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HomeMy WebLinkAbout0117 ELIJAH CHILDS LANE - Health 117 ELIJAH CHILDS LANE CENTERVILLE A = 171 269 0)),rford, NO. 1521/3 ORA li, 10% 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form GSM Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered in any way. A. Certification Important: When filling out 1. Property Information: forms on the computer,use 117 Elijah Childs Lane - Centerville, MA only the tab key Property Address to move your Wilfrid and Frances Sampson cursor-do not use the return Owner's Name key. 117 Elijah Childs Lane Owner's Address Centerville MA 02632 City/Town State Zip Code Date of Inspection: July, 21, 2005Date 2. Inspector: David D. Coughanowr, R.S. Name of Inspector Eco-Tech Environmental C x Company Name q 43 Triangle Circle - Company Address Sandwich MA _I 0256r City/Town State Zip Code; 508 364 0894 Telephone Number 1%) rn Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 11 S July, 21, 2005 Inspector's Signature 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. t5-2135.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'LAM A. Certification (cont.) 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it does not trigger any of the failure criteria listed below. The septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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: Lt5-21,35.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 2 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'GSM A. Certification (cont.) 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection 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 ❑ obstruction is removed ❑ 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 'I ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5-2135.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form A. Certification (cont.) 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (cont.): 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: t5-2135.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form } Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection 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 '/Z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] Yes No ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. t5-2135.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. YES NO ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5-2135.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Checklist 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection 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(3)(b)] t5-2135.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information 117 El#ah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection 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 gpd Number of current residents: 2 Does residence have a garbage grinder? Removal of grinder is recommended ® 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 ears usage d 206 gpd 9 ( Y 9 (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: current 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): t5-2135.doc•11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 8 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection General Information Pumping Records: Source of information: owner 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) ❑ Innovative/Alternative 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: Age: 4+years. Certificate of compliance issued 3128101 (Board of Health permit#2001-142) Were sewage odors detected when arriving at the site? ❑ Yes ® No t5-2135.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ;M Subsurface Sewage Disposal System Form C. System Information (cont.) 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection 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: 20+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Sewer appears structurally sound with no evidence of backup or leakage into dwelling Septic Tank(locate on site plan): Depth below grade: 1 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 ❑ Yes ❑ No certificate) Dimensions: 8.5 ft x 5 ft x 5 ft(1000 gallon) Sludge depth: 4 inches Distance from top of sludge to bottom of outlet tee or baffle 30 inches Scum thickness 1 inch Distance from top of scum to top of outlet tee or baffle 9 inches Distance from bottom of scum to bottom of outlet tee or baffle 14 inches How were dimensions determined? Probe to top of tank t5-2135.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 I Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 'GSM C. System Information (cont.) 117 ElUah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping not required at this time but maintenance pumping is recommended within and every two years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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 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): t5-2135.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form rG^M p Y C. System Information (cont.) 