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HomeMy WebLinkAbout0038 EVELYN CIRCLE - Health 38 Evelyn Circle Centerville P A = 187 062006 i IIII �pECYCIEp UPC 12543 o- No.53LOR -CO HASTINGS, MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle o Property Address Oliver Marti Owner Owner's Name information is tr Centerville {� Ma. 02632 08/29/2016 required for every C � page. Cityrrown State Zip Code Date of Inspection f.. Inspection results must be submitted on this form. Inspection forms may not be altered in any ' way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael T Bisienere use the return Name of Inspector key. Cape Septic Inspections Company Name 624 Old Barnstable Road Company Address Mashpee Ma. 02649 City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 09/06/2016 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. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 l�� ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required for every Centerville Ma. 02632 08/29/2016 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required for every Centerville Ma. 02632 08/29/2016 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is Centerville Ma. 02632 08/29/2016 required for every page. Citylrown State Zip Code Date of Inspection B. Certification (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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for 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 t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts f up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required for every Centerville Ma. 02632 08/29/2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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 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. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle ,p Property Address Oliver Marti Owner Owner's Name information is required for every, Centerville Ma. 02632 08/29/2016 page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ 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(5)] D. System Information 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owners Name information is required for every Centerville Ma. 02632 08/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system.inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ® Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name informatifor every on is required Centerville Ma. 02632 08/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •'' 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required for every Centerville Ma. 02632 08/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): There are two sewer pipes feeding the septic tank one from the home that is in the inlet end of the tank and one from the outside bathroom that is in the discharge side of the tank. Septic Tank(locate on site plan): Depth below grade: 14"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 certificate) ❑ Yes ❑ No Dimensions: standard H-10 1000 gallon Sludge depth: 3" t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts rA Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required for every Centerville Ma. 02632 08/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle apx. 35" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle apx. 5" Distance from bottom of scum to bottom of outlet tee or baffle apx. 12" How were dimensions determined? sludge Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I would recommend the new owner put the tank on a maint. plan with a local septic pumping co. based on the future use of the home.The Barnstable Health Dept. has a list of local pumping co. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required Centerville Ma. 02632 08/29/2016 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach co of current pumping contract(required). Is co attached? copy p P 9 copy ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required for every Centerville Ma. 02632 08/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): At the time of the inspection there no signs of solids carryover or evidence of past hydraulic failure. