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HomeMy WebLinkAbout0495 ELLIOTT ROAD - Health 495 Elliott Road Centerville A= 227-117 r 5 M E A D No.2-153LOR UPC 1ZSU t+' • Me&In uaO LO�SFI IWIWM1�Nm1�W Postal I � CERTIFIED MAIL. RECEIPT ►. Only; Provided) For delivery information visit our website at www.usps.comg, Ln rr1 Postage $ (C < N 0 Certified Fee N C3 Retum.Recelpt Fee r Postmark (Endorsement Required) O Here O Restricted Delivery Fee rq (Endorsement Required) CIO _Total Postage&Fees. O r Mr Juilus Palley 495 Elliott Road Centerville, MA 02632 Certified Dail Provides: ■ A mailing receipt (esenay)zoos eoor'ooae w,o�sd • A unique identifier for your ma'ifpie y ce ■ A record of delivery kept by the Postal Service for two years Important Reminders: ■ Certified Mail may ONLY ife combiridd with First-Class Maile or Priority Mail®. "■ Certified Mail is not available for any class of international mail. a NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Return Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811�to the article and add applicable postage to cover the fee.Endorse mailpiece Return Receipt Requested".To receive a fee waiver for a duplicate return receipt,a LISPS®postmark on your Certified Mail receipt is required. •For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mallpiece with the endorsement"Restricted-Delivery". • if a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix label with postage and mail. - j IMPORTANT:Save this receipt and present It when making an inquiry. i Internet access to delivery information is not available on mail addressed to APOs and FPOs. I . UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 7 I SENDER: COMPLETE THIS SECTION COMPLETE THIS SECTION ON DELIVERY, ■ Complete items 1,2,and 3.Also complete A. Signature item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse X ❑Addressee so that we can return the card to you. B. Received by(Printed Name) C. Date of Delivery ■ Attach this card to the back of the mailpiece, or on_the front if space permits. 1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes If YES,enter delivery address below: ❑No ,Mt Juilus Palley , 495 Elliott Road Centerville, MA 02632 " a. Service Type I ❑Certified Mail ❑Express Mail �j ❑Registered ❑Return Receipt for Merchandise — "— ❑Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number 7006 0810 0000 3524 5478 (Transfer.from service IabeQ PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540 t rs _ Barnstable ` IME T Town of Barnstable Regulatory Services Department j e"aC j BARNSMABLE, Public Health Division a679• �0 ArF°MAC a, 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7006 0810 0000 3524 5478 November 8, 2011 Mr. Jullius Palley 495 Elliott Road Centerville, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 495 Elliott Road, Centerville,MA was last inspected on 10/03/ 2011,by James M. Ford, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Needed Further Evaluation by the Local Approving Authority"under the guidelines of 1995 TITLE 5 (310 CMR 15.06) due to the following: • The Septic Tank and Leach Chambers are in the driveway and are not H-20 loading. The inspection of the septic system showed that the system "Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) However, it is recommended that the tank be replaced with a heavy duty (H-20) load bearing tank due to its location beneath the driveway. Another alternative would be to relocate the driveway. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health Documentl Barnstable Ic op COMMONWEALTH OF MASSACHUSETTS - a EXECUTIVE:OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5. OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 495 Elliott Road Centerville,MA 02632 Owner's Name: Julius Palley Owner's Address: Date of Inspection: October 3, 2011 Name of Inspector: (Please Print).Jaines M.4Ford Company Name: James M.Ford Mailing Address' P.O.Box 49 ' Osterville.MA `�02655-0049 Telephone Number: (508) 862-9400 4 CERTIFICATION STATEMENT ` C1 I certify that I have personally inspected the sewage disposal system at this address and that the information repprted /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 Ca .approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: t - Fq ses .. cditionally Passes ✓ N eds Further Evaluation by the Local Approving Autliority ;V rn p a is Inspector's Signature: Date: October 17, 2011 The system inspector shall s b it a copy oft is inspection report to the Approving Authority(Board of Health or DEP)within 30 days of com eting 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 pwner 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. Note: The Septic Tank and Leach 411,gmber is under the driveway and not H-20 loading Title 5 Inspection Fonn 6/15/2000 page]. Page 2 of 11 r OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 495 Elliott Road ' Centerville. MA Owner: Julius Palley Date of Inspection: October 3. 