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HomeMy WebLinkAbout0255 CONNERS ROAD - Health �� rclenterville E onne rs Road A = 251 prt of 59 fi No. 42101/3 ORA i 10 m m Commonwealth of Massachusetts Title 5 Official Inspection Form 19 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ass 6�✓less � Property Addressl �Cs V12 1 �J' < Ow per ON ner's Name /_ information is /CP ti +�i�l/G 6 , //'Y� 4 r geaed for every State Zip Code Date of spec n ff n Inspection results must be submitted on thIsform. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. b G6 tnporunt:When A. General Information Bing out fomB on the computer, use only the tab 1, Inspector key to move your cursor-do not use the return Name of Inspects key. �rO GGf� comparn Klarne /�(2 �Oo� O Company Address. Qty/Town State Zip Code 7elephon-a Wxnber �' 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5�10R 1l5.000). The system: Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority ilia, aspect is Signattre Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Tit al Ins pec lion F oam suits ewe sewage Dsposd system•page 1 of 17 tSm•3N3 • Commonwealth of Massachusetts Title 5 Official Inspection Form Qisp Subsurface Sewage bsal System Form -Not for Voluntary Assessments ass o'-14,4 ,�rj Property Address � /,q l.✓� Ow ner rrnatlon is Ow nQt s Name �e N 4evV I Ile / �'14 0)6 J a11-5- requiredforevery State Zip Code Date tns tion page. cityrrown B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E /always complete all of Section D A) System P s: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303,or in 310 CM 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. Check the box for"yes', "no"or"not determined"(Y,N, ND) for the following statements. If"not determined,"please ex0ain. The septic tank is metal and over 20 years old" or the septic tank(whether metal or not)is structurally unsound, exhibits subantial infiltration or exfiltration or tank failure is Imminent. System will pass inspection if the existint 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. ❑ Y ❑ N ❑ ND(Explain below): tyre-3M 3 TIde 50f6cial impecoon F orm Subsurteoe Sewage Disposal Spsem•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Volunta/ry� Assessments ; Is OV1✓1�rS /�� property Address Owner Ow ner s Name /f //�f d O 1 6 3� c 4LWJon Informationisl�ew ✓V�`(� //70`�e edforevery --------cityfrow StateZ�Code Qate of s B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): ❑ distribution box is le\eled or replaced ❑ Y ❑ N ❑ NO(Explain below): ❑ 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 ❑ Y ❑ N ❑ NO(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ NO(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health lth in order to determine if the system is failing to protect public health, safety or the e 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 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 Tine 5OM621 Im pwton F orm SUWd8M Sewage Dj3p0W S*M•Page 3 of 17 tSAS•Y13 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Co v►✓Je r S r42,) Property Address C4 l 0 We" Owner ow reps NameVol 1.2_ r rreequvrr ed or r every .._.._--�Q Date of s tbn page. City/Town State Zip Code pec B. Certification (coat.) 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. ❑ 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 fecal coliforrn 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 ill,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 Title 5 utAdg kvspectlan F orm Sutvsu lace Sevrago 0iwasOl System page 4 or V tsm•3rt3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Co V?✓I-erS r2c1 Roperty Address G, G l 0 �✓'G 11 O.v nor Oar Ws Name Information Is � ✓l/` / //� O� / 7� l �^ — requiredforevey non G State Zip Code Dateo hs0`btan page. Qy B. Certification (cant) Yes No Cl Required pumping more than 4 times in the last year NOT due to clogged or / obstructed pipe(s). Number of times pumped: . Cl ,t—J/ Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ 93/" Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 2/' 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.) ❑ 2//-, The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system f,�il . I have determined that one or more of the above failure criteria exist as described in 310 CM R 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the tit ure. 