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Xf Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required for every Centerville Ma. 02632 08/29/2016 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: Three ❑ 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.): At the time of the inspection there were no signs of past hydraulic failure. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required for every Centerville Ma. 02632 08/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on 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.): t5ins•3/13 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required for every Centerville Ma. 02632 08/29/2016 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately .31' 3�" Q I r 2� 3 = 33- 36 r � te\ ICI 9J J t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required for every Centerville Ma. 02632 08/29/2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15 plus feetfeet 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: You must describe how you established the high ground water elevation: I augered a hole at a lower elevation and shot it with a transit to show five plus feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 40 38 Evelyn Circle Property Address Oliver Marti Owner Owner's Name information is required for every Centerville Ma. 02632 08/29/2016 page. Citylrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file ©TrOM OF S NS 5 P10s FeeT t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1� 9 NO. v Fee M THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zipprication for Migogal 6petem Congtrurtion Permit Application for a Permit to Construct( . )Repair Upgrade( )Abandon( ) El Complete System El Individual Components Location Address or Lot No. 38 Evelyn C i r. Own is Name,Address and Tel.No. (5 0 8 )7 7 8—71 2 7 Centerville, MA 'G�enn OF Tobin Assessor'sMap/Parcel 38 Evelyn Circle Centerville, MA 187/62-6 Installer's Name,Address,and Tel.No. (5 0 "6 2—6 _0 _ Designer's Name,Address and Tel.No. g ,��- �'�� Weller & Associates Williams Building Co � 1645 Falmouth _Rd. 4C Centerville . P.O. Box 272 Yarmouthp — MA 0Fal 2632 Type of Building: Dwelling No.of Bedrooms 4 Lot Size 2 R ,R-4 n sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons - Showers(2 ) Cafeteria( ) Other Fixtures Design Flow II n gallons per day. Calculated daily flow 4 5 9 _ 9 gallons. Plan Date 3/2 4 fQ4 Number of sheets 1 Revision Date Title qii-- & Sewage Plan Size of Septic Tank 1 , 006 Type of S.A.S. leaching 3 500galldry wells w in. of stone Description of Soil, soil class 1 / perk rate less than f asa„al to r; min_ per inch. Nature of Repairs or Alterations(Answer when applicable) Rent ace leeching f i el cis 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 Enviro mental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this B et He ` / /r/o Signed Date `7 Application Approved by Date Application Disapproved for the o owing reasons Permit No. Date Issued d�. --------------------------------------- '"•1V ,f rf Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .. ak PUBLI C"HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS _ �Zlp#ficaction for Zizponl *p!5tem Con!5truction Permit Application for a Permit to Construct( . )Repair( rade s p ' �Upg ( )Abandon( ) El System El Components Location Address or Lot No. 38 Evelyn C i r. Ow 's Name, dress and,Tel.No. (5 0 8 )7 7 8—71 2 7 Centerville MA "� enn .. Tobin Assessor'sMap/Parcel 38 Eve yn Circle Centerville, MA 187 62-6 Installer's Name,Address,and Tel.No. (5 Q$ 6 2—6 •• Design Name,Address and Tel.No. j��/�. W� �er & Associates Williams Building Co 7-1 P.O. Box 272 Yarmouth P.O. Falmouth,111t 4C Centerville MA 02632 °"• -Type of Building: Dwelling No.of Bedrooms 4 Lot Size 2 8 r 8 3 0 sq.ft. $ Garbage Grinder( ) Other Type of Building No.of Persons Showers(2 ) Cafeteria(, ) Other Fixtures Design Flow 11 n gallons per day. Calculated daily flow 459.9 gallons. Plan Date 3/2 4/0 4 Number of sheets 1 Revision Date , Title Sitim A Sewage -R1 a Size of Septic Tank 1 '000 Type of S.A.S. eac ng 0 ga ry wells . or stone Description of Soil soil class 1 / perk rate less than/equal to 5 min- per inch. - Nature of Repairs or Alterations(Answer when applicable) Replace leechtka fields 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 ar`To� HHeeal,l. . Signed �� ' Date Application Approved by �. - Date Application Disapproved for the f llowing reasons 1 Permit No. �� �� Date Issued A-// 6 4 � .0 y��.c'd (I. �/'E J THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Y/I v/s"ter. Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(,,. )Repaired( ) Upgraded( ) Abandoned( )by ! at S W Eve 4e" has been construct ed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. t b`�-/ dated Installer Designer The issuance of this pe not beknstrgued as a guarantee that the s tem 'll �cho �asdesi,gni �, Date Inspector j M - ——— ————————————————————————— ————— -.. No. Fee'_:�(J THE COMMONWEALTH OF MASSACHUSETTS R i PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1i!5Po2;a1 *p.5tem Consaruction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at VO/1 n 'r c �n r�vl 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:Con c'on must be completed within three years of the date of this permit. Date: �� Approved by � TOWN OF BARNSTABLE LOCATION /% C I zf SEWAGE # VILLAGE L����'/�(/l� ASSESSOR'S MAP & LOT INSTALLER'S NAME&-PHONE NO.7;7;—M— z f 0—U .eia SEPTIC TANK CAPACITY A11,4 LEACHING'FACILI'I'Y: (type)'-1 (size) NO.OF BEDRObMS BUILDER OR OWNER �,/�f� PERMITDATE: zT,/�l eA • ____COMPLIANCE DATE: Separation Distance BetweenZh, : Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility t f Feet Private Water Supply Well and Leaching Facility'.(If any wells exist ' Al/A 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 - II d9LK O'� tIo tJSls s�V C �00 Commonweafth of Massachusetts Executive Office of Environmental Affairs John Grad D.E.P. Title V Septic inspector Department of � P.O. Box 2119 Environmental Protection Teaticket, MA 02536 MABIam F.Wald (508) 564-6813 3oNmor Trudy Coxe B�cnt,Y,EOEA David B.Struhs Comminiona SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION_FORM PART A CERTIFICATION Property Address: �'V��� �`� r (�Q�i�lV�t� Address of Owner: �® A Date of Inspection: LP Cv tlo (If different) 1 Name of Inspector: " 1,996, Company Name, Address and Telephone Number: CERTIFICATION STATEMENT ('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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: �ses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 repon to the appropriate regional office of the Department, of Environmental Protection. The original should be ;ern to the s>stem owner and copie, sell: to the bu)er, if applicable and the approving authority. INSPECTION SUMMARY: Chec B, C, or D: A) SYSTEM.PASSES: I h`r ave not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND), Describe basis of determination in all instances. 1f"not determined", explain why not) The septic tank is metal, cracked, structurally unsound,.shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) One Winter Street a Boston,Massachusetts 02106 • FAX(617)SWI049 . Telephone(617)292-UW Pnnied on It-ocied Paw, SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM' M, PART A CERTIFICATION (continued) Property Address: \� Owner: Date of Inspection: B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution,box. The system will pass,inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): t .,. broken pipe(s) are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED SY 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 the public health, safety and.the environment. . 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. Z) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS IRONS ENTFUNCTIONING IN A MANNER THAT PROTECT SAFETY AND THE E'�1THE PUBLIC HEALTH AND 1 ne .%Wen, n f -- r a� a .eutrc tangy anu lUii dU�OfpUOn Sy'�lrni al'i(I i5 Witl'ufi iV0' (cci.w o 5ui"a.c „otCr S'uNj '� 0. surface water supply. The s\s!ea- ha' a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from.a private water supply well, unless a well water analysis 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 S' ppm. .. D) SYSTEM FAILS: x I have determined that the system violates one or more of the following failure criteria as defined in'310 CMRJ15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. w..... Backup of sewage into facility.or system component due to an overloaded or clogged $AS 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. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: \ Date of Inspection: D) SYSTEM FAILS(continued): 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: . The following criteria apply to large systems in addition to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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' The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 0 ,1E",JQkK N `.'VICUL) Owner: `�(�( ,a Date of Inspection: i._'` CktQ Check if the following have been done: Fmping information was requested of the owner,occupant, and Board of Health. _j..Ptone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period, large volumes of water have not been introduced into the system recently or as part of this inspection. t�cS built plans have been obtained and examined. Note if they are not available with N/A. _j,1ke facility or dwelling was.inspected for signs of sewage back-up, _L T* system does not receive non-sanitary or industrial waste flow _,`,,-he site was inspected for signs of breakout. _ system components, excluding the Soil Absorption System, have been located on the site. _L,:Phe septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. _ Te size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _TFe faC;lot,.• ^ if diffarPnt from o ne,l were provided with information on the proper maintenance of Sub- Surface Disposal System. " (revised 8/15/95) 4- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Owner:. �`(1(�Y� qr Date of Inspectf�affii �1u1 qb FLOW CONDITIONS RESIDENTIAL: Design flow: �JL40.gallons Number of bedrooms: c' Number of current residents: Garbage grinder (yes or no):—:E�S Laundry connected to system (yes or no).: S _ Seasonal use (yes or no):110 - Water meter readings, if available: Last date of occupancy: COMMERCIAL/INDUSTRIAL: (1�* Type of establishment: Design flow:agallorfs/day 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 OTHER: (Describe) Last date of occupancy: y• __ ... ._. GENERAL INFORMATION PUMPING CORDS and s urce of information: System pumped as pan "of inspection: (yes or n )4e f If yes, volume pLimpedJt _,allons Reason for pumping: 9 TYPE OF SYSTEM tl--*--septic tank/distribution box/soil absorption_system Single cesspool M. Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all components, date installed.(if known) and source of information: Sewage odors detected when arriving at the site: (yes or no)� (revised 8/15/95) S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION (continued Property Address: Owner: Date of Inspec o 1 LQ�ato .. SEPTIC TANK:—L/', . (locate on site plan) Depth below grade: `�a 11 Material of construction: crete_metal _FRP—other(explain) Dimensions: \ tt . ►I t �� Sludge depth: �1 Distance from top of sludge to bottom of outlet tee or baffle:�Zf Scum thickness:_ Distance from top of scum to top of outlet tee or baffle: rt Distance from bottom of scum to bottom of outlet tee or baffler Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles depth of liquid level in relation to outlet invert, structural in�grity, evid nc leakage, etc.) av C GREASE TRAP:n\ (locate on site plan) Depth below grade: Material of construction: _concrete _metal FRP lother(explain) Dimensions: Scum tiuckne». Distance from top of scum to top of outlet tee or baffle: Distance from bottom nt cr gym to hottom of outlet tee or baffle Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 I , o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: SS O .� Owner: Date of Inspection: TIGHT OR HOLDING TANK:�� (locate on site plan) Depth below grade: Material of construction: concrete!metal _FRP,_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee,,condition of alarm and float switches, etc.) DISTRIBUTION BOX:y,,/ (locate on site plan) •A� Depth of liquid level above outlet invert:1 � s �r" Comments: (note i levei and distri' u�wn 1�ryudl, e�1 01 C Of sued: Caffto,Er, evidence of leakage into or out of box, etc.) �11 C 1C � `i�u s u.