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HomeMy WebLinkAbout0005 CLIFTON LANE - Health 5 Clifton Lane Centerville P A = 226 104 ��►►IIIf ��ECVCtpp UPC 12543 No.53—3LOR- �Posr.coNS°��� HASTINGS.MN Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Clifton Ln Property Address Keystone Asset Management Owner Owneft Name information is required for Centerville MA 02632 12-31-07 every page. Cityffown State Zip Code Date of inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. A. General information 1. Inspector. v` Shawn Mceiroy Name of inspector Shawn Mcelroy Enterprises Company Name 29 Atwater Dr Company Address E. Falmouth MA 02536 Cityfrown state Zip Code 1-508-495-0905 S13971 Telephone Number license Number B. Certification I certify that i have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section g5.34k—of Title 5(310 CMR 15.000).The system: R; c_ ® Passes ❑ Conditionally Passes ❑ Fairs 7 Y ❑ Needs Further Evaluation by the Local Approving Authority Ai- 12-31 07 Inspector's Sign re Date ash M The system inspector shall submit a copy of this inspection report to the Approvin 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. t5insp•081065 Title 5 Official Inspection Form:Subsurface Sew D"age tsposal System•Page 1 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 5 Clifton Ln Property Address Keystone Asset Management Owner Owner's Name information is required for Centerville MA 02632 12-31-07 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: System is in good working order with no recommendations. 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"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 exfittration 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 t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 5 Clifton Ln Property Address Keystone Asset Management Owner Owner's Name information is required for Centerville MA 02632 12-31-07 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) B) System Conditionally Passes(cont): ❑ distribution box is leveled or replace 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 replaceO ❑ 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: El 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, 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. t5insp-08/06 Idle 5 Official Inspection Fom-Subsurface Sewage Disposal System-Page 3 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Clifton Ln Property Address Keystone Asset Management Owner Owner's Name information is required for Centerville MA 02632 12-31-07 every page. Cdy/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cunt.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 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: ❑ ® 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. t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Clifton Ln Property Address Keystone Asset Management Owner Owner's Name information is required for Centerville MA 02632 12-31-07 every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) D) System Failure Criteria Applicable to All Systems (cunt.): 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 regional office of the Department. t5ins 08/06 P' Title 5lxfidal Inspection Form_Subsurface Sewage Deposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Clifton Ln Property Address Keystone Asset Management Y 9 Owner Owner's Name information is required for Centerville MA 02632 12-31-07 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility,or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp-08106 Title 5 Official inspection Forth:surface Sewage Disposal System-Page 6 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Clifton Ln Property Address Keystone Asset Management Owner Owner's Name information is required for Centerville MA 02632 12-31-07 every page. City/Town State Zip Code Date of Inspection 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: 0 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 past 2 years usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: 11-07 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 I Other(describe): t5insp-08M Title 5 Official fnspection Forth:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments w 5 Clifton Ln Property Address Keystone Asset Management Owner Owner's Name information is required for Centerville MA 02632 12-31-07 every page. City/Town state Zip Code Date of inspection D. System Information (cunt.) General Information Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (f yes, attach previous inspection records, if any) - ❑ Innovative/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: 1997 Were sewage odors detected when arriving at the site? ❑ Yes ® No t5insp-OW6 Title 5 Official fnspection Form:Subsurface Sewage Disposal SystBm-Page 8 of 15 Commonwealth of Massachusetts ,-NO-= Tifigm f; Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 5 U91015 L117. Keystone Asset Management Owner Owner's Name information L% required for Centerville MA 02632 12-31-07 every page. cityrrown state Lip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade, feet Material of construction: El cast iron 0 40 PVC El other(explain)-- Distance from pirate water supply well or suction line: fee Comments(on condition of joints,venting,evidence of leakage,atr,.)