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Home My WebLink About0124 CLIFTON LANE - Health .24 CLIFTON LANE, CENTERVILLE A=247-012 r llll � UPC 12543 �a Now HASTINGS. MN V AM:HUI. Oiaudreau Jr. 781+396+5874 10/10/2008 09:54 #957 P.001/002 JP OC ALBERT H. RUSSELL,M ATTORNEY AT LAW 101 MAIN STREET, SUITE 216 MEDFORD,MASSACHUSETTS 02155 Tel (781) 396-0760 Fax(781) 396-5874 L t FAX COVER SHEET Date: October 10, 2008 To: Thomas McKean No: (508) 790-6304 Subject: 124,Ciifton.Lane, Centerville, Tv1A r No. Pages: _ inc udes c®vzr s` eet) Dear'Tom: I represent Joan Berglund and her husband Rick Paige who are the Buyers today of the above-referenced locus. Yesterday, I saw for the first time a deed restriction that was agreed upon between you and Atty. Paul Attu, who represents the present owners. I didn't have any input in this restriction, and I would ask that you would consider what I have to say- Firstly, my clients have no quarrel with the notion that the current use of-the home ' should be restricted to a 3-bedroorn house, since that is what the current Title 5 regulations impose. The problem as I see it with the language of the restriction that is currently on the table is that it would forever limit the use to a 3-bedroom home, regardless of whether there has been a material change in the conditions or in the law. For That reason, I would respectfully ask you to consider me to add language to the end of the paragraph numbered 1 to read as follows: "provided, however, that the installation of a public sewerage system that services r.' the locus, and/or a change in the regulations of the Town of Barnstable restricting the locus to the use of a septic system for no more than three(3)bedrooms shall provide the then Owner of the locus the right to be relieved of the restrictions contained herain upon C1104T o application to the Town of Barnstable Board of Health." 1 �vkhvr. a e a�� ✓yvu x �-- `E} y a; ky? y fi t ( .Frj�wn:h.Bo u Jr. 1+ + 4 10/10/ D d:54 #857 P 2 #!.' . � . /[ Thomas McKean October 10 2008 \) Page Two \• Please advise. Thank you for your consideration. � A � \[ V !ru y ur% A\ � ALBERT H. SSELL JR. : 'H-\ . ! « c : Pall A{e%Esquire (0� 771 -l04 • � \! . f , . : �. . . . . . w� • j \\ � �� . . . �. #b .. . ! L .� . � . | .m, . . . /® . . < Hi . , \ .�y • :: . . \\\:/ . C Ot ram.... or, i 1 L t Vi n (~co rr\ glesfoo l o� �1. 144o r\ .j Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane _ Property Address Jankel Cyker Owner Owner's Name information is Centerville MA 02632 08/02/08 required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. When filling out A. General Information {►tT5131 - forms on the computer,use 1. Inspector: only the tab key i to move your Michael Kellett1 cursor-do not Name of Inspector use the return key. Aardvark Environmental Inspections Company Name P.O. BOX 896 Company Address East Dennis MA 02641 Citylrown State Zip Code 508-385-7608 S13742 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 o +he time of tine my-pe- ion. was performed based on my training and experience in the prover Function and-;maintenance of on siten - - - _—=au'c i3i:�u% "-je, �- :sici-ice. s�a3s ' D::— =ss'a'` vv'�y'a`.'� icsaa aaa x_ �.'r,`e s ss � s vi Title r i— .0° a T' - t y`'s m— � Passes ❑ Conditionally Passes ❑ Falls w,d co ❑ Needs Further Evaluation by the Local Approving Authority ++t 08/04/08 n Inspector's Signature Date SLY ti ..i i, �L- 1 e ;i, e e , s all ss�bmit a copy of this inspection report to the Approving Authority (Board ;ply_:- ,t or i:_ S i_itl it z ays ct co—pieti a this inspection. If the system is a shared system or ns a oes gn I<;w o. s u,000 gpu or greater, the inspector and the system owner shall submit the - - -- - _ - _ - ----- --- a �E `. E U GIiII VVt./il.ai.3VfSi iV ifiV VSf�Vi. iI fa F/l/11Lc%V4.. Cdi i`L li L b1 Yb Vf VV -f\.i G4l lfiV 1§.1. rscf.Fs 4sie sa aaaPssa sssa rs.�s4�av d s� _ AA __- -.:c .tea.._.._a... .. i.: 6_:�-- -nnr! -ong 8_. !-a �3' i9? .;onn- and --a§0.,le-ti- � !! 3#'§S94§� SJ3 --_ .• 4 _ .._.4 ___`ice-.- _�r' .. _.ra�-"<- - - - •' e._- _m��._ -._- � ---- .- _.- �,..... _ �._--- _g ;•�.'..}3�a-ai t59=+• .'a 9;r'ea'sai�3Ga i°."+' f33 xYi 5§a 8^__� 16a 0 ' M Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane Property Address Jankel Cyker Owner Owner's Name information is Centerville MA 02632 08/02/08 required for State Zip Code Date of Inspection every page. Cityrrown B. Certification (coot.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or 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"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed I` Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Forme Not for Voluntary Assessments s..°' 124 Clifton Lane Property Address Jankel Cyker. Owner Owner's Name information is Centerville MA 02632 08/02/08 required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,N 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. Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 124 Clifton Lane Property Address Jankel Cyker Owner Owner's Name information is required for Centerville MA 02632 08/02/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **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 Y 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane Property Address Jankel Cyker Owner Owner's Name information is Centerville MA 02632 08/02/08 required for every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ZI 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 If 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane Property Address Jankel Cyker Owner Owners Name information is Centerville MA 02632 08/02/08 required for every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® 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)] 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane Property Address Jankel Cyker Owner Owner's Name information is Centerville MA 02632 08/02/08 required for every page. Cityfrown 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 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes ® No current Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 124 Clifton Lane Property Address Jankel C ker Owner Owner's Name information is Centerville MA 02632 08/02/08 required for State Zip Code Date of Inspection every page. Citylrown D. System Information (cont.) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes 0 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) El maintenance technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 01/20/95 per BOH Were sewage odors detected when arriving at the site? ❑ Yes 0 No Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane Property Address Jankel Cyker - Owner Owner's Name information is Centerville MA 02632 08/02/08 required for every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 3.5 Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 0.2 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000 gallons 3" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 29" 2" Scum thickness 8" Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? measured Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane Property Address Jankel Cyker Owner Owner's Name information is required for Centerville MA 02632 08/02/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was sound and tight with tees in place and liquid at outlet invert. 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 tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — Date of last um in P P 9 Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane Property Address Jankel Cyker Owner Owner's Name information is required for Centerville MA 02632 08/02/08 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) 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 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 box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: 0 Yes ❑ No Commonwealth of Massachusetts Title 5 Official Inspection Form WNW Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane Property Address Jankel Cyker Owner Owner's Name information is required for Centerville MA 02632 08/02/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: z leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): This system has a 6'x6' precast pit surrounded by two feet of stone. There was 19"of liquid in the pit. Commonvvea0th of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane Property Address Jankel Cyker Owner Owner's Name information is Centerville . MA 02632 08/02/08 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cons.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration b 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.): I � Commonwealth of Massachusetts Title 5 official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane Property Address Jankel Cyker Owner Owner's Name information is Centerville MA 02632 _ 08/02/08 required for State Zip Code Date of Inspection every page. Cityrrown Do System information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. I d,l I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 124 Clifton Lane Property Address Jankel Cyker Owner Owner's Name information is required for Centerville MA 02632 08/02/08 every page. Cityrrown State Zip Code Date of Inspection D. System information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 20.0 Estimated depth to ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20 feet. q - - `A'7 ®lam FEB ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allp iraitiun for Diti-Vu3tt1 Wurku Tunutrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (%,'�an Individual Sewage Disposal System at Location-Address or Lot No. ... Y'----------------------------------------- -------------------1.... ..................................................... Owner `n Address a .................. � 1 —.� 64Sr4!Q- �?C� --.----------------- `. C�-- ?. ................................. Installer Address d Type of Building Size Lot............................Sq. feet ------------ U Dwelling— No. of Bedrooms.__ Expansion Attic ( ) Garbage Grinder ( ) . ------------ — aOther—Type,of Building ............................ No. of persons---------------------------- Showers ( ) Cafeteria ( ) Other fixtures . ------------------------------------------- -------------- DesignW Flow......._____ ._.__gallons per person per day. Total daily flow.._....3 _�_.......'�•'�---------------• g P P P Y. y ......................gallons. WSeptic Tank-V Liquid capacity-_W.Wgal Ions Length-----7------ Width_ ._---_-_-. Diameter................ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft. 1Z—.------ Depth below inlet..... ........... Total leaching area..__..___._....._.s ft. � Seepage Pit No......... .......... Diameter._._ _ p g sq. Other Distribution box ( ) Dosing tank ( ) •" Percolation Test Results Performed by.......................................................................... Date...................................... a - ,.a Test 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........................ a -----------------------•-------------------------------------------------------...------------...---......................................................... 0 Description of Soil........................................................................................................................................................................ x U ----------------•-...---•-•------•--•---------------•---------------------------------------------------------•••-•••----•------------------....