�rr,c� , PUMP CHAMBER:CAV-1 (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 6/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: ODate o nspd nwner .?jf , t%" -►1U6 f SOIL ABSORPTION SYSTEM (SAS):i+ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: � l, �,� leaching pits, number._ k-"` 1 .leaching chambers, number:_ leaching galleries, number. leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number. J Com nts: (note condition of soil, si s of hydraulic failure, le I of po ing, conditio ot'vegetation,etc.) `f T CESSPOOLS: (locate c 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 ground:.atc ; inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRI W: (locate on site plan) Materials of construction: pimen�tons: Depth of solids: Comments. (note condition of soil, signs of hydraulic failure, level.ofponding, condition of vegetation, etc,) (revised 8/15/95) B i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addd/reess: 3 S 61 "f\-QAfCk Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' CAC I © Q� 0 AA 176 �C Rc ,� Ap 3b; e gf `I 3 DEPTH TO GROUNDWATER Depth to groundwater: `d feet l 1 c method of determination or approximation: V J (revised 8/15/95) 9 TOWN OF BARNSTABLE LOCATION !. lI 2G 1 Zf SEWAGE # VILLAGE ��� ����� ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. //f+? SEPTIC TANK CAPACITY �_��1�i4/ � 4: OA LEACHING FACILITY: (type) (size) � NO.OF BEDROOMS BUILDER OR OWNER PERMUDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility M �� Feet Private Water Supply Well and Leaching Facility (If any wells exist Al/A 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 facih /l/ Feet Furnished by "���--- 6a�k a pr tl0vs� Bex o / P ,�j00 THE COMMONWEALTH OF MASSACHUSETTS SOAR ®►F HEALTH Applira#ilan for DhiposFal Works Tnnitrnrtinn Frrmit Application is hereby made for a Permit to Construct %) or Repair ( ) an Individual Sewage Disposal System at i-- --- . _........ Address o - - �o� w� !.........!...:.. - -......-------------------•-•........--•---- _________________________________________ Instal er Address UType of Building Size Lot_M. _____ ___._Sq. feet , Dwelling—No. of Bedrooms_____ LS________________________________Expansion Attic Garbage Grinder ((, � Other—T e of Building __ No. of persons____________________________ Showers — Cafeteria Q' Other fixtuur-es -------------------------------•-- W Design Flow............��_.....................gallons per person per day. Total daily flow__.-___�_30......................gallons. WSeptic Tank—Liquid capacity_) kallons Length .d-•• Width--A_-1-O_'_Diameter________________ Depth__,2t�__ r x Disposal Trench—No_____________________ Width__.................... Total Length........... Total leaching area--------------------sq. ft. Seepage Pit No.........I ______. Diameter_____0.`A...__.___ Depth`�below inlet....t_ ..... Total leaching area_ �..sq. ft. Z Other Distribution box `r 65 Dosin tank llC '-' Percolation Test Results Performed by-__.__�,- ' j °: : aTest Pit No. 1... 2-_minutes per inch Depth of Test Pit----lz......... Depth to ground water_,&4o-9:_1i.�oou^.w,6) GT., Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil......0--"2....... ? ---------------------- U ---•------------------- ................................... 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 TI'i 1E 5 of the State Sanitailey Cdhe and gne rther agrees not to place the system in operation until a Certificate of Compliance has t d ealth. igned- -----_-• J. ................ D ApplicationApproved By-•••-- ••--•--5`-• - ••---•-•-....-----•-••••••--•--•-•-----------•-- ......----� ... . •---•- Date Application Disapproved for the following reasons-----------------------------------------------------------...................................................... -•----•--•----------•--------------------------------------------------------------------------------------••-•-•----------•-•••-•--•-------•---•-•---••-•••---•--•---••••••••-•----••••--•••---•-•----- Date PermitNo..... ............. .......................... Issued....................................................... Date r &Z No.. .-.