- Septic Tank(locate on site plan): Depth below grade: 2" reef Material of construction: 0 concrete []metal [3 fiberglass E]polyethylene ❑other(explain) If tank is metal,Est age, yelffs Is age confirmed r by a Ceifficate of Compliance?(attach a copy of cefffficate� 0 Yes 0 No --------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 Gai Sludge depth:. r Distance from top of sludge to baftm of outlet.tee or baffle 290 Scum thickness 0 Distance from top of scum to top of outlet tee or ba,ffle Distance from bottom of scum to bottom of outlet tee or baffle 1.6" flow were dim,en sons determilned? Tape t5insp-08106 Tdie 5 OfftaW Inspection Fonm Subsurface Sewage Disposal System-Page 9 of 15 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Frapzr?;Adrd:��� Keystone Asset Management Owner owner's Name information for uoce€s Centerville MA 02632 12-31-07 required every page. City/Town state Zip Code Date of inspection D. System Information (corn.) Comments(on pumping recoendations, inlet and outtet tee or baffle condition, structural integrity, liquid levels as rented to outlet invert;evidence of teak etc_): Tank in good condition With-all:baffles.ire place. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal ❑fiberglass polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet teee 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 conditiortr structural integrity, liquid levels as related to outlet invert, evidence of teakage, etc.): Tight or Holding Tank(tan, mast be pumped attune of inspection)ate on site plan): Depth below grade: Material of construction: ❑ concrete ❑metal ❑fibefgJasSr ❑polyethylene ❑other(explain): t5insp-08106 TNe 5-Official,Inspec6ars Fom:_Subsurface.Sage QisF [System-Page 10 of 15 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 5 Clifton Ln Property Address Keystone Asset Management Owner Owner's Name information is required for Centerville MA 02632 12-31-07 every page. Cityfrowrn State Zip Code Date of Inspection D. System Information (cont-) Tight or Holding Tank(coat_) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order. ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan). Depth of liquid level above outlet invert 0 Comments(note if box is level and distribution to outlets equal,,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good Condition. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5insp•08/06 Title 5 Ofidal inspeclian R=Subsurface Sewage Disposal System•Rage 11 of 15 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Clifton ILin Keystone Asset Management Owner Owners Name informLs ation required for Centerville MA 02632 12 31-07 every page. cityrrown State Zip code Date of Inspection D. System Information (colt.)- Comments(note condition of pump chamber,con.ditiort of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why:. Type: ® leaching pits number: 1-6'x8' ® leaching chambers number: 3-cultec 330's ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ❑ overflow cesspool number: ❑ innovativetaftemative system Typetnarne of technology- Comments(note condition of soil, signs of hydraubcc faffare, level of ponding,damp soil, condition of vegetation,etc.): Both structures are in good operating condition with no sign of back-up or break-out. t5insp-08M Title 5 CTtricW Inspection Form:Suhsuftee Smage Disposal,System-Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments b 5 Clifton Ln Property Address Keystone Asset Management Owner Owner's Name information is required for Centerville MA 02632 12-31-07 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.): t5insp-Oa/06 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 13 of 15 fifiMt11Onwea to of nnsssachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Clifton Ln Property Address Keystone Asset Management Owner Owner's Name information is required for Centerville MA 02632 12-31-07 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. A -0- 6'4 6_0- 17 " A-L 25zl, i rrn�f A-14 - 19"G Q• 011, "insp-081t16 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 14 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 5 Clifton Ln Property Address Keystone Asset Management Owner Owner's Name information is required for Centerville MA 02632 12-31-07 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to ground water: 21' 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 hale 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: Original design records indicate groundwater at 14'glow bottom of leach pit. t5insp•Qa/06 Tate 5 Offictal Inman form:Subswface Sewage Disposal System-Page 15 of 15 THE Town of Barnstable � OF 1pk Regulatory Services SARNSTABLE A; Thomas-F. Geiler, Director y MASS. . 