
I certify that I have personally.inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and,experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Conditionally Passes
Ne2dqurther Evaluation by the Local Approving Authority
"-FVmls
i
Inspector's Signature: Date: June 30, 2001
The system inspector shall subm 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,
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 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
-CERTIFICATION (continued)
Property Address: 60 Captain Jac's Road
Centerville, MA u.
Owner: Tony Carafone
Date of Inspection: June 27, 2001 - --
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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired., The system,upon completion of the replacement or repair,as approved,by.the Board of Health,will pass.
Answer yes,no or not determined'(Y,N,ND)in the for the following statements: If"nof 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
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due t6 brokeri or obstructed pipe(s): The system will
ass ins ectiori if with approval of the Board of Health - ._.
P P ( PP )�
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 60 Captain Jac's Road--
Centerville, MA :...._.... E;
Owner: Tony Carafone
Date of Inspection: June 27, 2001
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`Boa'rd"of Health(and Public Water Supplier;if any)'determm6 that the
system is functioning in a manner that protects the public health,.safety,and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 106'feet of a
surface water supply or tributary to a,surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply:
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well.water analysis,perfo.med 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 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 60 Captain Jac's Road
Centerville, MA
Owner: Tony Carafone
Date of Inspection: June 27, 2001
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than.100;feet but greater than 50.feet from a.private water
supply well with no acceptable water quality analysis. [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.]
No (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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`yes"or"no"to each of the following:
(T'he following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
-CHECKLIST
Property Address: 60 Captain Jac's Road..
Centerville, MA `
Owner: Tony Carafone
Date of Inspection: June 27, 2001
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓_ Pumping information was.provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or:.dwelling inspected for signs.of sewage,backup?;
✓: Was'the:site inspected for signs of break out?
.Were all system componentsi:excluding the SAS,located on site
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
paf
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 60 Captain Jac's Road
Centerville. MA
Owner: Tony Carafone -.._
Date of Inspection: June 27, 2001
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 5
Does residence have a garbage grinder(yes or no): No
Is laundnj on a separate sewage system(yes or no): No— [if yes separate inspection required].
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): 2000-88,000 gals.; 1999-95,000 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gnd
.Basis.of design flow(seats/persons/sgft,etc)
Grease trap present(yes or no): t.
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no)
Water meter readings, if available: -
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped in 2000 - per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped- gallons--How Was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
InnovativeJAlternative 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
'Oth&-(describe). r
Approximate_age of all.components,date installed(if known)and source of information:
May 24, 1999-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
Property Address: 60 Captain Jac's Road--
Centerville, MA
Owner: Tony Carafone
Date of Inspection: June 27, 2001
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron 40 PVC _other(explain):
Distance from private water surply well or suction liner
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 10"
Material of construction: ✓ concrete _metal _fiberglass ---. . polyethylene...
_other(explain)If tank is metal list age: Is.age-confirmed-by..a Certificate-of.Compliance-(yes or'no): (attach a'copy of
certificate)
Dimensions: 1000 gal. .._. .. ..... ,
Sludge depth: 2"
r
Distance from top of sludge to bottom of outlet.tee or baffle: ... 30'.'....1. .
Scum thickness: 5" "
Distance from top of scum to top of outlet tee or baffle: 9"
Distance from bottom of scum to bottom of outlet tee or baffle: .10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
The tees were present The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
Material of construction: _concrete _metal fiberglass _polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from.top of scum to top of outlet tee or baffle: ;
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping
Comments(on pumping recommendations,-inlet and outlet.tee.or.baffle.condition,.structural integrity Jiquid levels
as related to outlet invert,evidence of leakage,etc.):
�7.. r r :
I
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
• SYSTEM.INFORMATION (continued)
Property Address: 60 Captain Jac's Road
Centerville, AM
Owner: Tony Carafone
Date of Inspection: June 27, 2001
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: aallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBiTTIQN BOX; V,, :; if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level and there were no signs of leakage. There were no signs of back-up or failure from the leach field. The
outlet invert was 24"below grade.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition 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
SYSTEM'INFORMATION (continued)
Property Address: 60 Captain Jac's Road
Centerville. MA
Owner: Tony Carafone
Date of Inspection: June 27, 2001
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching chambers,number:
leaching galleries,number:
✓ leaching trenches,number, length: S-infiltrators with 4'stone and 14"under(per as built card)
leaching fields,number,dimensions:
- ✓ overflow cesspool,number: 1
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.):
The leach field was not dug up. 'There were h6:W ns of failure'in the D=b"oz: The bottom to j rade was;approximately 36". The
old overflow cesspool was not dug up. Speed levelers were present.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
..SYSTEM,INFORMATION (continued)
Property Address: 60 Captain Jac's Road
Centerville, MA
Owner: Tony Carafone
Date of Inspection: June 27, 2001
Map: 194
Parcel. 057
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.