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 ❑ 0 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 11 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. Title50Md81IrepeCt0nF0rM sumeme sewageDlapaaal Spbm-Page SOW Ors-3M 3 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address � l(ob✓�(� Om Her Ow Hers Name / I_ / AEI pa.4" information is ( n iN-fP�✓1/� �i/� _ /' required for every crown `-�_- State Z�Code Date of Inspection page. Q►Y C. Checklist Check if the following have been done. You must indicate"yes'or"no" as to each of the following: Yes ❑ 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? Cl s 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 NIA) 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)) D. System Information Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms). --'— —'— T14e50f 8InsoecuanFcurt SUWWaceSwmgepispoea 3Yatem•Page00117 gim a Y13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o2SS C0-44-e..s Rj Property Address � (o Pi// ----- ON ner information Is OwnersCeD) 6 v►�/V/ `l requiredforevery State Zip Code Date f inspection page. City Now n D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) a--No— Laundry system inspected? El Yes Yes [I No Seasonal use? Water meter readings, if available (last 2 years usage(gpd)): Detail: ❑ Yes No Sump pump? C. Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Ga9ons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? Yes ❑ No 0 No Non-sanitary waste discharged to the Title 5 system? ❑ Yes Water meter readings, if available: Title Soffldef ftpeotlon F aTa Suturf ooe SO"O MP089 System•Pape 7 of 17 tWnt•Sn9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address ON ner Om ner's rbr,e inforrreaon is �e �,� D�6 3� , e� ✓Vt l� required f or every page. gty/Town State Zip Code Date of Ihs, tbn D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: gallons �-c How was quantity pumped determined? —;7 Gtlh ;0-46 �i Reason for pumping: Type of Sy , 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) ❑ Innovative/Altemative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner)and a copy of latest inspection of the VA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (descri be): YueSorudal IropaetlmFonx Sub8Lrf*MSQ*MQ01$P0 el SYMM•Pa0*80 17 tuna 3113 Commonwealth of Massachusetts mmm Title 5 Official Inspection Form Subsurface Sewage/Disposal System Form -Not for Volluuuntary Assessments Roperty Address of ner Qfv ner's Na i nf requiredfor me ✓ / //�� / ormation is t3very State Zip Code Date Inspectbn Me. C�y/Tawn D. System Information (cont.) Approximate age of all components, date installed o(i known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): —2 ^ i/ Depth below grade: feet j Material of constructi;��4OPVC [I cast iron ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, eudence of leakage, etc.): I/ Septic Tank(locate on site plan): Depth below grade: feet Material 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)_ / % YAs ❑ No Dimensions: Sludge depth: ttloSpMtlal lmpoCJonFarm SubOUYaoo SGVA90Dlapasd Sysmm•page 9of 17 15m•3113 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments Property Address 4,:;� /oWe,� Cw ner Om ner's Name /^ information is /C ✓(/G `� 0'�G Z) J required for every Page. My/Town State Zip Code We 9t Insowtion D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 1471e Je How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): O-i" f✓t S Q v h�� 1-e,�� r T '0. cow. /72 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 pumping: Date Sns-3M 3 TItle 5 0ffidd Inspecbm F orm SubsuAeW Sewage Dieposd Sp*m•Page 10 d V I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c2of-S Cvovivrs 4�2d Property Address ON fief ON ne$Name Inforrrubw Is requited for every aL page. City/Town State Zip Code Dat of Mpection D. System Information (cunt) 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): 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.): I Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ey-3n3 T1Ve60rfidd ftpeedwFarm Subnowe Sewapedeposd System-Papa 11 d V tr# t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments J� ptoperiy Address aN ner ON Her m s Nae Mfomlatbn is required for every page. UYRown State Zip Code bate 9f lns t n — D. System Information (cont.) Distribution Box (f present must be opened)(locate on site plan): Depth of liquid level above outlet invert -T Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms in working order. ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): I • If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption Systiem (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5 ns 3M3 Tide6Oficid Ira poobanFarm Subsurfabe Saaageolsposo System-Pape 12 d 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow ner Ow /�om atlon b ner s Name M v6 / �/] O�6 d required for every ` page. Cfkyf row n state Zip Code Date dt Wpection D. System Information (cont.) Type: 0-1 ❑ leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. Cl leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): aJ'q'e L 0'1�7 1 &0 S114-f 0- 44� lr4 cle 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 t5m-3rt3 Ttle5Of dImpeceonF arm SubswaoeSewege01sposatSystem Page 13of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage DisposalSystem Forth -Not for Voluntary Assessments Property Address c' / ci 4W� I hfommtion is 2� �✓I/f14 required for every _•` h5 page. City(rown State Zip Code Date of k*pecobn D. System Information (cunt.) 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.): we-W3 TIC 30MGI9lrapactlmFamt SuWWwe 3ewageD1spwd 31otom•Pepe/4 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o2SS o H 17�,r f Property Address Al //'0 � Owner Owner's Name 4 infomlatfon is �1^„�✓(/l required for every page. Uy/Town State Zip Code We its Wn D. System Information (cost.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ❑ drawing attached separately v�r e n Cal 0 ca -o2o•y -SO -as -,2 One 3113 Tile50MCISI If19peCOMFOI7n SUI)SMaCe Sewape01WIDW Sgeam•Pape lbaf 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments d- �a cot4ner5 Property Address Av 6vz, Ow ner Ox ner's Name information is Ce w jw-re //-t AX required f or every page. Ctyrrown State Zip Code Date df Inspection D. System Information (cost.) Site Exam ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / 1 _ Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record Nchecked, 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: 601 ✓� �� C�tiIM G✓1G ��`� ✓ ' V die-, tihN�l.�a Before filing this Inspection Report, please see Report Completeness Checklist on next page. Sm,3H3 T10 50MOM Mpecacn Form SubsLoace SewVe DLVmd Slftm-Pape 18 d 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments PrOlMdYAWMs C19- led QvM reMa evey a� Cp -k & 0.� 6 ,3,)- page. Wfra nn State ZQ Code Date of hspeclion E. Report Completeness Checklist B Inspection Summary: A, B, C, D, or E checked 2- trtspection Summary D(System Failure Criteria Applicable to All Systems)completed L�J S stem Information—Estimated depth to high groundwater U Sketch of Sewage Dsposal System either drawn on page 15 or attached in separate isle On-Y13 TWSOfkiW ImPmOmForm l Awzrm sew*Dwp*w$yam'Np 17 d V f j r i E Town of Barnstable Office: 508-862-4644 Regulatory Services Department Fax: 508-790-6304 snxvnut r Public Health Division Mass: Thomas A.McKean,CHO i6�9- ♦� ova 200 Main Street, Hyannis, MA 02601 Payment Receipt :Septic Inspection Payment received: $25.00 (Check) on 5/13/2015 Permit number: 10864 ,Check number: 1639 Check amount: $25.00 Name on check: Janet L. Hallowell !Owner: WALTER E &JANET L TRS HALLOWELL !Address: 255 CONNERS ROAD, Centerville k Town of Barnstable Office: 508-862-4644 Fax: 508-790-6304 Regulatory Services Department sasi� rnB14 Public Health Division v MASS. Thomas A.McKean,CHO �ArFo 39+ 200 Main Street,Hyannis, MA 02601 Payment Receipt 'Septic Inspection Payment received: $25.00 (Check) on 5/13/2015 Permit number: 10864 'Check number: 1639 Check amount: $25.00 Name on check: Janet L. Hallowell .Owner: WALTER E &JANET L TRS HALLOWELL Address: 255 CONNERS ROAD,Centerville E TOWN OF BARNSTABLE LOCATION AST COhVtGrl 864� SEWAGE # a001- 49 VILLAGE G e-Vilt h/i ifG ASSESSOR'S MAP & LOT O• INSTALLER'S NAME&PHONE NO. t7C/(,*M ke-Mew?