0 1639. Public Health .Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. No. 7 3 Fee ed -�- ' THE COMMONWEALTH OF MASSACHUSETTS Enter in co4 uter: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS LY\ 01p rication for Mi.5po0ar 6?5tem Construction Permit iw A 0% p on for P rmit to Construct( )Repair(k/S'Upgrade(v)Abandon( ) ❑Complete System ❑Individual Components Location ddres or Lot NO. Owner's Name,Address and Tel.No. ,5-08^M/ S',36 8 Assessor's Ps S' /S Cen 1i6V<ST ,v,r/?�/1m:.✓6./>�, 01�'65r Install''s Name,Address,and Tel.No. ya -5-6yz Designer's Name,Address and Tel.No. P os -el ,/A� 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 Nature of Repairs or Alterations(Answer when appl'cable) Uo cS'Aor /SOD 6�/SPD%r c �/�ifr B6it — r,,rr so CA, lu 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 issu by this and of Signed Datea— Application Approved by %Ld!!54Date O �- 7 Application Disapproved for the ollow reasons Permit No. Date Issued - —.__ -- _-----------------------------y------ ._. �. �- -� i :7. No. ��� �: �r /; � Fee THE COMMONWEAL OF MASSACHUSETTS Entered in ter: Yes -------PU. LIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ff s✓ .F � .. 01 rication forigogapgtem� ongtruction Permit Application for a P rmit to Construct( _)Repair(KUpgrade(v')Abandon O ❑Complete System ❑Individual Components V. r Location Addres or Lot N -Owner's'Name,Address and Tel.No. .Surf` -66 •S36 6 s Assessor's p/Parcel CF,vTF��, i /s,2 C'ei teA ST N•✓?a'Aoi.«6I>/i. O-86y Ins er's Name,Address,and Tel.No. ya 8-5 64/O� Designer's Name,Address and Tel.No. GO2Ooe\� MpuS_ OAT /. fti ��Rv�v!' I OS7C'«,I1c Type of Building: Dwelling No.of Bedrooms J Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flaw gallons. 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 appl'cable) Uv Cr A o c- /.SOO 6�1_Se- %,c 7;�/t, -9%S77 �ok �- 3c,,r cc 3-3o C i'�rYJ f3 fv(�eUU0�c) �� /`YS704(2 -OL I`S7C4(! Date last inspected: Agreement: s. 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 beenssu y this azd of a Signed =�G Date O;rllt Application Approved by Date U Application Disapproved for theYollowilk reasons Permit No. 7 - 3 / Date Issued ell, ' -------------- -----------�� ---- 4X'? ----- ' , Y THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compriance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(Upgraded( ) Abandoned( )by at 50 c) ©�D C 2,,Z;��V c e e, 1• has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9�-J? Vc-' dated Installer Designer The issuance of this pe t shall of be construed as a guarantee that the syste will unction as designed. Date Inspector ` J r --------------------------------------- No. ZZ._a3/ Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 'Wigpogar *pgtem Congtruction,permit Permission is hereby granted to Construct( pair(- Upgrade( )Abandon( ) System located at Sd0 0/0 �,24/fl'1 " �'e�V7- 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 th• permit. Date: A o— 77 Approved by 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) I, Cop hereby certify that the application for disposal works construction permit signed by me dated , concerning the property located at 5-00 0� o C(z i I)e 11 - Ce ,x o meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED : DATE: �p?� LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. j xert �. �. �C�,, ISoc�SA1. f 9N/� 1\{e.� ��s 1 , �o � d r � L r V 3 ��-�J Cu lTe c 3 3 a C�iA,v`�e2.5 � S v r�ro,,,,,,�,�, �7 �yd,` 5`��-e. - C l.1 - 11 - �2� "" �-` TOWN 0 B� LE LOCH CIOZ`. - SEWAGE # _, VILLAGE /������ ASSESSOR'S MAP & LOTa96 64 INSTALLER'S NAME&PHONE NO. Cv 2Ou It P(J)— SEPTIC TANK CAPACITY A5-0 C C,97 LEACHING FACILITY: (type) 61A 3 Cv//CC 336}(size) 7 ?6 NO.OF BEDROOMS BUILDER OR OWNER t r1""l � i 'eez BUILDER C� PERMIT DATE: ZU A C -a c` 'S 7 COMPLIANCE DATE:" '6' r 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 T,qn� , all ' c A � CL/F� TOWN Of BARNSTABLJE LOCATION .� �I7 G /c C SEWAGE # "3/6 ASSESSOR'S MAP dt LOT;O— C�"7 INSTALLER'S NAME&PHONE NO._lC C'1'Cr?u .1 u M O t i)— SEPTIC TANK CAPACITY 1S-0 C tj/}/ LEACHING FACILITY: (type) 4!!