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection 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.): Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert At outlet inverts 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.): D-box appears structurally sound with no evidence of leakage in or out. Few solids in sump. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No t5-2135.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection 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: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appeared unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. A bucket of water was poured into the distribution box and was observed to pass through in a rapid and unobstructed manner, and could be heard splashing down into the leaching gallery. I t5-2135.doc• 11/2004 Title 5 Official Inspection Form: Subsurface Sewage Disposal System Page 13 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5-2135.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 117 Elijah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection 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. LOCATIONS A B C 1 29.5 f t 50 f t 2 21 Ft 42.5 Ft 3 27.5 ft 25.5 Ft SEPTIC TANK I o o 2 B ❑ D-BOX A EXISTING 3 LEACHING DWELLING GALLERY # 117 C W Z J K W 1- 3 I ELIJAH CHILDS LANE NOT TO SCALE t5-2135.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 117 El#ah Childs Lane Property Address Centerville MA 02632 City/Town State Zip Code Wilfrid and Frances Sampson July, 21, 2005 Owner's Name Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: 20+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: Barnstable GIS Department You must describe how you established the high ground water elevation: Town of Barnstable GIS Department records indicate that the property is over 20 feet above groundwater table. t5-2135.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 No,-,? a �� U/ Fee o / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for Mi5poot 6pgtem Construction Permit Application for a Permit to Construct( )Repair( /pgrade( )Abandon( ) O Complete System L/Individual Components Location Address or Lot No. // 1 J �o Jj!/a �` Owner's Name, ddress d Tel.No. Assessor's Map/Parcel /� GI (�!�! /Ga'.5 �/���CQ.�y� CGlr/f/`///)(!f Installer's Name,Ad ress,and Tel.No. Designer's Name,Address and Tel.No. 7 -9 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( C� Other Type of Building e%CeKo.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow D gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ®DD ype of S.A.`S. 6X yZ.ZS�X Z Description of Soil 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 on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is ar H lth. Signed --! 1 Date cr/9. ";:9l Application Approved by Date Application Disapproved for the following reasons Permit No. �� f Y2 —— Date Issued —— — -- 'r TOWN OF BARN STABLE Ci / 2 Z f` LOCATION Z/7 �Iidh C� /� y, _— SEWAGE# VILLAGE GeA124f rl/>,11e ASSESSOR'S MAP & LOT 7�— INSTALLER'S NAME&PHONE NO. �OG��'Il Cdlf�% 7 7/"� '� SEPTIC TANK CAPACITY /d�D � /STl? LEACHING FACILITY: (type) .(size) NO. OF:BEDROOMS BUILDER OR OWNER PERMTTDATE: _ COMPLIANCE DATE: . Separation Distance Between the: Feet IMaximum Adjusted Groundwater Table and Bottom of Leaching Facility . 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. r I within.300 feet of leaching facility) Feet, 1... Furnished.:by fjc� I 34, yr6' �rar I I ? C/o fir _ j b No / Fee�o 0/ d THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye/ Lex PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS � 01pprication for -Mizpoml *potem Construction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) El Complete System I individual Components Location Address or Lot No. Owner's Name,Address d Tel.No. //7 vU//r�✓ aSQ� sow Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's;Name,Address and Tel.No. o� foGoiGo�rs�` Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( � Other Type of Building 2 eq o.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow ,/� gallons per day. Calculated daily flow .3.3,!2 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank f/ �1 , Type of S.A.S. &K !!ML 7 Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1 Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B and He lth. _ Signed Date /�l Application Approved by _ Date 3 /_ / Application Disapproved for the following reasons Permit No. (Z Date Issued ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTI Y, that the On-site Sewage Disposal System Constructed( )Repaired ( V Upgraded( ) Abandoned( )by /�GD at i ,`/ has been constructed in accordance with the provisions of Tit e 5 and the for Disposal System Construction Permit No. 1/ — /'-/ dated 3-/6 Installer 4:4 r In ((Isffi Designer The issuance of this p rmit jall,not be construed as a guarantee that the syste will f nctio s designed. Date 3 7; / 0 Inspector_ Tip ---------------------- -------------------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migpogar 6potem Construction Permit Permission is hereby granted to Construct( ) epair Up .rade )Abandon( ) System located at /f r C L/It I1 t 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:Co struction must be completed within three years of the date of this permit. Date: 1 Approved-byQ , U'C" NOTICE: This Form Is To Betsed For the Repair Of Failed Septic Systems.Only. - CERTIFICATION OF SKETCH AND APP LI A C TION FOR A DISPOSAL WORKS CONSTR IICTION PERMIT OIIT DESIGNED PLANS ereby cet tuy that the application for disposal works cons=ction permit signed by me dated ���`�� concerning the property located.at 117 1f G //, , 6,ew meets all of the following criteria:. +� 7-he failed system is conne=ed to a residential dwelling aniv. There are no commercial or business /,ices associated With the dw i mg. Y :ae soil.is c!as-ined as CLASS I and the `—. �oiation rate is i�s Han or equal : ; 7 edands wi•=n 1 oo s^ Here are no w :of tine oroDes,.,,,s.