2011 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please explain. The septic tank is metal and over 20,years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed 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: 2 I Page 3 of 11 ' OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART A CERTIFICATION (continued) Property Address: 495 Elliott Road Centerville, MA Owner: Julius Palley Date of Inspection: October 3. 2011 . 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 * The Septic Tank and Leach Chambers are in the driveway and are not H-20 loading 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: 3 f Page 4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 495 Elliott Road Centerville, MA ' Owner: Julius Palley Date of Inspection: October 3, 2011 D. 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%2 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 10,006 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 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 495 Elliott Road Centerville, MA Owner: Julius Palley Date of Inspection: October 3. 2011 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: 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 is unacceptable) [310 CMR 15.302(3)(b)]. I 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 495 Elliott Road Centerville, MA Owner: Julius Palley Date of Inspection: October 3, 2011 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): N/a 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: 0 Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): No [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: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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: Unavailable 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: Installed on unknown date Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 e OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 495 Elliott Road Centerville, MA Owner: Julius Palley Date of Inspection: October 3, 2011 BUILDING SEWER(locate on site plan) 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: 20" 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: 1500 gal. H-1 D Sludge depth: 2„ Distance from top of sludge to bottom of outlet tee or baffle: 28" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined:" Measuring 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.). Tees were present. There was no sign of leakage. Note: The tank is under the asphalt driveway. 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 outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 495 Elliott Road Centerville, MA Owner: Julius Palley Date of Inspection: October 3, 2011 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: - 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.): Could not locate PUMP CHAMBER: 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.): i 8 i Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 495 Elliott Road Centerville. .MA Owner: Julius Palley Date of Inspection: October 3, 2011 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: 2 leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: Innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): One of the chambers is under the driveway, the other is under the grass. The bottom to grade was 4.5' 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 ofvegetation,etc.): PRIVY: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property,Address: . 495 Elliott Road Centerville, MA Owner: Julius Palley Date of Inspection: October 3, 2011 SKETCH OF SEWAGE DISPOSAL SYSTEM' Provide a sketch of the sewage disposal system including ties to at least two permanent referencelandmarks or benchmarks. Locate all wells within 100 feet.. Locate.where public water supply enters the building. �f O�T boot � b 6 io Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C , SYSTEM INFORMATION (continued) Property Address: 495 Elliott Road Centerville, MA Owner: Julius Palley Date of Inspection: October 3, 2011 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 8 +/- 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: Usiniz Barnstable topographic and water contours maps, the maps were showing approximately 8'+/-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 needs fier•ther evaluation. This report is not a warranty or guarantee that the system will f cn,ctiorn properly ire the future. There have 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 systenn which have not been located and inspected: 11 ( �. No. 