� �T� T 3 CL,/jr336(size) 7 JCc�Sr NO.OF BEDROOMS 3 RtUDER OR OWNER (1 wt `)v Hcez PERMITDATE: 5�: c -a�� S7 COMPLIANCE DATE: --2,, — / 7 .S.epaTation 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 ov, w r i `• COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL,AFFAIRS F' DEPART=NT OF ZNVIRONMENTAE PROTECTION a .Soo 0/0, (S�/`��v,Ile R)) old / // 01 c�d�'eSs OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A G/, CERTIFICATION S � ,�, Property Add, L. 6i he- E1V EQ owner's Name Owner's Address: S c .7 tag 1 4 TO of Ger, rv,' sy "G 0 Bl-E /� OF. 0 TOWH epT Name of Inspector; print)Company Nan= �a MaOing Addr'rss: o T�G�f 'r � (��R o x oL V� Telephone Number: oa 6 q' PARCEL CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposalbelow is MO.accurft and compide, system at this training and experieooe is as al the time of the inspec�i�• � bid on�4 Rw approved system inspector iirnction and of on site sewage disposalamled sys�,I am a DEP pwwant to S'ecction 15—W of Title S(310 CMB 11000). The sy : �/ Passes NConditronaily Passes Fails ee*Further Evaluation by the Local Approving Amity Inspector's Signature: Date: 41 � The system inspector shall subnut a copy of this won�n to the Apprmng DEP)within 30 days of completing this inspoodion.If theAuthorit (Bow of health or gpd or greater,the inspector and the stem owner shop is a shared systtemem or has a design flow of 1 o,000 DEP.The original should be sent to the system owner and copiessent to the buyer, cableregi and torwe he onal of the approving Notes and Comments ""This report only describes conditions at the time of in mspectio.and under the conns of use th time,This inspection does not address how the system el perform is the fature ender 6 orat t conditions of use: different I . _ fto2of11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE SUBSURFACE SEWAGE DISPOSAL SYSTEM PART A ON FORM INSPECTI �S CERTIFICATION(cond..d) Property Address: C 1, r o� r. L g onne � L Date of ". fl teary: Check AAC90 or E/_ WA_n complete al of Section D A` $ �paw _. I have not 6rmd any ifs whichthat any►of the fwlrae 13.303 ar in 310 CMR 13.304 exist.Any'>hiW l a teds not evalnated aro below. tbed in 310 C'd1�1R Comm X System Conditionally Passes: One Of more system conponeou as desaAW in the--Conditional repaired'Ile system,„pan comlleton of the� ,as me section Board of Haak win past. Answer yea,no ar not determined(y,NND)in the for the fall . , 8 t�If not den p kM The septic tank is metal and over 20 Unsound, shuctmany its ssbgidi hi nation c r Years old'or the septic tank(w l or not)is e'�in8 tank is replaced with a oompdying sep�• aPproved%UUM of tank failm is 11Od° will per , •on if din *A metal septic teak will pass mspectipn if it is strucpaally �leaking�Bawd of Iiealtl� indicabing 1>us the tank is lest than 20 years old is available. and if a C ND explain; - Obsuvado ofsewaW b2dmP or baaak out or high statie water level in the 4 add o'er broken,settled or uneven d�,•b„w box, System win m P�n If(with due to brokm of broken pWs)ale replaced obstruction is removed disutution box is leveled or reps ND explain; sYVCm required lamming more than 4 times a year due to brakes or Pas inspection if(with approval of the Board of Healthy °bsftucted PP*).The system will broken pipes)are r+ep>u obstruction is removed ND explain: . d • Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO FOIM PART A ORM CERTIFICATION(coati Property Adder 01 h Owner. P-A Oa / Dare of Inspectim. ,6 G Mulber EvalutIOU is Required by the Board of gqm Co mkionsexist which req&c fbriher a i� the faahng to Protect:public health s2{ty or the e' Board of Health in aad�to if the system L System wM paW nnjm Boats of HeaM determina it acco system is not! b a manner rdance with 310 O 151 )that the which protect public:heath,sahty and the ftwhummeft — Cesspool or privy is within-V feet of a surfaos wad Co of i�T is with sa f+oot of a b°rdern6vegwetlaod or salt marsh 2 System wil fail amass the Board of Health(and Public Water Supplier system is>�uning IN manner that p the public health,sa and it any)dete m that the The system has a septic tank and soil ��e water supply or tributary to a sudaa abswpd�s (systm aIId the SAS is within 100 feet of a system has a sepdc tank and SAS and the SAS is within s Zone I of a public water SqV Y The system has a septic tank and SAS and the SAS is within 50*9 of a private water supply well. 1 wathas a tank and SAS and the SAS is less than 100 feet but SO feet or more liom a supply well Method used to d astance ;�system passes if the welt bacteria and volatle organic comp � �a DEP oe�tifiod W03',for coNfam the that the well is Ponutie faahue criteria are t ngguvd q�y of and nihft anma t0 a2 less than S ppm,provided t from that amlity� be attached to this form, Other. { I • Page 4 of 11 OFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(contiinued) Property Address: �i �7`O IA L g a-- Owner: Daft of Inspection: D. System Failure Criteria applicable to all systems: Yon must indictee`yes"or`tor to each of the following for an inspections: Yes ✓—/Bwkop of sewage into hmhV Or Wstem Componad due to overloaded Z '" a°r ton ftg of affluent to the scufate of the ground yM or clogged SAS or cesspod t gged SAS or cesspool waters doe to as overloaded or - '/-Sttaafte hhgmd levd in the&SUR }�above pet um-at due to an overloaded or clogged SAS or 001 �e�imd�m cesspool is less than 6"below M-ect