---••••--••----------------•---------------------------- w -------------------------------------------------------------------------------------------- -----------------------------------------t-................................................ ......... U Nature of&epa s or Alterations=Answer hena plicable.-._�'lti-,5:!A-(t-_-.1000.�' ° ------------•--- eY....-----5� 1n J �.<-.. ----------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be issued by the boa of h th. / I A/ Signed .......... ... ........... ..... .... ... ... `.��.... M Dare Appllcation Approved BY j------------------------------------.---------------------------------- Im-". Application Disapproved for the fo owing reasont: ..............................--....------------------------------------------------------....-------------------------------------- --------------------------------------------------- ------------------------------------- ------ �/sx. LW Date I Permit No. --".---..L..- �--------------- Issued ..._....�r� -..��f� ..-.... L ................. No Fr:B........1.....G........ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . TOWN OF BARNSTABLE A41pliratiou for Ditjipoittl Wor1w Tomitrortiotn rrrmit Application is hereby made for a Permit to Construct ( ) or Repair (�_<an Individual Sewage Disposal f, System at: ------ Location-Address ` or Lot No. .................. .. �-P Y' t-\�. t> ..�..................................................... Owner Address - .0 --- Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms---3------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ...-------------------------------------------------------------- W Design Flow_.....___' ..S7..................... per person per day. Total daily flow..__._7 _P______._.___..........gallons. WSeptic Tank-�Liquid capacity._k.0(_(__galIons Length__________ Width__._--------- Diameter................ Depth................ x Disposal Trench—No_ ____________________ Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......... ---------- Diameter----�_> -------- Depth below inlet..__.q........... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I-----------------minutes per inch Depth of Test Pit__..._-_---__-______ Depth to ground water........................ 44 Test Pit No. 2...............minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ P4 .....••--••••-----------------•-----•----••-•----•--------••••-••-•-•--•-•---•---•-••---••-•----••--•......................................................... 0 Description of Soil..........................................................................................................................--........... --•-•----•---•-••-•--•••....... x FU ---------•-----------------------------•-•------------------------------. -----------------------....................................................................................................... W U Nature of Repai s or Alterations—Answer hen a plicable._. �V--`l-A__(i---._�.Ol?d_Sz' t-�-C:-- -1 V1(,t •-- ....... p - ------------------ ��`------.... ' T ` ...STG -=---'----------------------------------- ------. ----- ------.. .......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Coae" ^The undersigned further agrees not to place the system in operation until a Certificate of Compliance has,bee 'issued'by thejboarof health. 1 Al Signed ---------- .... .. ........... �� x 1 v r/ Dace Q e1 Application Approved By _........_......... ^�"--� -``� a,...,i.... .... p ----------------- (..off..-..L 1 C" -1y� Application Disapproved for the fo lowing rearonr: - --- ..>.... .:..------------------------------------------------...----...-.........-------.. Permit No. ..... 1 - ��/... ....?.... .�(... .... .. ..��...... - Issued .......- L/ e .................... ace ------------------------ -------------------`-----------— �.--�.�,—�, ———--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certifi a e of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( fir by ---v9. . �-.. 1 r .✓� .5. 0 1...C---------------------------------------------------------------------------------------------------------- I �a i� at -------------------------- .............. ...... . .-----..�..�` rao L4 ti:----------------------------------------------------------......-------------------------- ---has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ._-.�1'.�/.--.`..� ..7--------- dated .......-....... _. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. _ ---------- DATE._----- - - .:. --------------------- Inspector-4.-------- ............................... / �f IF THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No... I;1 .�_ ,�/ FEE....... r C,- Uhip000l Workii Tonotrurtion rrrmit Permission is hereby granted............................ IF .L. :J.�-(..--------------...----------------------••---••----....... to Construct ( ) or Repair (W--azy-Individual Sewage Disposal System atNo.......................................... .........4-ket--'-.................................................................................. Street -7 � as shown on the application for Disposal Works Construction Permit No\�y-7�__l_.. Dated........, 3..-.l U--...�Ll fBoard of Health DATE................. U = � ... -----------••••• �J FORM 36508 HOBBS♦!<WARREN.INC..PUBLISHERS TOWN OF BARNSTABLE b LOCATION D 1�J SEWAGE # VILLAGE -��-r�.��Gv(S i J f�l ASSESSOR'S MAP & LOTR 97—al�Z INSTALLER'S NAME&PHONE NO. 1��//_`.i�V�1(� SEPTIC TANK CAPACITY 1 DDO 6 Fa t 10 AJ LEACHING FACELITY: (type) V(2e-Ca4 l P 1 (size) &Y6 NO.OF BEDROOMS � `� UILDE OR OWNER C- 1 `6' �� ► �. PERMTTDATE: OMPLIANCE DATE: "2:,:T ,;F- 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 s� o Caq 0 W\p I vbc)S.r 1000 i=kovu