't3 t � I Fee _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION — TOWN OF BARNSTABLE, MASSACHUSETTS es Zipplicatiou.for �Digozat *paem Cougtruction Permit Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. s�g�— me Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ,f_p& >// d7,�/o Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. / 7" Type of Building: r _)E i kq. ZaDwelling No.of Bedrooms -7 Lot Size ft. Garbage Grinder ( ) Other Type of Buildings= 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 �� Q�15Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �i��f'T>4�� �'� � /��-o 0 Gi4 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 Certificate of Compliance has been issued by this Board of Health. .y Signed Date Application Approved by n, Date Application Disapproved by: Date for the following reasons Permit No. 2-o (.Z Date Issued Z Z .. i k: G I�\ No. Fee W THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF--BARNSTABLE, MASSACHUSETTS Yes V; i F 0[ppYication for 0i!5pogal 6pgtem congtruction Permit Application for a Permit to Construct( ) Repair({Upgrade( ) Abandon( ) ❑ Complete System LJ Individual Components e Location Address or Lot No.79 S /� �� Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 7 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. / 7 Type of Building: Lot Dwelling No.of Bedrooms Size t 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� �a GA;Type of S.A.S. Description of Soil Y Nature of Repairs or Alterations(Answer when applicable) .1�c�'�/'''iG >►'_/9�°/F' /s✓ /,.��/!mod"".l!/��/. 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 Certificate of Compliance has been issued by this Board of Health. .+� Signed Date / - . 3 r �X Application Approved by ( Date 7�2 - -2 Application.Disapproved by: Date for the following reasons Permit No. 20 (-2 ? Date Issued a311 Z i THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS 1S TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by at IC 9 .� /o J,y` !�o i!O ��''rEG�`/ +�ias been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. : .o► 1 - Z C1 dated Installer lT>-*W .G er46:'©44`,O',,e- Designer /?_' #bedrooms 3 Approved design flow �! gpd The issuance of this permit shall not be"construed as a guarantee that the system will function a��s-designed. - Date / ) Inspector t � No ��•�i� � ��� - -- - -- - -_ _ ,.. _ Fee 4 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS Di.5pogal *pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair ( � Upgrade ( ) Abandon ( ) System located at �9 S" s�t��/a �►o�► p and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of thi perms Date -7 1 y Approved by � < AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION J'�"9S SEWAGE# VILLAGE c::-<rA-�c 5�elIel ASSESSOR'S MAP&PARCEL C;iA 7—��, INSTALLER'S NAME&PHONE NO. LT�/�! !Gs-e�o�'e - cJ'�oa�i SEPTIC TANK CAPACITY O r o " d:N 1!o�✓ f� LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER 4�, /9��L�`� 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) Feet FURNISHED BY 1�eor r 4Z4FF � W ;L i 1 ' - aaz Y 271 , 3 '3#`° So http://issgl2/intranet/propdata/prebuilt.aspx?mappar=227117&seq=2 9/30/2013 c /` F I TOWN OFy�BARNSTABLE LCI:ATION 14q]� I o-Tr -`d SEWAGE# VILLAGE Cm5ery,14- ASSESSOR'S MAP&PARCEL S 1 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ISUO LEACHING FACILITY:(type) CAAAAKS (size) NO.OF BEDROOMS OWNER Al�,y 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) Feet FURNISHED BY Ford I'L,As // �f Ong Aoo� A- Q� oZ 13 to pnv� 331 sa , `1 .� yy1 ssr l Ga TOWN OF BARNSTABLE LOCNTION —SEWAGE# o2 ®--"°Z a VILLAGE .-:-e-A—��ieAOZZ&ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ® s"® 0 �,(z�'o LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER 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) Feet FURNISHED BY r boor j 3 1 Ire" 1 � i i' Jf � .r' l d 7. a c 1, --3- V N I 0 � . YN j i 721luOaalr i 13 TI 6T-A lac LAuomt, /$ r P.,0.tH I ti W? 5 5 P P—A , f l4c� No.. .. ...._.. .. Flea..........................._ 3-_.L 6,5 THE COMMONWEALTH OF MASSACHUSETTS N �� BOARD OF HEALTH _.............!.''-.`f.,................OF............�JP�R-±�LSTf ........................... Appliration for Uhip uttl Hijarkii Tomitnutiurt thrmi# Application is ttx maderfor a Permit to Construct (0) or Repair ( ) an Individual Sewage Disposal System at: • `T'�` ........... ..__.. �u .....�................. ...•.....-------------�!!� f� '` '.`-�-�•......... .......... Location--Address ^� ... �ort�Lt�NFo. ....................._... ... _......... .. O . .............»........... Owner Address W M Installer Address // Q7i Type of Building Size Lot.--��.---�t..`1`q..Sq. feet U Dwelling No. of Bedrooms.•.....�..................................t g— Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g ---------------------------- P ( ) — Cafeteria ( ) dOther fixtures ................... •-••--•••.......