or available volume is less than ��qWred pig more than 4 times in the last year Na due to clogged or ��$ow, times Pad pipe(s).Number E/ on of the SAS,cesspool or privy is below high goormd water elevation, portion of /water supply. cesspool or privy is within 100 feet of a surface wad ywpppy or tabutaty to a surface ��y ports n of a cesspool or privy is within a Zone 1 of a public well. /Any Porte°°of a cesspool or privy is within 50 feet of a private water SW*welL _ c/ supplywell with Any em than 100 fed but greater than SO feet ftm a private water performed at a DEP certified laboratoer ry, ems. IT>h p d the wen water arratysis, indicsdes that the well Is free from r9'for cA m thatorm bacteria and volatile organic impounds nitrogen and poQattost tibm that faeilHy and the of ammunis are nitrate nifrotea is equal to or less than S ppm,provided thate goer�re dkria A/ copy of the analysis most be attached to this form.] ! V Q (Yea/No)The system Laft I have determined that one or noa of the above f the system fiWLailure as Heahh to descrOjed in what will>thereforeTim �n e�he Board of necessary to correct the fai owner should COS the E. Large Systems: To be considered a large system the system must serve a f gpd. sty with a design flow of 10,000 gpd to 15,000 You must indicate either`Yes"or"ne to each of the following: (The 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 tnbutary to a surface drinlang water supply — the system is located t a supply well five atrogen rea(Interim Wellhead Protection Area—IWPA)or a Zone II of a public water u mapped If you have answered"yes"to any question in Section E the system is considered a si `Yes"in Section D above the large system has failed owner or Z��t threat,or answered signi5c M threat under Section E or failed under Section D shall r �qm considered a 15.304.The system owner should coact the appropriate regional ou e�rdanm with 310 CN R Page S at l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSE&Vff TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORAM PART B CBECKL[ST Prop"Aad-- ,le- �3�-- owser: Date autos; Chest if the g have been dma You most k&case`vee at"nog'as to each of the foitoaring �IJo was provided by the owner,owupod.or Baandaf Heabb Were any otffie system caszpo cats pumped ad in thepcevx=two weeps the system modved normal Boors in the psevicnra two week period Have large mA mm atwater bees fi t d to the system recently ce as port of this man Were as bulk plans a€the system obtained and mamhzed'1(K&9 were not a nft as MA) _ Was the facility air dwemng inspected for of sewav back up _ Was the site iospecbed for signsof break out Were A system comPongnts,cwhiding the SAS,located on site Wen of baffles or the tank =wvemd,opcnect and the alr tha tack far the oo On �►nmkmd atconsbuchM dimwdoaa,depth of liquid;depth ofshsige and depth afscom Was the ovaer(and omquou lf&ffcremftm°v+ner)p vwded with inftsubm on p sabsarfaoe sewage&Rxm l the The sue and kcsdoa of the Soil Absorption System(SAS)an the site has been determined based as Yes no� . I/ &&rmatic&Fm emmpt,a plan at the Board of Heatth, wd15.302(3)(b))( is uooceptabk)E310CMR of the failure criteria related to Part C is at issue appudmada®of distance Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address¢ Owner: ��Q ✓v, Oa- 6�� Date of Inse; Q RTMENT" FLOW CONDITIONS Nizzaber of bedrooms(desigp): 3 Number of bedrooms(actual): DESIGN flow based an 310 bZ 15.203(for example: 110 Wd x#of bedrooms): 2-3O Number of current red&wx / Does r+eddence bm a gauge grinder Oms or no):e''0 Is laundry an a sepsraoe sewagF system ON as ao):^ Wyes �►s9siem inspecoed Omar nux /— Seasa®at use:(yea ar my./tro water meter read' M it avaSabta f1"2 yem usage Up*): Last class of aoarpmsy; ic„ �- CO1MD USTRI" TRU of establishmeok Design!flow(basedon 310 CMR 15.203): sod Basis of design now Grease�I �ar noj: Industrial waste bolding tank pteseut 6=or no). N°II'sa*Xy wasta discharged to the Title 5 system(yes or no):—Waft meter reading:,if available: Last date Of wxupanglase;•, OTHER(descrbe): moping Be=* GENERAL 24MRMATiON Source of information; r �P ox /� If volume as Pwt of the inspection(yes or no):�0 a"�r �S o ® 1 Reason for pump—�—How was quantity pumped mod? �f SYSTEM Septic task won sail system _Single cesspool —OverBow cesspool —ftiV7 =Ins(yes or no)(if yes,attach previous inspection rem ifany) native technology. Attach a copy of the current opemou obtained from system owner) »>aenanoe contract(to be __._Tight tank _Attach a copy of the DEP approval _Other(describe): ApproxmW age of all components,date inst2flW(if]mown)and s information: were sewage odors detected when arriving at the site(yesofno):/YU Par 7of11 . . OFFICIAL INSPECTION FORM_ . .. SUBSURFACE SEWAGE DISPOSALNOT FOR VOLUNTARY ASS - PART C STEM INSPECTION FORM p �� ,���� /SYSTEM INFORMATION(oontinaed} 'rOPeatyAddre - Owner: CNL# Date ofIn� /G 0 BUILDING SBWEg(locate site plan) �m itn� 4 P VC other(el). watercounnaft(OR confition te wa orsoc�� evidence otleair i -.). SEPTIC TANXDeA �( og sue piaa) lowMWMW =-- �/ ). fibergl If tank is meW fig � t X by a Certificate of Compriana(yes Or no):_..