HomeMy WebLinkAbout0141 ELLIOTT ROAD - Health l4 Elliott Road
Centerville
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No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ftpYiration for Bisposai *pstrm Construction J)efmit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /(///� ' � /-� Owner's Name,Address,and Tel.No.
Assessor's Map/Parce yg L(C[ � ���t� � W/ &G"/1
Installer's Name,Address,and Tel.N� ^ Designer's Name,Address,and Tel.No.
L Zo a f Z
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when 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 E vironmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board He th.
Signed . Date Z
Application Approved by Date 6
Application Disapproved by Date
for the following reasons
Permit No. C�/'��- X'P Date Issued
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for -Disposal *pstem Construction Hermit
Application fora Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. J!1/ /ll�
� 4 0 Owner's Name,Address,and Tel.No.
Assessor'sMap/Parceq T8�S
'D # i4t� g
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( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) I'd ec.. /
Date last inspected:
Agreement:
F The undersigned agrees to ensure the construction and mai&nance 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 Certificate of
Compliance has been issued by this Board, He th.
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. �o/�-� � Date Issued
- _------------------- ' -- - - - ' _.___._ _ ------------------
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 �La� C G y"V., .("Ua )� ✓
Jat ZVI e:lhGr 4 9 , has been constructed in accordance / J
with the provisions of Title 5 and the for Disposal System Construction Permit Nob' /a -X lydated LP [ �'--
Installer ���pi d✓A >,3 r/ , Designer
#bedrooms V Approved design flow gpd
The issuance of this permit shal not be construed as a guarantee that the system will-fa'ns ion as d`e igned.
Date (D���i Inspector
------ - -------
aO' �J� --------- -----------------Fee--- -
No.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
]Disposal 6pstem Construction �ermit
Permission is hereby granted to Construct( ) Repair(klf" Upgrade( ) Abandon( )
System located at &Z ��j
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction mus be co ple ed within three years of the date of this permit.
Date to Approved b
c
COMMONWEALTH.OF MASSACHUSETTS
a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a
DEPARTMENT OF E,NVIRONMENTAL'.PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM- NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGEDISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 141 Elliot Road
Centerville,MA 02632 .I Owner's Name: Dick Ehvell I
Owner's Address:
Date of Inspection: June 7: 2012
Name of Inspector: (Please'Print) James M. Ford
Company Name: James M.Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number:. (508)862-9400
CERTIFICATION STATEMENT. r c
I certify that I have personally inspected the sewage disposal system at this.address and.that the information repUled
—113
below is true,accurate and complete as of the time of the inspection. T -The inspection was performed base on my..-
training and-experience in the proper function and maintenance of on site sewage,disposal systems. . I am.a DEl' .
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The!'system: ,
✓ Passes Wr- rm►
Conditionally Passes
N F.r�
Fs Further Evaluation by the Local Approving Authority
it
Inspector's Signature: Date: June 10,2012
The system inspector shall su4 a copy of this inspection report to the.Approving Authority(Board of Health or
DEP)within30 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.
Notes and Comments
****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:
Title 5lnspection Form .6/15/2000 page I
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Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 141 Elliot Road
Centerville,MA
Owner: Dick Elwell
Date of Inspection: June 7, 2012
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
i
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:
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.
j Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound;exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a.Certificate of Compliance
indicating that the tank is less than 20 years old is available.
! ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s).or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
li 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:
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Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 141 Elliot Road.
Centerville,MA
Owner: Dick Elwell
Date of Inspection: June 7, 2012
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the,environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR.15.303 (1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier,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:.
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Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM
PART A
CERTIFICATION (continued)
Property Address: 141 Elliot Road
Centerville,MA
Owner: Dick Ehvell
Date of Inspection: June 7, 2012
1). System Failure Criteria applicable to all systems:
You must indicate either"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.].
No (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.
E. Large System:,
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd-
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to.large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 fees 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.
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 141 Elliot Road
Centerville,MA
Owner: Dick Elwell
Date of Inspection: June 7, 2012
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 pant of this inspection?
Were as built plans of the system,obtained and examined T(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 breakout?
✓ Were all system components,: 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?
F ✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
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The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ 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
j
is unacceptable) [310 CMR 15.302(3)(b)].
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Page 6 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 141 Elliot Road
Centerville,MA
Owner: Dick Elwell
Date of Inspection: June 7, 2012
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design)`. 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: 2
Does residence have.a garbage grinder(yes or no): N/a
Is laundry on a separate sewage system(yes or no): N/a [if yes,separate inspection required]
Laundry system inspected(yes or no): no
Seasonal use(yes or no): no
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design now(seats/persons/sq/ft etc:):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped 12 pears ako-per owner
Was system pumped as part of the inspection(yes or 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:
Date of installation 911711985 per as-built card
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 141 Elliot Road
Centerville,MA
Owner: Dick Elwell
Date of Inspection: June 7, 2612
BUILDING SEWER(locate on site plan)i
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:.
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 45".