•--•............................................................................................................. Design Flow.................'...r���.......gallons per person per day. Total daily flow.................� 4............gallons. WSeptic Tank—Liquid capacity l?�gallons Length._.l.l'_.!_l : Width: '. .::_. Diameter................ Depth. . x Disposal Trench—No. .....Z.......... Width--__`+.. <'... Total Length....'�`�_...... Total leaching area.._....Ss�._.sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (yC) Dosing tank ( ) a Percolation Test Results Performed by........................ ...................................... Date.......\. 2...... `............ Test Pit No. 1...t Z...minutes per inch Depth of Test Pit.......I L......_ Depth to ground water....... 44 Test Pit No. 2----._..2....minutes per inch Depth of Test Pit....... Depth to ground water....... ! ..... ...............................................................r..................-•----•--•--•----......................................................... O Description of Soil... � t � 3 ._ .••-- -- ..... ......- .... ' 1 Z' U lu -rtn 1 ...:............T!-F..` =---- �=('........f'C'T ` C�:.-_Z�._l l l ............ ..................... _ �.. ............­- ------- ..•.._�`-�.��!�.�........Z... ................Fit.--. L+_..'"�cl?.............4. ........ 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 4ITL: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certifi to of Compliance has bee issued by the board o�lth. - G� Signed .............. ..... Date Application Approved By..- ------------------------------ -... -.9. ..... Date Application Disapproved for the following reasons:--------•--------------------------------------------------------------------------•-•.........._.........._ .. .....................•-....---•-•..........-•-•-••---...-••••---•...-••-------•-•••••-•------••••.........---•-..........--••---•----•---•••-••---•••-••--••-••-••-•--•-......------••••............... Date PermitNo............ ------------------ Issued_....................................................... Date • f No...._... FEs......1...._............. '�• ` THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH 5 )... .. ....................0 F............. ......................... f Xp#ftration for Diopooa1 I orko Cionotrurtion Permit Application is hereby made for a Permit to Construct (�C) or Repair ( ) an Individual Sewage Disposal System at: .5 /,`�' ti`� ,c9`Tr�'1#_?�' , � i Zo l_ L-1 c i IGr ; lTt ................ .»_..._.. ...Location............................................. Address...... ..._...._....... ........_.......... . ...................................... or Lot No. ..........._............. ......................»..».._..--•-_._............,.._.::..--^----......._.:.........._.�..;,.. .:....................---............_._....:..._...._........__..._............................. Owner Address - `stall.............. �:.• ... " `�`�� S-. feet M Installer Address Size Lot.�`�✓:.. Type of Building q U Dwelling No. of Bedrooms............................................Ex ansion Attic t a g— p ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------------•-- --------------•••-----......--•---•--.-------•-----------------•-•---•---•-••---------•---•-------.................-•-••--••--..•--•- W Design Flow...................' O----...-��' 5---..�----gallons per person per day. Total daily flow................. �> ............gallons. WSeptic Tank—Liquid capacity---_A �gallons Length._. Diameter................ x Disposal Trench—No. ...._�.......... Width...'':•_.nn .. Total Length....-'+`'....... Total leaching area.......!4�5c2---sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( X) Dosing tank ( ) ''' Percolation Test Results Performed by.......... :�.................................. Date......-................................- ,.� Test Pit No. 1...:.......minutes per inch Depth of Test Pit....... ........ Depth to ground water........ GTE Test Pit No. 2.__.L.z__._minutes per inch Depth of Test Pit.......1......... Depth to ground water.......i"'r�...... a t x � o-(,• L �ODescription of Soil...:o t : (' : 7 . 3• - •-•- , -»...._ ?.... f� -...-- .- - z.. .. ........ ......._•----- ..... .. �_ . --- ....:'-......... �... .... L .. .0 '- ------ -------- -------- --•--....-•--- -.--------------•----•------------------• ---- = .............................................................. 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,ITL: 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the�booa'rd oof�health. Signed/�/f't`� `-'l.-a_._ k ,-�t.C�...._. a!1 � 7 - /... Application Approved B \9 _. :.. .:..._`.: .......- *j � „ PP PP Y =•-: _.��.. .... .... ......................