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10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
1.
SYSTEM°INFORMATION (continued)
Property Address: 60 Captain Jac's Road-
Centerville, MA
Owner: Tony Carafone
Date of Inspection: June 27, 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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: topographic and water contours maps
Checked with.local,excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and the Cape Cod Commission water contours map the maps were showing
approximately 80'+/- to groundwater at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied, relating to the system, the inspection and/or this report.
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TOWN OF BARNSTABLE
LOCATION ��, CC,nc',) . C c C s SEWAGE # I�
j VILLAGE spa �e t ,{ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. i�I t;1-N 01 -A e.S
SEPTIC TANK CAPACITY (Z)(� C)
LEACHING FACILITY: (size) ( .;lc�C `✓��
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: Ell I ]'I A COMPLIANCE DATE:���
Separation Distance Between the: ' J�L
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility _�l �'AT u 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) I V4 Feet
Furnished by
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i
No. € �' Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for �Wgpogaf *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) D Complete System O Individual Components
Location Address or Lot No. Ile 0 /1 Owner' Na Address and Tel.No.
Assessor's Map/Parcel ��
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Na re of Repairs or Alterations(Answer when a plicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by Board o ealth.
Signed Date S'-A�" 5
Application Approved by Datea�99'
Application Disapproved fort folio ng reasons
Permit No. Date Issued v57—,,Z/— 9
Fee
No.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
2ppricat on for Mtgpogal *potem Construction Vertu
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. `j V T, ..�„ Owner's Name.Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Teel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder.( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan DateNumber of sheets Revision Date
Title
Size of Septic Tank' Type of S.A.S.
Description of Soil
Na re of Repairs or Alterations(Answer when_a plicable)
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 Certifi-
cate of Compliance has been issued by Board o ealth.
Signed Date
Application Approved by Date 57—�j,II
Application Disapproved for t9folldvvIng reasons
Permit No. Date Issued ��'2
.s_
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTI?thhat the -site Sewag Disposal System Constructed( )Repaired (graded( )
Abandoned( )by
at 0 /?mac has been constructed in accordance
with the provisipoof Title an the for Dis osal System Construction Permit No. dated S 1
Installer Designer
The issuance of this permit shall not be constru as arantee that the sy(em w'11 functi n s j4jf n d.
Date �` a — g / Inspector v rd
No. — Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
'Wi5pogar *p!5tem CotWtruction Vermit
Permission is hereby granted to Construct( ) epair(grade( )Abandon( )
System located at 60
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: S' '02 /— �/ 9 Approved by
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
CLI, hereby certify that the application for disposal works
construction permit signed by me dated S—d 1- 9 q concerning the
property located at o meets all of the
following criteria:
• The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
• The soil is classified as CLASS I and the percolation rate is less than or equal to S minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than five feet above the
mammum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation +the NlkY.High G.W. Adjustment. = 3 s
DIFFERENCE BETWEEN A and B o.2 1�
� SIGNED DATE:
(Sketch proposed plan of system on back].
q:health folder.cat
,
TOWN OF BARNSTABLE
LOCATION &Q CAV)k A6S SEWAGE #
VILLAGE C�wT ✓► ASSESSOR'S MAP & LOT /°l y O S7
INSTALLER'S NAME&PHONE NO. I U M A-5
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) S Tn�,�f/.��U/J (size) �STOvt�- ly��U+'►Ct
NO. OF BEDROOMS
BUILDER OR OWNER 0✓� l��/ �On�
PERMIT DATE: 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 facili ) Feet .
Furnished by
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TOWN OF BARNSTABLE
"LOCATION SEWAGE # � c
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. Svc /°^'�,S SEPTIC TANK CAPACITY k�l �4 t Of) g i N 4 Q 0 d/G
LEACHING FACILITY: (type) �� t��'ts►t�'�'�_(size) ,i�c.� Sty=
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility . '
Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
i
At
00 F�� V �o a� � as-
P�
' � :a
ra Board of Health ` s
Town of Barnstable
N®.. P.O. Box 534 b o
.................... Hyannis, Massachusetts 02601 Fnz..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F HEALTH
OF..... ........... ... . ............................
Apphration for UWposa1 Workii Tonotrnrtion Prrmit
Application is hereby 1,, dj for Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
�—
Lo tion Address o t o.
.._. ... _..... ••...••••.••.........•..... ...... • .....................................
Own dr
a ....... ...................••....... ...... ..................................