Material of construction: ✓ concrete . ' metal _fiberglass _polyethylene
other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate), .
Dimensions: 1250 gala
Sludge depth: 2 ,
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 101, i
Distance from-top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measurinz stick
Comments(on pumping recommendations, 'inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.).
The tees ivere present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outletinvert,evidence of leakage,etc.):
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Page 8 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 141 Elliot Road
Centerville MA
Owner: Dick Elivell
Date of Inspection: June.7.2012''
TIGHT or HOLDING TANK: None (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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
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: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
` A new D-Box was insialled after the inspection. see Permit#2012486
PU
MP CHAMBE
R: None .(locate on site plan)
Pumps.in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
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• Page 9 of 11 ;
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 141 Elliot Road
Centerville,MA
Owner: Dick Elwell
Date of Inspection: June 7, 2012
SOIL ABSORPTION SYSTEM (SAS): ,, ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2- 1000 Qal. leach nits with 1'o stone-ver design vlan
leaching chambers,number:
leaching galleries, number:
Teaching 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.):
77re leach wits had.2''of ivater on the bottom There did not appear to be any signs of failure A camera was used for the inspection
CESSPOOLS: None (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 or no)`. _
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
f Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
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! Page 10 of 11
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jOFFICIAL INSPECTION FORM_NOT FOR VOLUNTARY A
SUBSURFACE SEWA
GE DISPOSAL SYSTEM INSPECTION FORM
PART C
! SYSTEM.INFORMATION (continued)
Property Address: 141 Elliot Roac%
Centerville MA
Owner: Dick Elwell
Date of Inspection: June 7, 2012
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.
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Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 141 Elliot Road
Centerville,Mid
Owner: Dick Elwell
Date of Inspection: June 7, 2012
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 30+/- feet
Please indicate.(check) all methods used to.determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole,within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain: .
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours naps the naps were showing approximately 30 +/ to ground water at this
site.
This report has been prepared only for the septic system and components described herein. This septic system has been
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that,the system will
fauaction properly in.the facture. There hoe been no warranties or guarantees, either.expressed, written or implied,
relating to the septic system, the inspection, this report and/or any components of the septic system which have not
been located and inspected.
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No.`.-�............ 1 OP J �Fmc...�.�°�:......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
...._......._.TOWN...................OF......BARNS.TAB.LE.........................................................
I Appliratiun for Bi-spuual Works Tunitrurttun Frrutt#
Application-is hereby made for a Permit to Construct (XX) or Repair ( ) an Individual Sewage Disposal
System at:
El 1 'ott Road,•.Centervi 11 e _ Lot 6 ................• ___--- -...........
Location-Address or Lot No.
e,J
•-••••••••-•...•••••. ............................................................... --•---....•--•--•-••----------•--••--.........._................-•--•--•........._....-•-...•••---
Owner Address
Gary Tavares Falmouth
Installer Address
Type of Building Size Lot__22,_394.............Sq. feet
U Dwelling—No. of Bedrooms____.-_---4...............................Expansion Attic ( ) Garbage Grinder (NO)
Other—Type of Building ___..____.. No. of ersons____________________________ Showers
a YP g -•----•---------- ------P--- ( ) — Cafeteria ( )
Otherfixtures --- --- ---------------------------------------------------------------- ----------
w Design Flow.......11 Q_________________________•____gallons per AX per day. Total daily flow_____44Q_________..__________.____._____gallons.
WSeptic Tank—Liquid capacity).250...gallons Length________________ Width................ Diameter________________ Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........ __._..__..__ Diameter......... _..____.__ Depth below inlet....6.............. Total leaching area._4.00........sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
0.4 Percolation Test Results l Agformed by.......................................................................... Date........................................
Test Pit No. 1______0►"_____minutes per inch Depth of Test Pit...1_0_i.......... Depth to ground water.nQne..............
4q Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 -•--------••-•-------•-----••--•-----•----------••--••-----•--....----•..............•-••••••._..............................................................
O Description of Soil.......loam-_&...Su_b--S011•--.0•-2'.,-_-UQa11_.und__1r4__1.0................................................................
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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 iITLL 5 of the State Sanitary Co he un ersigned furt r agre o place the sy tem
operation until a Certificate of Compliance has been ss d the ar
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Signed
Djto
Application Approved By---••-••-•- -�--•-•---'�"•_----��_- - ----••---------------------------- --._._.� Y-7__/ �'�'S
Date
Application Disapproved for the following reasons:.............................................................................................................
-
...--•-----------------------------•-----------------•--•---------------•-----------...------.....
...................................................Date
PermitNo......................................................... Issued.......................................................
Date
No--------—----------- FizB............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............TOWN..................OF......BARNSTABLE........................................................
Application is hereby"made for a Permit to Construct (XX) or Repair an Individual Sewage Disposal
System at:
Lot6 e------*........................ ......*----------------------- -----------*-----------...............................
Location- ';;' or Lot No.
e Locat' Address
.......... -----------------*------------- ------------------------- ............ -------------—----------*---------------*""-**,-*".................