-otic system Y :ae a arc no arvate wc:i m _.s within.__o :of the proposed searic s+semi se:e is no incase in flow and/orchanQc_ n, _c oromsea ^Here are no varanees.:e used or ne---d= ne bottom of the proposed leaching Lacihry will not be located less than Eve feet above the psarm=adjusted,-oundwate:table elevarion_ (Adjust the ,toundwater.table using the Ftimptor ethod when apoticablej. if the S.4.5.wtll be looted with.Zo te_,of any veg_..ated we.lands. 'tee bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the na.-datum ad mud groundwater table elevation, Please complete the followinb A) Top of Ground Surface EIevation(using GIS information) v B) GM.Elevation 3 0 —the MAX high G.W. A4usrment. 3�= 3 3 Da—PIRENCEP BETWEEN A and B . ,3 SKsNM : DATE: (Sketch Proposed Play of system on back]. +x 1 ` � 1 Ca� act�y ����'r�'�'®�s 1- 6 �� �° � - - - - - - - - 6 ,X � z,2�X - - - - �+�y� P � �� �� �,���I,�e�1 P� o I � �� ? �� ��� TOWN OF BARNSSTABLE C LOCATION � ��o!/dI C� //Gf-� `�, SEWAGE VILLAGE Le�i:f r//r11f ASSESSOR'S MAP &LOT Z 71—20 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) /0 ,Jrg.XX A NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: ,3 COMPLIANCE DATE: 3 -`'Z 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 a within 300 feet of leaching facility) 6 Feet Furnished by JCL ve, t� a ::Nadi - G B Fzs .................... THE COMMONWEALTH OF MASSACHUSETTS �.� BOARD OF HEALTH rC................OF........- . Appliration for Disposal Works Tonstrnrtion Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst> . ......_...................... .. ..��. ................. ... &cation-A ress o 0 ........ .... ... .... ... .............. .................... •.... .. ......... ----------------------------------------- Owner Address Installer Address U Type of Building Size Lot-./ _f--- _Sq. feet �. Dwelling—No. of Bedrooms...............V------------------Expansion Attic ( ) Garbage Grinder (� Other—T e of Building ..... No. of persons............................ Showers a YP g ---------------•------- P ( ) — Cafeteria ( ) Otherfixtures ------------•-•-••--------------------------------•----------------------------------------------•---------------------------:............_....------ W Design Flow............................................gallons per person per day. Total daily flow...........:K 3...5�...........gallons. WSeptic Tank—Liquid'capacity gallons Length................ Width................ Diameter__-_____-___-_ Depth................ Disposal Trench—No. .................... Width..................... Total Length.....................Total.leaching area....................sq. ft. 3 Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................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........................ 9 •----------------------------------•----•-------•.....---------......-----------•---•----•------•--•......................................................... 0 Description of Soil.........................................................................................................................-.............................................. x w -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable._.............................................................................................. .......................... -...... ---.......... ------------- .......------------------------ •------------------•--------------------------------•--------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of 71'IU 5 of the State Sanitary Code—The undersigned urther agrees not to place the system in operation until a Certificate of Compliance has been ' s ..by the -rd of ealth. ned. ...-----•--..........-----......... ---------•-�------- -.....' Date Application Approved .. Date Application Disap .i d r the following reasons:.............................................................................................................. .......................................••---•---•----•-----....------........--.....----•-------------------------------------------------------------------------------- ---------------•- Date PermitNo....................................................... Issued........................................................ Date .6................_ THE COMMONWEALTH OF MASSACHUSETTS � .-- BOARD OF HEALTH ............. ........... ................OF.......... x!7�'+► jr.'G�7t'.-.f?'.� .: -----•------.....