Installer Address
Q Type of Building Size LotA_.&..O.�q. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures --------------------------------
W Design Flow.._..__ _I_ __________________________gallons per person per day. Total daily flow_._ .........................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dos in 4a!,Percolation Test Results Performed by. .. .. .... .......Y.4..................... Date...____-1.' �_0..7_-----__.aTest Pit No. 1________________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........................
----------•------ . -- - - -.
ODescription of Soil ...._...._.. • - -- ---------------.............................................................
x
c., ---------------------- -,t r .,s.J..
w t
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 iITILj 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
op on until Certificate of Compliance has been issued by the board of lI lth.
1 /�
/ Date
Application Approved By---------- --------- =---��-..........................
Date
Application Disapproved for the following reasons-----------------•----------------•-•----•-------•-•-----------•--•---.-------------------=---------------•.....
-•...........................................•--------------.......------•-------.......------------........------------------------------------------------------------------------...._-----•-•--••--
Date
Permit No... ..-•-•-------------------. Issued....... ---.....
i
.51
.................
THE COMMONWEALTH OF,MASSACHUSETTS
BOARD OF HEALTH
Appliration for Dis' pasal Murk Tnnstru rtion Famit
�1
Application is hereby
de for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at ` fi �!
ra j� No.
Location-, . /�ii/� . JJ.�/.
......_... l .. �. ..........................................
Owner 'f Addre s
.............•--•-------- %- rr . „i;.f.'
/� - .... .....................................
Installer
Address
d Type of Building y Size Lot _-_-&...O-ZeSq. feet
aDwelling—No. of Bedrooms.........._____.............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures _...-•--•------•----•-•---•-••------•----------•---•-•-•-----------•••------•-----••---•...---•-•-. . ...----
w Design Flow...... i.>...........................gallons per:person per day. Total daily flow_._�..I C2-__.._____•.._.___•--_.___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 ( ) Dosin, ;tank
aPercolation Test Results Performed byfC .... -!........................... Date. 1..................................
Test Pit No. I................minutes per inch Depth of Test Pit___!'.............. Depth to ground water........................
Is, Test Pit No. 2................minutes per inch Depth of Test Pit____________________ Depth to ground water................_______-
a ................. ,V..................... r .............•-••-.-•••---•-••••-••-------.........................................................
D Description of Soil_. >, t . .......
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 rovisions of TITIZ 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
op ion
until Certificate of Compliance has been issued by the board of health.
g(. / fined_ *�i j -�� 'Er .c,t. €<_r_
.^ F f Date
Application Approved BY :~--��w, ^"_ t ._:.. . ' - .....--•--•--------•. ={
U t Date
Application Disapproved for the following reasons________________________________________________________________________________________________________________
..............•-----------•-••---.•._..-..---•-----=-----•-=•--------•--•-----------...----•-----...---...---•------------•-••-----•---•-••----•-•--•••---------•-•-•-•----------••-----•••••--•-•--••--
Dat
Permit No. s.-...r ----------•---------------- Issued_..... e
.............-•----.--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF, HEALTH
..........................................................
(Irdifiratt itf mptiana +
THIfIIS TO' CERTIFY .That the Individual Sewage Disposal System constructed (�or Re it )
by•••- ff�✓ ., ! _, ..-._..-•-•----...---•-----=---- ---- . ...--•-----• ---•---•---------------------•-------.._....-----•---
Installer l
has been installed m accordance wit i the provisions of TITLE 5 of The State Sanitary Cod as d cribed in the
application for Disposal Works C nstruction Permit No.__."� :_ z _•.___-_.-. dated_....-_�_ _= .1'_. . "a_____
.......... .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS�TRIDE AS A GU RANTEE THAT THE
SYSTEM WILL F TI N SATISFACTORY.
DATE..................... ............................... P Inspector - .............................................
F
+ THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
jZ
No .t_..::.- -•5 FEE=s.
Disposal Worko %T=otri Uan autit
Permission is hereby granted-•-..............................................
----•-•----•-•------------_..----------------------
.---------..-.. _.....-.........
to Construct or Repair ( � ) an Individual Sewage Disposal System ,ray
Q- _Street--- --- --�•a -••--•-----' 2+ ----•----.......
as shown on the application for Disposal Works Constructs No._�s�_".____._i___-_Dated...1_ .._ ................•._....
r Board of Health �
DATE �D...,-�------------------------------------•-•----
FORM 1255 A. M. SULKIN, INC., BOSTON
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LOCATION SEWAGE PERMIT NO.
1. 7—o2-3 fiUf 4
VILLAGE
INSTALLER'S NAME i ADDRESS
C�ET� 1/L-0 ff/ey 47;�t-6-.
R 1-1 L D E R OR OWN ER
DATE PERMIT ISSUED 1. o ��
DATE COMPLIANCE ISSUED �_ 10 _��
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