(aftwh a copy of Dimensiont- Sledge depft Dismnoe= a, to bottom atoutlet tee ar baffle: 3_ ostg Distaooei� _� top scam to top Ofoutlet tee or baffle:Distance How aasfde m odonflet orba®e Comments(on pmnpingreoovr` aped to 04 and tee �" m ba$le co �' , , l integrity,liquid levels ° ' p V e Q s. GREXU T on sue plan) Depth below grade:_ maftw(( )°ion—concrete _. �sa_polyethylene_,othen Dimendom. scorn tom; DistaaceMft"Som top scam to tOP o[Outlet tee or baffle: hom bottom D �scnm to bottom of outlet tee arba Comments as rebW to( egzevOmme a�fu� oM inlet ad outlet tee m ba$1e ,& M etc. • co on,dal ,liquid levels OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMKM SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(cou&ueM Addrn7/6�H w Owner. l Date of Inspecd0Q: G TIGHT or HOLDING TANK;=(taak must be pumped at time of )&gts=site Plan) Dcpth below grade: Material of co"sm metal Design Flaw: Abu=;,, bo or ne): Alarm Date �S Alarm wodoag order oft of no): Cow(condition of m and floes s%tcbes,eta): DLSTROUTION BOM- (if present must be opened)(locate on site ` pin) Depth of liquid levd above outlet mvmrt:4(V* 7q Commeaw(note if boor is level wd distnbu nOWft eqi*�9 evidence of solids �o or out of bow ettk �Y any evidence of )-e. ° No PUW CHAMIMw /"on site plan) AimPa in working order(ea at nor Alarms in waddeg Mjw(yes or nor CommcM(note condition dpump dWnbea,condition of »md 2PPmt=M:M etc.): Pale 9 of l l OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oonti Property Address: Owner. GvG!/terv� Date of Inspection: 1 SOIL ABSORPTION SYSTEM(SAS); (locate an site per,euavadon not reqWiree If SAS not located explain why: Pita►mmabea: �o X 8chambas, �' �B 0,;> C�c.1 / 7�2G C (SIG►., hPrj WcWn8 overflow cesspool,rmmber: o�-3s e •� Comments(mo c on W of ; etc.): / � icum level of poading damp ,can of�getation, o ��► CESSPOOLS- /�( must be pmmped as part cf inspcWoaXioc�c®site pica) Number and conrlprafio& Depth�h—top of lfgaid to inlet iavect: �soM : D Di�om<af Materials aft; Ian of water ,(yea or no): Comments(nok condition of soil,signs of hydmulic fame,levd ofpondWa condition of vegetatioq etc.): PRIVY:..LV (loc*on site Plan) Materials of construction: Dimensions: Depth of solids: CommeM(note coition of soil,signs of hydraulic failure,level of pon&lg,condition of vegetation,etc-): 9 r palls to d l l • OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS •`` SDBSMWACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(c=tit u4 Property Addy G/ lew o Al--ea n..G owner. 3� Daft of hupectiem g/ / SHBTCH OF SEWAGE DRWOSAL SYSTEM Provide a sketch tithe se,"r 8 ties to at least two permanent refaeem l of bend Locate an wells within 100 fed.Locate where public water supply enters the bm'kbg, G 1� Q 3 - O a3' �O . PaBellafll OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C r SYSTEM INFORMATION(wnti=ed) Property Address J le Vi G ct Owner. wi e- GN v / �� �� Dale of Sli7'Z EXAM Slope Sudaoe water Check odlar ShalioW wetly Famed depth to gto�d water �-� feet . Please nee(check)air methods used to detemine the bio gvmd water aftsbm from system desip phs on tecnfd-If chocked dete of design ph reviewed: site( PnpaKObbservation halo mw ISO feet SAS) Checlnod with local Bawd of Healthexp�laine G� Acoessed USGS daW=*cgA ( h won) To� YOU meat you o h ground w � : Gr s- / Q!/ tea. ` �� G, a•r d . S' 0°' - ^ _ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Se 1.wage Disposal System Constructed ( )Repaired (VI")"Upgraded ( ) Abandoned( )by at as been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer GO kno Designer The issuance of this pe t sh 1 of be construed as a guarantee that the syste will function as designed. Date Inspector i I Fee so THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION . BARNSTABLE, MASSACHUSETTS Mi5poq;a[ &psStem Construction Permit Permission is hereby granted to Construct( ) pair( Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of th's permit. Date: j�=A- 0-97 Approved by Bruce MacaUlster SHORELINE CONSTRUCTION 87 Pond Street OstervWe, Mass. 02655 eze•ss2s William Butler July 17, 1997 152 Central St. N. Reading, MA 01864 � C1;s�-y, lam► Re: 560-91d--C-�atg�e--Rd- Centervil-le Enclosed is a copy of the septic permit and certificate of compliance. Entire form is on record at the Town of Barnstable Board of Health Dept. The septic system installed is a Title V system as required by law. The system consists of the following: ° 1 ,500 gallon septic tank Distribution box-piped to 1,000 gallon precast pit surrounded by 1 1/2" stone and piped also to 3-Cultec Chamber 330's surrounded by 2-3' of 1 1/2" stone. 