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Home My WebLink About0020 CROSBY ROAD - Health 20 CROSBY RD. CENTERVILLE •A = 230 171 l t a I! I SlII J��►«® llll UPC 12534 No.2-153LOR HASTINGS,MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Crosby Circle Property Address Rockwood Owner Owner's Name information is Centerville required for MA 02632 March 15, 2011 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. Please see completeness checklist at the end of the form. Important: A. General Information When filling out I I ' forms on the computer,use 1. Inspector: only the tab key to move your Patrick.M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Rod ti Company Address Marstons Mills MA 02648 CitylTown State Zip Code 508.428.1779 SI 12855 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. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CM 15.000). The system: i ® Passes I ❑ Conditionally Passes ❑ Fails ❑ Needs Furthe� Evaluation by the Local Approving Authority cl , / March 15 Job# 11-32 In ector's SI nature Date The system inspe for 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 apprdpriate 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. Thislinspection does not address how the system will perform in the future under the same or different conditions of use. Lk I I t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys m•Page'of 17 I I I i Commonwealth of Massachusetts s Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Crosby Circle Property Address Rockwood Owner Owner's Name information is required for Centerville MA 02632 March 15, 2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (Cont.) I Inspection Summ. ry: 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. I Comments: Tank is not in need of pumping at this time, leaching system was upgraded and shows no signs of failure. I I 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," plea a explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsou d, 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 o." Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): I 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth �of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Crosby Circle Property Address Rockwood Owner Owner's Name information is required for Centerville MA 02632 March 15, 2011 I every page. City/Town State Zip Code Date of Inspection B. Certificatio ' (cont.) B) System Con itionally 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 ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i I I ❑ 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): ❑ brokeh pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstr Iction is removed ❑ Y ❑ N ❑ ND (Explain below): I - i I I I C) Further Evaluation is Required by the Board of Health: ❑ Conditions exit 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 I ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 3f 17 I Commonwealth 'of Massachusetts Title 5 Official Inspection Form Subsurface Sewagel Disposal System Form - Not for Voluntary Assessments 20 Crosby Circle _ Property Address Rockwood Owner Owner's Name information is required for Centerville _ _MA _ 02632 March 15, 2011 every page. City/Town I State Zip Code Date of Inspection B. Certification (cont.) 2. System w II fail unless the Board of Health (and Public Water Supplier, if any) determines tiat 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 s�stem has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, p�ovided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I i I I I D) System Failure Criteria Applicable to All Systems: i You must indicate"Yes" or "No" to each of the following for all inspections: I I Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® I Discharge or ponding of effluent to the surface of the ground or surface waters I 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 15ins•09/08 T,IIe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 o:'17 Commonwealth !of Massachusetts Title 5 Official Inspection Form Subsurface Sewagel Disposal System Form - Not for Voluntary Assessments I 20 Crosby Circle Property Address Rockwood j Owner Owner's Name information is I required for Centerville j MA 02632 March 15, 2011 every page. Cityrrown I State Zip Code Date of Inspection B. Certificatio (cont.) Yes No j i ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® I Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® I 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.] ❑ ® i The system is a cesspool serving a facility with a design flow of I 2000gpd- 10,000 d gp ❑ ® i 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. Ii 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 i ❑ ❑ the system is within 400 feet of a surface drinking water supply i ❑ ❑ j 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 answer�d "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 larcle 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I 20 Crosby Circle Property Address Rockwood Owner Owner's Name I information is required for MA__Centerville 02632 _ March 15, 2011 � _, _ 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 i ® ❑ Pumping information was provided by the owner, occupant, or Board of Health I ❑ ® Were any of the system components pumped out in the previous two weeks? I ❑ ® Has the system received normal flows in the previous two week period? El ® 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) ® ❑ I 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 tangy: Inspected for the condition of the baffles or tees, material of construction, j 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: ® ❑ j 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 ® El i approximation of distance is unacceptable) [310 CMR 15.302(5)] i D. System Information Residential Flow gonditions: i 