Gary Tavares Owner Falmouth Address
Installer Address
Type of Building Size Lot-24394............Sq. feet
U
Dwelling—No. of Bedrooms..........4...............................Expansion Attic Garbage Grinder (NO)
P-4 Other—Type of Building ............................ No. of persons____________________________ Showers Cafeteria
QI
Other fixtures --------------------------------------SM-----------------------------------------------------------------------------------------------------------
Design Flow.......119........................;......gallons per�WX per day. Total daily flow.....4.40.................................gallons.
04 Septic Tank—Liquid capacityl-M...gallons Length________________ Width_..___._______.. Diameter................. Depth-.............
Disposal Trench—No_ ____________________ Width___.;.............. Total Length........#........... Total leaching area----- ..............sq. ft.
Seepage Pit No.......2--- ........ Diameter._.__._..Q. ....... Depth below inlet._.0.............. Total leaching area...4.OQ........sq. f t.
Other Distribution box.( Dosing tank
Percolation Test Results I atrformed by.......................................................................... Date........................................
Test Pit No. .....minutes per inch Depth of Test Pit...19............ Depth to ground water.11MM-------------
GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.__._...___.________ Depth to ground water........................
.................................................................................................
.............................................................
0 Description of Soil-----..1.o.an...&...sub...soi.1...to.1'.....clean-sa.nd---to---10..................................................................
....... ..• ...... ........ ..... ...- ............ ........ .... ......
I...................................................................................................................................................................................................
.......................................................................................—:...................... ......................................................................................
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 TITLE '5 of the State Sanitary Code— The undersigned- furtl"br agree&,aot to place the s t y em/ Xn
operation until a Certificate of Compliance has been issued by the board A _ 73
Signed----0........................................ ------------I--------------------------- --------------------------------0P
D
Application Approved By.._--"'--s I.......12... .............................. ....... .....7-7i ------
Date
Application Disapproved for. the following reasons:................................................................................................................
.......................................................................................................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF-HEALTH
4)VVrV
.........................................OF.....................................................................................
Tntifiratr of Tompliana
THIS 1 0 CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
>�-T
by-----0------ .................................................................................................................................
.......... J
at................................................4 -----------------------------------------------------------------------------*---------------------------
E 5 of The State Sanitary C d �as ftseibed in the
has been installed in accordance with the provisions of TITLE 0
y
application for Disposal Works Construction Permit No-______`---------------- dated- .......1-4........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
--
DATE..-••.. • ............................................ Inspector...... ..................................... ............................
THE COMMONWEALTH OF MASSACHUSETTS
1-1
BOARD Of HEALT H
........OF........... ..........................
............ ..
No:...-
...............
Pnstrurtiatt "trutit
1,2 � I
Permission is hereby 'granted______.._. ...................................................................................
nted........ 4......... ......
to Construct r Repair(i w an Indjvidual Sewage I�! .posal Sy,,?
atNo.................................j�........t= ...........!�.................................................................................. .....
Street C;
I /...
as shown on the application for Disposal Works Construction Permit V=�"�'........... Dated_______......r j............................
........................ ......................... ..............................
Board of Health
DATE....................... ?- L
......................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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PETER-,.'- IJI HARD43 do"
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NO.-2973
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BAXTER & NYE, INC.
Registered Land Surveyors and Civil Engineers
7 Parker Road/Osterville, Massachusetts 02655/Tel. (617)428-9131
WILLIAM C.NYE,R.L.S.-President
RICHARD A.BAXTER,R.L.S.-Vice President PETER SULLIVAN,P.E.-Vice President-Engineering
December 4 , 1986
Town of Barnstable
Board of Health
367 Main Street
Hyannis, MA 02601
RE; Lot 6 - Elliott Road
Dear Board .
This is to inform you that the septic system at the
subject lot has been installed in accordance with the
approved plan.
Very truly yours,
Peter Sullivan, P . E .
Baxter & Nye, Inc.
PS/fmj
�P�Tt1 OF MASS
PETER
o SULLIVAN
V 0 1
No. 29733
�CISTL-��p�w`<
FSSIONAL E�A"/
MEMBERS OF
CAPE COD SOCIETY OF PROFESSIONAL ENGINEERS AND LAND SURVEYORS/AMERICAN CONGRESS ON SURVEYING AND MAPPING
MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS AND CIVIL ENGINEERS
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LOCATION \ SEWAGF PERMIT NO.
VILLAGE Lp
INSTALL CVS NAME' a ADDRESS
R�
R U I L WR OR OWN ER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED J�` ��
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TOWN OF BARNSTABLE C
LOCATION I I I I �^( SEWAGE#
VILLAGE C6674\ 61_ ASSESSOR'S MAP&PARCEL.'� l
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY a,$O
LEACHING FACILITY- (type) (size)
NO.OF BEDROOMS
OWNER ��IJJL 1
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) I Feet
FURNISHED BY /\S GCk_1 G �—F
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