�y ! Fps. .........._ THE COMMONWEALTH OF MASSACHUSETTS BOAR. E HEALTH ___..... `1 `'-°..............oF........ ......... .-............ .................................................. Appliration for Disposal Works Tonstrnrtion lirrmit Application is hereby made for a Permit to Construct (/X) or Repair ( ) an Individual Sewage Disposal System-at.: I - - t- l `E l --k t,.. t ic:C �.L �i�r,a ice-ZQI(C e 6—U- ( �Ic> - _ •-------------------------------------------------•----------_--------•-- ------•-----••----------_---•--- = T��VG t� p7 ---- -----------•-•------------•---------------- .1 � /f' �� Ib t No. _._..... r G�°Y er 6/1/Z lv�. ••-----------•-••--•--•--•-•-••••--•. •--•-•----•-----•--•--------•-----------•-•--.......--•-••...................................•--- � Installer Address Type of Building Size Lot..Z:-:1_ _ __Sq. feet Dwelling—No. of Bedrooms............................................Expansion Attic A9 Garbage Grinder ( j `4 Other—T e of Building ............... No. of ersons.....__..............__..... Showers aOther fixtures ---------------------------------------------•--------'-----------------------------------••-------- ------------------ -..- WDesign Flow____................ ______________________gallons per persor}1 er clay. Total daily flow............................................ to s., , W Septic Tank—Liquid*capacity..... Length.S, Width.-"4..___t-?.. Diameter_ _____________ Depth._`? .. x Disposal Trench—No. .................... Widt _.___-------_-_-__- Total Length....... ._. Total leaching area_._..._____ sq. ft. Seepage Pit No,---•__--- -ar.. Diameter...__���........ De t1�i below inlet_____�: �.______ Total leaching area._ a._sq. ft. Other Distribution box o c Dosi tank �O _---- Percolation Test Result , Performed by-__' L'�Z-e DGt(-=:_�-G—t I4 ` .G Date....................._ _��_r=__._.. Test Pit No. 1....... per inch Depth of Test Pit.... _.`-........ Depth to ground water._r: `)-'__(Z&ZoV fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit....:._............. Depth to ground water........................ D Description of Soil------ x ......... ......................••-•--•-•-_----- -•-•••......••---••----...................................................................... w U Nature of Repairs or Alterations—Answer when applicable................................................................................................ -•-----------------•---------•---....-----------•------------------------------------.....•---_.....-•••-------••-----•---••---•---••---•-••--•--•-••••-•--•--•••-•••••-•--••••--••--...•-•--••-•--•-•-- Agreement: The undersigned agrees to install the aforedescribed Individua Sewage Disposal System..in accordance with the provisions of TIT1S 5 of the State Sanitary Code—The unde si ned�further agrees not to place the system in operation until a Certificate of Compliance has been •ss by tl . a d ofi_health. / -- Signed--- -��•_............................ Application Approved By...... =_ ------ ... ` fin------. Date Application Disapproved for the following reasons:....................................................................... ........................................ ....---...-•-------•---'---•-•--•---------------•------------- ...----------------------------------------••--...------ Date PermitNo.................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD ,[�7 F HEAL H ............l.&� ....of (9rrtifiratr of TomvliFanrr THIS'IS TO CERTIFY;That the Individual Sewage Disposal System constructed ( or Re aired b ....._ 1�caw rn �( P ) y- =---------------------------------------- --------------------------------...-•-•--------•---•--------•-- f tl L_ v l � Ins a ler� at ---------------•- �=- v-�.= '�`'`' ` -l--r'•.-..------.......r--�-;....-------------•-----------------•---------•..------------•----•--------------- 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._�—,- .�_._I--?-1........... dated......?. �. ---- ................. 1' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL L U CTION SATISFACTORY. �/)& DATE. - ................................................ Inspector_ TX•---........---•-•-•-•---•---••••--••-••----...