'T C> Yin d4W' I �] t /' ��..-----'" f / IV /Y) # i _A 9-1 OvT��r �°Y It I -C') Ld1 TOWN 9F BAPSTABLE - - LOCATION / c c SEWAGE # VILLAGE Cc—�7eFlrt-- f C ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE N0. c'+Q00 N �`n.nv `1P 5 y SEPTIC TANK CAPACITY 45-0 0 LEACHING FACILITY: (type) o6 9 YY CZ/TC (size) 7 X NO.OF BEDROOMS _ BUILDER OR OWNER PERMIT DATE: 6 `2 C _'177 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 J w 'l i ' Sea'chfor Map/Parcel�`�a �x 226104 � ��� e 3 " `� 3 � � Tgwnof Barnstabi'e �~ p ,' i®ntal tope )226104 r� Business Naine� Zon ofContibutxo .tN)� ; r Phone� 000 � 0000000� F,uei�Stora Tank ermit � �*- s �� -� 2 ��'� H 5 Di pos lmyork s : ctxo Per FtIeJP unit No � `"t .: 97 315 nT A� y x xt p p 06/23/1997 O let on Dates w In 1500 ST 3 CCULTEX 3 STONE " map Uw r 226104 ner' WELLES JOHN H p gploc " 5 CLIFTON LANE x , � s ��`t,"��.' /�3jY .S,.�Y`tCt C✓ "/1 />,�`t � .,5< ,¢ �--''>G � M�?,,�t� �! � 4 'M � �A„ .. w L y No. s.'... ?: FEE....�...�r.Q�....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ----------------- --- --T-own...OF........Larns-tahla.----------------------...................--.......... Appliratiun for UiupuuFal Works Tunitrurtiun rrntif Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal System at: 154 Green wood Ave:., ?�3 �iI1 s.�..M�...... .........................................._..-----... - ................_.. .......--• ........................................... George -Address or Lot No. George J. Tzimorangas „ 8 Washington.St:t Lrookline=_MA __.02146 Owner Address W A & B Cesspool Service 128__Bishofs Terrace, Hyannis,.-A, 0260.. ,-� ..................... ----..... . � Installer Address d Type of Building Size.Lot----- --------- -------Sq. feet UDwelling—No. of Bedrooms.................... ......................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—T e of Building .......... No. of persons------------3--_--------. Showers — Cafeteria Q' Other fixtures ............................................................... W Design Flow............................................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. Seepage Pit No..................... Diameter.---_--_---.----.-- Depth below inlet--.................. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit---.--.............. Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----.................... W ----------------------------------------- ------------------ •------------------------ -....... ....---- ------------------------ --------------------------------- ODescription of Soil................SarA............................................................------------------------••------------------------------------------•-------••••- W U --•-•••••••••••--•---------••-•••-•--•-•••---•----••••---•-••••-----•----•---•••-•-••..........•--••--•-•--•••-••••-•-•..............•••--•------•----••-•----••••••------•------------•-•------•••-•-- W -••-•••----•---------------------••-----•-•••--••••------------••••-••-••-••.......-•••---••----••••----••-•--------------------•••••--•-----------•--•-•••••-•••••••---•••••......-•••••-•---•------••- UNature of Repairs or Alterations-Answer when applicable,_1 nstalla tian..of...a-•1,1100...gal1orL--segtLc.Aank and LODQ..gallan_..st-anc...packed-.lsach..Tait...(averfl.Qw).................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITYLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the oard f health. Signed = j ... ....3/2242..-•------- y� Date Application Approved By........... _ A.....--a,// --....................... ............3/220 ..--------- Date Application Disapproved for the following reasons:-•-----------------------------------------•--------•-------------------------------...•-- ......------------- ----•------•--••••--•-----------••-•--•-••••-•-----•••-•-•------.....-•----•--••••---........•-•---•---••-••--------•-----------•--•----------•-••--------•...•--------•-••-••••----•---•----••------••- Date Permit No..,?O,2----------------------------------------------- Issued---------------- 122182 Date MiONUAIPALT OF MASSACHUSETTS TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE e & �er- U c 1I/1C ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 0 (tYPe) LEACHING FACILITY: ' A 3 �� T C c 5(size) k� � 3^ NO.OF BEDROOMS S BUILDER OR OWNER e t/ . 7 t7 Se 17 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) 1.4ggec k-C-A Feet Edge of Wetland and Leaching Facility(If any wetlands exist 12 within 300 feet o leaching facility -Feet Furnished by JI�CcG�h 'TOWN OF BARNSTABLE LOCATION SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY.(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet J g �' Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY TOWN OF BARNSTABLE LOCATION C` � ` SEWAGE # VILLAGE �eA ¢'P1_ U l I ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 0-60 C�a LEACHING FACIL=: (type) ?' 