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 I i 15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage jDisposal System Form - Not for Voluntary Assessments i 20 Crosby Circle Property Address i Rockwood Owner Owner's Name information is Centerville ! MA 02632 March 15, 2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: i 0 Number of current!residents: i Does residence h've a garbage grinder? ❑ Yes ® No Is laundry on a se arate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No i Seasonaluse? ❑ Yes ® No i Water meter readings, if available (last 2 years usage (gpd)): Detail: --------------- Sump pump? ❑ Yes ® No May 1, 2010 Last date of occupancy: Date Commercial/Industrial Flow Conditions: i Type of Establishment: — I 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 wastel discharged to the Title 5 system? ❑ Yes ❑ No i Water meter readings, if available: — t5ins•09/08 Title 5 Official Inspection Forms Subsurface Sewage Disposal System•Page 7 cf 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage(Disposal System Form - Not for Voluntary Assessments I I 20 Crosby Circle Property Address Rockwood Owner Owner's Name information is required for Centerville . MA 02632 March 15, 2011 _ _ every page. City/Town State Zip Code Date of Inspection D. System Information (Cont.) i Last date of occupancy/use: Date Other(describe below): i General Information Pumping Records: Source of information: Tank pumped 3/25/10 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) (if yes, attach previous inspection records, if any) I ❑ Innovative/Alternative 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): 15ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 20 Crosby Circle _ Property Address Rockwood Owner Owner's Name information is required for Centerville MA 02632 March 15, 2011 _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) i Approximate age bf all components, date installed (if known) and source of information: Leaching system ihstalled in 1999, tank is original. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 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.): I Septic Tank (locate on site plan): 1' Depth below grade; feet i Material of construction: i ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i i If tank is metal, list age: ---- years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ElYes ElNo 8.5' long x 5.2'wide- 1000 gal. — Dimensions: — Sludge depth: 011 - t5ins•09/08 Title 5 Official Inspection form Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage'Disposal System Form - Not for Voluntary Assessments I i �., 20 Crosby Circle Property Address Rockwood _ Owner Owner's Name — --- information is required for Centerville _ M_A_ 02632 March 15, 2011 every page. CitylTown State Zip Code Date of Inspection D. System Information (Cont.) Septic Tank (cont.) Distance from top!of sludge to bottom of outlet tee or baffle il Scum thickness 0 i Distance from top'of scum to top of outlet tee or baffle Distance from bott i om of scum to bottom of outlet tee or baffle How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank had been pumped 4-5 weeks prior to vacancy and had not yet filled to operating level. Tees were intact and clear and tank was structurally sound. — I Grease Trap (locate on site plan): Depth below grade) feet I Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): i 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 t5ins•09/08 Title 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 10 o`17 k Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage IDisposal System Form - Not for Voluntary Assessments M 20 Crosby Circle Property Address Rockwood Owner Owner's Name information is required for Centerville MA_ 02632 March 15, 2011 _ every page. Cityrrown State Zip Code Date of Inspection D. System Wd,irmation (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as relpted to outlet invert, evidence of leakage, etc.).- Tight or Holding tank (tank must be pumped at time of inspection) (locate on site plan): I Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): i 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 s "Attach copy of current pumping contract (required). Is copy attached? El Yes ❑ No 15ins•09/08 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 cf 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form - Not for Voluntary Assessments a 20 Crosby Circle _ Property Address Rockwood _ Owner Owner's Name information is required for Centerville MA _02632 March 15, 2011 _ every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid levf6l above outlet invert 0 1. Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leaka0e into or out of box, etc.): No solids or high stains present. i Pump Chamber(I;ocate 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 i Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located,;explain why: t5ins•09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage;Disposal System Form - Not for Voluntary Assessments 20 Crosby Circle Property Address Rockwood _ Owner Owner's Name information is Centerville MA 02632 March 15, 2011 required for _ _ _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Four infiltrators.-- ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields - number, dimensions: ❑ overflow cesspool number: I ❑ innbvative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Interior of infiltrators were video inspected with no evidence of surcharge found. 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage!Disposal System Form - Not for Voluntary Assessments 20 Crosby Circle e Property Address Rockwood _ Owner Owner's Name information is required for Centerville MA 02632 March 15, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (Cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on slite plan): i Materials of construction: -- Dimensions -------- Depth of solids — Comments (note Condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i i t5ins•09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -a Subsurface SewageDisposal System Form Not for Voluntary Assessments _< ✓ 20 Crosby Circle __._.