--•-••--•-........-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF........................................................ J , . No......................... FEE..:..:.....:........... Disposal Works Tonstrnrtion "Permit Permission is_hereby granted..4� �-:j.'.:)__.__.:`..I_ -._\_ e 0_______________ _ -----------•-•---------------------------- to Construct �(` ) or Repair. ( ) an Individual Sewage-Disposal System as shown on the application for Disposal Works Construction Permit NO,. __ .... Dated.......... --- =` Board of Health DATE.............----•....................... =-=_-==•-------.......--------------•-• FORM 1255 HOBBS & WARREN. INC., PUBLISHERS -SEE 'S v+,E 1 T Z-/Z �LA, Na �ae�n��� cz --MA.ttaC 3 x 110 X = 330 EtlfD ��Pr1G'Thr�K 3k I►o x 1 s'(=>i-1 _ �19.5C-s1�► �P�jll of'; ; L16a Iood G-tAt_1p1.1`T/�I.�1: r PETER SULLIVAN a .:;: ►51=t:>5A.L-fi�- -�- USS 6G�7 1.W1Ti�(� NO. 29733 f j �,�Fss, '�Tc'',�• 2Mt►.t e,l►aLN ' ca�Al BAXTER r,. f`iG.21043 jjr a JfH O F—T�5T+1pLE IZ-r-'s6S W 40.5' +"- = 38 +C�= 39,C) Lo.°M 4 � sV6b016 . 1 tiAv tv 1 Nq �"gr aK IN`/ 14' T �G7o c�raL�p►.,t�,-� 1/ \44I-rjjQ Cf�VSEF D t-oTCo �Vc.L�ti! ZOlaf% 2Bs •� ice- .Au ���e.>�rac.>�: 1�o�ATLtL �i 2.o�sE7 a��K �f�G�F ����a rl �MP�`(5 �!i 1�-�-�{� �tv�L1►J� �RU� -3Rx�z� v E 1►a c. 6�K ��Qu 1�.�M��S �FTtr•�-ra�uN ��Isr�e..� In S�e�lF^(oe5 aF �e►� 81_� , �7 IS tJC3i" C.�v ►-t Ms 2S 3-5-8� �c�c.�1.�° �c���E�A►a�y j �l M�IaT Sct�Y��(�Tt}'�T1F'-FS1�.T5 5�t�Cl! t-1EeSDr-1 S+�ac.1L'� taC3'i'"�t= UscpT� w SZEAS'-OUT �oMPu np�..t SLOPS �' / 40' -- - �V V, 25'+ L Tt „ N ..... '... LOT CO 3s . z8 72 L c> 09 �\. �� •� "`�' ,yN OF�y PETER R;ICHARD r "' o SULLIVAN A. k v BAXTER ��try I No. 29733 Rio.2�M 11 Fib ti At El-E-YA IO&A 7.S�_ - -7A-r-E�. N1�e.�t-a q, ►9s � { �n*7 t l Town of Barnstable Regulatory Services do Thomas F.Geiler,Director • BARNSTABLE, MASS. g Public Health Division 1639. ♦0 p'FD►A°'�° Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: A Designer: `D N tEL. Installer_:} Address: �� X7 Address:} - Get= tLLE On Gn _ was issued a permit to install a r =(date) staller septic system at �/� GYM ' C�r�IiOt based on a design drawn by 1 (address) A dated MAIZC4 Z+ -2c,r4—. (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system)but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. a. � �'ZH OF hfASS9 o� DPAIEL E. BRAMAN — - CIVIL :(--Instal_er' Signatu--ee No. 32686C a �0 ccGist ERA\�4 FS'S/ONAL ECG (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form ,ASKS-SOW S MAP N PARCEL 6 L�0C.ATIO;NC6_ SEWAGE PERMIT NO. VILLAGE INSTALLER'S NAME i ADDRESS S U I L D E R OR OWNER cr-, 2 DATE - . PERMIT ,ISSUED L/ DATE COMPLIANCE ISSUED i Jr f ------- PROff iLff-: NOT TO SCAM LAYER OF�-/8"PEASTONE rr / p ARDE2 �OULE OVES TO MTHIN LEVEL PATE: I Z-Z 3- TP FON , ( l T WS1E STO f "� �' -- 2 f✓ LP��,04' 4 r_ b" OF FN SFEP GRADE. FOR MIN. 2' FELN=IS Fi YGoRA'D E TWEFSNTEIS PERO RATE: ....�G7 \. ��.. �� TOP a F 3e- I 7 \ 7�� S 3 V.46 3S. D� 15MTOM ® � 3.3,�a N O rl e T 3G,a 8 �p Jv I I 000 OAU-ON S,3 SEPARATION / Y Z (✓' ' -!EFT G TANG CX'i s "i.�/ IA141. �a \ - �41y z8, DDs ION DATA DAILY PLOW: (y)¢EDROOMS x 119 CIPP yT o cvPD � ter.✓ SEPT 6 TANK:�'yc� ePD x200% 9sc> C�PD �?��ST. `�''� 3c►z USE:,Q'CEIALLON PRECAST SEPTL TANK Z IS Zoo o I '�9-sT LEACHING FACILfFY: USE:763) sX '.S'x Z'ti Soo C7- CAPACITY: / WALL: . 93'le 3,7,6, D I t� I T ATOM: /3'�C 33.s'�ro,�y' Z2, 3 OEt �ERAL. I CIO I D5 TOTAL: --� i CONTRACTOR TO 15E RESPONSIt5LE FOR THE LOCATION OF ALL UTILfFIES, A15OVE AND U PEReROUNP,PR I OR TO ANY EXCAVATI ON OR 6ON5TRUGT I ON. �i'� ' o•'='�n�N z'.� - - + C _ I z. SEPT`IC SYSTEM TO M INST-ALLEP IN COMPLIANCE WITH 310 GMR 15,00:TITLE V 3. THIS PLAN 6 NOT TO M USED FOR PROPERTY LINE DETERMINATION 4. ALL D15TURMP AREAS TO 15E LOAMEP AND SEEDED 5. CONTRACTOR TO PROVIDE'1 4 HOUR NOTICE FOR ANY REGZUIREP INSPECTIONS 3 j' STEVE t TE MAN ' 3 'tt M , �5EWAaE PLAN IS �- ` PREPARED FOR; �/.�✓ S/ EiL,ca ?o.�►�-ti/ SCALE: DRAWN t�Y: J015 NUMBER: PATE: ti1,g2,Z,l' Zaoy SHEET: WELLER & A�5061ATD3 1645 FALMOUTl1 RP - SUITE AC GENTERVILLE, MA OUM TO .: (505) 775-0735 N FAX: (505) 775-0754 PROFESSIONAL ENGINEERS & LAND SURVEYORS