/ SEPTIC TANK CAPACITY / t LEACHING FACILITY: (type) 3 CU'1QIAC✓LA L;r (size) �; x 2.4 NO.QF BEDROOMS BUILDER OR OWNER I G 13UiG1rS .tYI>L PERMITDATE: ✓-//7 j 1 COMPLPANCE DATE- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i r �N n? t 3o&1t 1 } d ee No. F — THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye�� PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(ppYication for Migpoal *pgtem Construction Permit Application for a Permit to Construct Repair( )Upgrade( )Abandon( ) Es omplete System ❑Individual Components Location Address or Lot Noojs, CO/VA/JE�05 i-b Owner's Name,Address and Tel.No. -7 — l0 yQ CFN-F,AV J"—r W1 10 Assessor's Map/Parcel ,,Y5 /D� L Oro�'/ � f� �ro � S�f 6 Installer's Name,Address,and Tel.No. �� 3Q0 S Designer's Name,Address and Tel.No. 7i)04 J<F—AWF—ay )Ax7iFk, N49 r- IWA6,-elv Type of Building: Dwelling No.of Bedrooms 3 Lot Size Ss, 966 sq. ft. Garbage Grinder(Alo Other Type of Building LVM FAA&9 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 33 o gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank �d D �n'Pr �S Type of S.A.S. Description of Soil V+-> fO F-2 L ii'y Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described sitesewage disposal system in accordance with the provisions of Title 5 of the Envir mental Code and not to pla system in operation until a Certifi- cate of Compliance has been i ed and o. e Signed Date Application Approved by Date JAGJ Application Disapproved for the following reasons Permit No. �� Date Issued �r No. C Fee-"' ` ! e 1!®Y THE COMMONWEALTH OF MASSACHUSETTS I En;efed'in computer: YeC/ Y "k/PUBLIC HEALTH DIVISION -TOWN OF.BARN-STABLES MASSAC4USETTS 0 ' R Application for M(Opozar dip.5ttft Construction Permit Application for a Permit to Construct( v)Repair( )Upgrade( )Abandon( ) LS�Complete System ❑Individual Components - Location Address or Lot No.a1S$ C,#AW,5je-, F-D Owner's Name,Address and Tel.No. -2-7/— Assessor's Map/Parcel 64 YS (w 5/ I P.49TOF 5-1 -" Installer's Name,Address,and Tel.No. -3 6ji d 300 S Designer's Name,Address and Tel.No. EAWF a y 4 /+x T-Eie, A/Kc= r- floi-lo 6,e4� Type of Building: Dwelling No.of Bedrooms Lot Size s5 �lD�p sq. ft. Garbage Grinder(a/c) Other Type of Building WAOD FAA Mi�--' No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title ` Size of Septic Tank 50a („'A 1LoAj S Type of S.A.S. Description of Soil ✓44 f 2 L 6 t f Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described -&te-sewage disposal system in accordance with the provisions of Title 5 of the Envir _mental Code and not to placrott b sys teem in operation until a Certifi- cate of Compliance has been is ed i and oft'. n Signed ILI 11 Date Application Approved by C' U V Date Application Disapproved for the following reasons Permit No. ' !!! A Date Issued - I - V I I /_ , THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(✓ )Repaired( )Upgraded( ) Abandoned( )by 7 y M K F'.v v F 0 y at �2 5 5 CoivAl6,e S Pb , C E.iv'YF_2 V 1u has onstructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No ,ated Installer Designer The issuanc of t 's permit shall not be construed as a guarantee that the syst tTt i1Lf c ion as st ned.i Date U - Inspectors �——————————————————————— No-1——— T Fee ,20r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS lwigoat 7Rej tent Construction Permit Perm -Permission is hereby granted to construct( r( )Upgrade( )A andon( ) System located at 5, 60>V 944 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:Constru tioon� ust be completed within three years of the date of thisrmit. J Date: -711 ( © � Approved by 1 l IOU I& je v 4- DD 0 S zv'� 0 z W n Lp s mMCI a N9 non I s O i• 0 (�in J, II p F a F—a I_, 0 J. ~.ip 7 { l g I — ----- --- - - --- ul o p n,4 z rm z i rn 1p ip LU - I l I - o G 1' � ; o A d• > �, I e N r f 0 e p. - 1 •so.ai a.IS-7 i i I g•.4. � 9'-4• � . .. A �7 18'•o• j lc w I I I � �o 'tiI I LO j I r a or a P n �� }— 5,.�•. s`�' I r 1 - I ' I �— I.—...-- I 6- 0 L P m K D 0 0Z < f 2n I i c pD i� I I at ee I 1 F -I PLANA',(YA/-Ct' /. �Dry I �� a I� ' I? a zD I o r I � o I to ' c g r I I I ' Z ! i o II i L I l-. - ✓ f j -S— ►--- � r'_QI ol I I Rvz L- J - I 1-0 2 Lo'-o' j• I TOWN OF BARNSTABLE ' c LOCATION A ST C 0 PIAMS Roo, SEWAGE # a 001- A%? VILLAGE GGMIC/I/i IIG ASSESSOR'S MAP & LOT O-Oci INSTALLER'S NAME&PHONE NO. t76e/ _4>M I amme;v SEPTIC TANK CAPACITY 4SbO 4k& LEACHING FACILITY: (type) 3 Ad7ZAaPACr U*?i1f (size) X. 24 NO. OF BEDROOMS 3 BUMDER OR OWNER SiwSiaG Syi LaG�S f/LL PERMITDATE: ✓�17 bI COMPLIANCE.DATE: Separation Distance Between the: + Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 23 l�G [5 1' _ zs 30 I .- _- ,;2 1 u°}#t; a `," v h i 7�k-y +t c�k - fi za z' is u . ._ .. ,,... ,n' s. .._ ''hi'.x �.,{ e,<f 'i` :!k a a.:;r�R'' ,"f� r t..z �, '!?:-c :"�4+''c. <, '' .F wit�h+ay.•T r}f t �?;J :, K., 'lima iw l :ro f'- ;.�.,.., i -. t: a ,'_. a.t� L ffl S+ � c.:,. r,. ..:r `+._ e + r d f r } ,a �... :..s.. 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