---- Ap iration for UhipogFaf Workii Tonotrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System-at• ............. •....--• - �,� ............ " .......................... ......... ............................ Location-Address o .. _.._ :....-- - -----------------------------------•------ W L f e� Owner t Address Installer Address + Type of Building Size Lot....., ....40:_ Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria P4 Other fixtures ----------------•--------------- - W Design Flow•................................ ........gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid*capacity/_'i lons Length.....:.......... Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet....._.............. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1­4 Percolation Test Results Performed by.......................................................................... Date....................................... aTest Pit No. I................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•____•_____-___...______ ------------------------- ------ -------------------------------------•--•-•.....-••---------.---•--.......................................................... 0 Description of Soil........................................................................................................................................................................ W --••••-----•-------•-•--••--•---••----•••-•••••••-•---•-•-----.....--•••-•-••--••--••-•-••••••••-••....---•••-••--••-•-------•-----•---•----•---••-•-••••-•-••••-•-•--••-------•---•-••----•----•--_.... UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------•-------------------•-..................---•••---••---......._._........---•............-••-• -••-••-••-•-------•--------•--••--•-•-••••-••-••--•-----•-•••••-••••-•-•--•••-•-------------•••--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code— The undersigned lurther agrees not to place the system in operation until a Certificate of Compliance has been sue by ard of,health S' _ . o f'?..._..._d .......-•.. ... -•••--.....- ate Application Approvej Date Application Disapprohe following reasons:................................................................................................................. ..............•••••-•-•-•-••-•-••----•-•-----••----•--••••--------•---•-•--•--•-•----•----•--••-...........---••---•-•--•-•-•••••--•--••--•••-----•••---•••--•••••-•---••••••--••••-- •----------- Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...............................I......I...OF..................................................................................... Trrtifiratr of TuntpfiFanrr TS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by------------------- ... .._......... . ------•---- Insc u --- at........................ ��•--� -------•--{r ems, ......................................... 17 has been installed in accordtlim with the provisions of TITLE 5 of The State Sanitary/6ARANTEE s scribed in the application for Disposal Works Construction Permit No "� �.................... dated__ PP PJ Srf THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A THAT THE . SYSTEM WILL FUNCTION SATISFACTORY. /� /� DATE............... I/...--...... Inspector......... 1`, !�*' THE COMMONWEALTH OF MASSACHUSETTS BOA OF ........................O ...................................... 0' Nouq.....! . 1 .... FE04................... �i���a� 1 nrk� �nn�trnrtinn rr�tit � - Permission ' ereby granted•-/ .-...._ ,/....--- .............................................................. to Construct ) or Repair ) n I vId l evCpa �ePispo System at No �/ �fj� 7 :%^ "" =�� .E c:. + r.'Z�R ---------- Street as shown on the application for D' os 1 Works Construction Permit Nogl-41%� ...... Dated�,�._��.................... --------------- -...... --------------------------------------------------------- --------- ----.......... _ Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS `T"(at-�!,�_ �Jr. !rJC, 17, • .4.-9'i 43 ` =D 15l5=-. t .O - ;-E>0 sp.r. 3� pry.:��'v CAir ly.P.D. ZN I 6 t. i:.,,A,t i_-( 4 hey eft. �..�5�. � l;�,r•• M G O 1 t N. ?aG43 r o jo � r 1 � � tar 1.U gyp_. .... ._..,. ,{ .�,.'.`+'.'2'.�.�'.":�!Q'S77f '7:�J��N/%T I/�.�tjL�%�i\•�'.�- ��•!"!�= q�.•r j ! r Uod 16N r v! 5u15 swt- INV. � TA4SC i ago K5• B t>Jv ,GRAVEL_ INV. b�.3 i';'.I• i..ti�h^.Hi 5 t t Y,T '.� VZ 4vns,�F n MCANJM 'STONE 4998 CrAfi7c? r.. t 1 F`'i7_ r•t L_f=. .- -~�- Lvcnr101-4 GEtyT�R,vt��. .VZ- 45.8 �-E u S�AL-c Tt-d A-r %14 L;. T-0t)RDA Tj©lit 51-tc^v a.J SQL_A tom! %Q t-le.t't_t�l,1 Cca/1r�nt_�(S u.11Tt-1 "C`lt�_ �11�C_-.Lt�-�t✓ � 'T'N C L O"T 4 4}' C. SEG . t2C-GtS'C�C=t:i�� 1....til.E�� 5Ua..'�i�..Yvf�'.`•; I Tt4t•S P I-A ,-i 1 uoT l!be> D ot..s pr;.! it�lrt-i?:1:✓IC:W i ac1t:./t.�{ ;� T�aL UFG�irT'�, �f ts✓wU� ANi�LI r�_n.h,t'T 3 It) l�r_-_1't,t'Mti�!! �nY t.tt.4�4a - _ ALAiy t-,. ok , — X"70 "L"OTC A T ION S EW 11 E PERMIT NO. Lor 44 fit„t..i�.N �i I LPS Lai VILLAGE CAUTeeV I Liz U 4ss INSTALLER'S NAME i ADDRESS BUILDER OR OWNER W ALL l kcG , " m4ss , DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 9�7 LA ,d► �"o��'Box .. 4 2' P �.—. do - To�". ttG -► 3d g_ r�+D'$ox _ 4 .—.To Prr 4