__ --- ----- Property Address Rockwood Owner Owner's Name information is Centerville required for MA 02632 March 15, 2011 __--.___C.__-----...__ - _—_.--- every page, CityfTown State Zip ode Date of Inspection 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 . . . . . . . . . . 1 t 18 31 1 27 Back Yard. i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .,, 20 Crosby Circle Property Address Rockwood Owner Owner's Name information is required for Centerville _ —_ _ _MA _02632 March 15, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar, ® Shallow wells Estimated depth to high ground water: 14' feet i Please indicate al 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: Perc test performed for repair on 6/9/99 found water at 14 feet. i Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments 20 Crosby Circle Property Address Rockwood Owner Owner's Name information is required for Centerville MA 02632 March 15, 2011 every page. Cityrrown State Zip Code Date of Inspection E. Report Comipleteness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATI.7e-Alerdtt `65 b 6"r E#�✓�SP VILLAGE ASSESSOR'S MAP&PARCEL S NAME&PHONE NO rt rle.le n h l I SEPTIC TANK CAPACITY 1000 4^ v LEACHING FACILITY: (type)7:;K�^�,Pi,17rctor'S (size) NO.OF BEDROOMS O WNER�Oc,Lu�v o j PERMIT DATE: CWt==ZrE DATE:Zr5i/-7 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 t,f•+ i '4f f . •kl Jar `k jam' ! f ft f f 4: kf .,•fl.f.l f.l .,•f.,. •.f.tf,, f�.f•tfy f . 18 31 1 27 Back Yard. No. Fee 60 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS Rpprication for Mgpogal *pgtem Congtruction permit Application for a Permit to Construct( )Repair W ,Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. ( (Z q O�nQer'Iss\Name,IV ress and Tel No Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. � Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(Ap 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 Tanke)dt y\! -4 ®I'�CU Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) (�V f P� �t 6&"' 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 iss e, by thi oard th. q Signed _ Date y Application Approved by md o Date Application Disapproved for the following reasons Permit No. Date Issued No. Fee 0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: - PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes Application for �N.5paal &pgtem Congtruction Permit Application for a Permit to Construct( )Repair Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. cco,�� 2 C ; On Name,IVS(re ss an�flJ,NoC. rAJO'samldT--- Assessor's Map/Parcel q _o p Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 2(.( Qcc k rzw ff /\Ls 0a60 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( Ap Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures .r Design Flow gallons per day. Calculated daily flow gallons. ' Plan- Date Number of sheets Revision Date Title Size of Septic TankEX(5k�nfl (060 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)L1 CI Date last inspected: Agreement: r' The undersigned agrees to ensure thepconstruction and maintenance of the afore described on-site sewage disposal system i,- 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 iss by thi - oard' th. �� i Signed Date o n Application Approved by r I- o f' ��` /�. 1 Date Application Disapproved for the following reasons Permit No. ..r Date Issued IL _x THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired (V)Upgraded( ) Abandoned( )by cl!'V at qcj C has a constructed in accordance with the provisi s of Title 5 and the for Disposal System Construction Permit NoY4 dated�— Installer ��c7JA Designer The issuance of this pe tt s A al btbe;construed as a guarantee that the system will function s de�gned! r r Date Inspector � ��I�1'1,,T�rll 0 -----------------------------Fee �-- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS �Digpogar 6pgtem Congtruction Permit Permission is hereby granted to Construct( )Repair )Upgrade( )Aba don( ) System located atU 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 b com a ed 'thin three years of the date oft ' -rmit. `� n Date: Approved by f �t"i�/t�'G� �-C. i 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) L hereby certify that the application for disposal works construction permit signed by me dated (� C�� concerning the property located at 20 Cc--<Ds�� z V meets all of the following criteria: /The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. •/ The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. �• ere are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the ma-dmurn adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] �If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14) feet above the ma�cimum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W. Elevation +the MAX High G.W. Adjustment v� DIFFERENCE BETWEEN A and B ILI r, 1 SIGNED : DATE:6(Ci ` _l ct [Sketch proposed plan of system on back]. q:health folder:cert �,;. . ., J '1 ��- } 0 6 K TOWN OF BARNSTABLE C LOCATION ^r e3 SEWAGE # -VILLAGE CV N4 ASSESSOR'S MAP & LOT go INSTALLER'S NAME&PHONE NO. '22 Sbq 5 SEPTIC TANK CAPACITY 9, l SA I t�ptl �Ux- LEACHING FACILITY: (type) (size) t^ r'f NO,OF BEDROOMS �C/?�,c l^es u,- -fr BUILDER OR OWNER -10 nr� C I G-r VL- ` PERMTTDATE:G /5I / 55I 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) Q n Q, Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by RAJ t 4 i U Y _ . r G.L. 'm LOCA , 10, SEWAGE PERMIT NO VILLAGE I N S T A LLER'S NA E „ i_ ADDRESS r ,J R U I L D E R 0R OWN R C ® DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �� a V ✓ , 'Z�r x � �� 3 r.R• �1/( �,�`