•...... Date •...=••.... Application Disapproved for the following reasons:............................................................................................................ ZZ= .............•--....•---•-••••----•..........--••----------•.................-----...........------.........._..........._..........------•-•--•. ------------•---........-- ............... Date :- PermitNo...............::.........---.....................-...... Issued_....................................................... Date _ _____ __._. _...�. ...,.,....,�.._.._, -- ___ _ �a .. .._. , THE COMMONWEALTH OF MASSACHUSETTS BOARD OfF� HEALTH ��.w.................OF................h'�??`p .. ........................................... Trrttf irate of TompftFturr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O or Repaired ( ) by.......................-•••....:? ...... _ = ` . ......................... ................ =`�•----- ........................................................ -. , _u r .. 1). Installer ,. !.,, has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No............:....:.....:.... .. ... dated-............................................... THE ISSUANCE OF THIS CERTIFICATE SHALL,NOT BE CONSTRUED AS A GUARANTEE-THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......��..... ''-�:.-- ---•.................. Inspec'or_ / 7/. '?,c:._................................................. f - .n...+ ...m..,«.....p _.._________.._p — _,•r .•IDAw_.e...rwr M.•kdva,..e.n,n•.n-.rw,....w___.'__..__.r..wn..}w.._—I-•iwer------------- ----..------w,.__.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH NO� --- OF..................................................................................... f ...:.._--��... FEE........................ Disposal 11orkii Ton,strudiatt rrrmtt � Permissionis hereby granted...........f.�.-•---- ---------•.......---......................................................................... to Construct ( ,�) or Repair ( ) an Individual Sewage Disposal System at No........... ..-�-.... .^.... ` _=A-= ,.« 1 , _ Street as shown on the application for Disposal Works Construction Permit No.................Z. Dated.... ...`C4.,1.............. �.-`Uj.__�-------- -------------------------------------------» �} } V lloard of Health DATE........................ /... ................................... y , x r . u REFER TO 20 9 IRC 0 _ S 8 TH EDITION. MASSA H ETT C U. S E U O 01 , cif " NOT S..E . . . :. GENERAL i for, Before final Drawings and Specifications are issued o A. 1. e e a P 9 , - sc� building r i 'e hall be submitted to all overnm u const uct onth shall _9 9 9 a lic l` .local and encies to insure their compliance with all aPP ab e _9 p national codes If code discrepancies in Drawin s and/or - - : shall be notified of such cn Specification s'a ear the Designer P - building` ffici I and `m ri in b Builder orofficial,_-discr"ancies writing , eN_ p 9 Y o comply Ilowe o alter Drawm s and Specifications so as t c _ a d t 9P.Y : be ins. Q rnm odes before construction • ,with ove c 9 . governing rov I from the ov rnin official,2. U on written receipt of a a e e p pp governing p , b submitted a r v d final Drawin s and S ecifications shal a su tte oe p pp .9 to the Builder by the Designer' ri on tr ction C i ar discover"d dun the c s u 3. 'If code discre'anc es e e pro mocess Des9Hershall be notified and allowed am le time t , r ni z `remedy said disc e a c es _ p _ 4 All workpe rform omPpIY with all applic o cal,.state rdi and r ulations and Y,and national buildm codes ordinances e 9_ 9 all oth authorities thorities haven ur sd ct o — 9J , r: II be rsubcontractors,su Hers and fabricato s shall C� . B. All cont actors _ Pp f r win h S ecifications and for Z responsible for the content o D a s a d p 9 p sin f a ro Hate mat na s and work' J the sup I' and de o e ,- ppY _9 p @rformance. ishall, a lied _f C. All manufactured articles materials and e u ent be _,m _ , and conditioned in strict •y�installed erected usetl cleaned a c e L recommendations. ,.accordance with manufacturerse M _ C r r e option of the Builder and shall be at the f-- D. All alte Hates a e at th o on u r` n addition o or in lieu of he Builders re uest constructed i ad t t e t <. q >'Z nDrawings.al c ion sin icated o Ica constru t a d _ tY _ _ W .: .: is � � r n 1 ndiscrepancies. Z m - E. SPB Desi ns is not res onsible fo a a 9 p _any J O r i ` r vi w"plans before start of const uct on- Builder&Homeownerto e e __ 1.., , _ — v7 l..rL , W _ Cn wM R EA R ELEVAT I O N w c } Z o : : , > , o Z w ' Uj Z W _ o 0 o . , w J 4V H J W Z O - ` Cr_ _._ w — • SCALE: 1 4rr_ / 10 DATE;,.. .. ,._. _. . _._- . _��..�_ 11 14/1 4 - DRAWN BY PAB REVISI N 0 S I HT ELEVAT RIGO AWING NUMBER i r f: 1 COY HT. PB DESIGNS2014 ,, G S i