3 Te c 5(size) �Wd— 3^336 s NO.OF BEDROOMS 3 BUILDER OR OWNER _T Jp 5Se74- /►'I/1cZ� PERMITDATE: 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 o leachingfacility) Feet Furnished by '54, a Zvi /_ nr tR No.&? .__.... - Fizs..$.... .......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '" .. ............ --------- ...T.M--n....OF.......F.arrestabhe.._..-...--... - ° Appliratilatt for Big in'tt, Works Tomitrurttntt Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal System at: Yr....Green..Qod..A 0x,...HAnags-*--Mg-----02C01..._.... --•...................................................•-------------.......------........---....-- Location-Address or Lot No. Ceo?1',e J._ zimoxan as---------------•-------•-------..._...-•------ 5f3 Washin-tor, St. . Brookline. MA ..0211�6 ..... Owner Address a A & B Cesspool Service 128-�?ishops Terrace, Hyannis, MA 02601_ Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms__________________2_..-__-_______________-Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons__.___.__.3_______________ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) Otherfixtures ---------------------------- -------------------•-----------------------•------------...-----------------....-•----------....---..-_...-•---•----•--- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 1:4 Septic Tank—Liquid ca.pacity............gallons Length................ Width................ Diameter________________ Depth................ 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 ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ <s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 •-•-•-•••--••••••••-•-•-•-•••-------••••---••-•••-----•-•--•-••-._...---•.....................•_...•........................................................ ODescription of Soil...............SairL.............................................................................................................................................. W w UNature of Repairs or Alterations—Answer when applicable.-installatlon_-of__a._1,000..gallon._septl-C__tank and_1,000•--gallon-_st_one-•-packed_leach--p-it---(averfl_aw.)-.-----•--•---•--•---•-•----•••----•••-••-•••••-••-••-•------------------------•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITITE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by thoardrof health. Signed.e:�.��fli6.." t 1,11t-IC,C.,,e G`3CJ C). 22 82 Application Approved BY .... �_...r'�....... 12282-----•- Date Application Disapproved for the following reasons-------------------------------------•----------------------------------------------------------------.....__.._ -------••-----------------------------------•------------•--------------•--------------•-----------------...-------------•----------------------------------------------------------------------•-•------ Date Permit No..Z -_-_--_. Issued._.._..... 3 22//82 ---,•-----••••---••-------------- Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ................T.QM..............OF...................B%=St ble...................................._... Trrtgfiratr of Taaatttpliatta THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (( ) or Repaired (x ) by A & .B Cesspool Service,__128 Bishops Terrace, Hyannis� NCI 02601 ...............•---•---•••...._••---•-- taller 1 Greenwood Ave., _Hyannis,- MA 02 ------r®orge---J. Tzimorangas........................................... at.._.._•-.fir-t.�. . --- ---- has been,installed in accordance with the provisions of Ty�T L: r f The State Sanitary Code ps des ribed in the application for Disposal Works Construction Permit iV'o."2"._-_ __________________ dated..-.._____-_-/_22/__t_5.............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE-THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......--•---�/f_..X82......... Inspector................................................. .......................: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town OF.-...Earnstable .................... ...... ............................. No... . ..-:. FEE...........0........ �i��aaa��t1 aark� ��tt��rUatt rrbtit Permission is hereby granted.................___A & B Cesspool Service ----------------------------------------------------••-................_...- to Construct ( ) or Repair an Individual Se a e Disposal System at No......15 Greenwood Ave., Hyannis, 02 0 - George J. Tzimorangas ........................................... Street as shown on the application for Disposal Works Construction Permit No.$.2.'___.._______ Dated-----------44 2/82 ---------------------------------------- 4/ /�32 B r of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS f- �l�Nur�B ` S C4-lFTo� !-rx neel/i� L O' ION SWAGE PERMIT NO. 4.r VI J� ",ulkAx�- I N S T A LLER'$ DAME i ADDRESS Z 3 UILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED r �+*�w ------------------ 3. /0 0 l `