HomeMy WebLinkAbout1343 FALMOUTH ROAD/RTE 28 - Health 1343 Fa . .ou#h Toad (Rt
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COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form. Inspection forms may not be altered in any way.
A. General Information
1. Property Information:
1343 FALMOUTH ROAD — CENTERVILLE, MA 02632
Property Address
SHARON & DEBRA KNIGHT
Owner's Name
1343 FALMOUTH ROAD 01
Owner's Address
t
CENTERVILLE MA 02632 _
Cityrrown State Zip Code
SEPTEMBER 20, 2007 > �
Date I
<
�-' tt;
2, Inspector: €o�#
RICHARD K. CANNON 1 .
Name of Inspector --
A & B CANCOi FTI
Company Name
350 MAIN STREET
Company Address
WEST YARMOUTH MA 02673
City/Town State Zip Code
508-775-2800
Telephone 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
Nee r4mict
by the Local Approving Authority
Q2D o`7
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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page I of 2
COMMONWEALTH OF MASSACHUSETTS
T r Title 5 Official Inspection Form T
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. Certification (cont.)
1343 FALMOUTH ROAD
Owner's Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
Inspection Summary: Check A, B, C, D or E/always complete all of Section D
A) System Passes:
1 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: N/A
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:
Tide 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 2
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
1343 FALMOUTH ROAD
Owner's Address
CENTERVILLE MA 02632
Citylrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
B) System Conditionally Passes (cont.): N/A
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):
Elbroken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND Explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health: O!A
ElConditions 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
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
COMMONWEALTH OF MASSACHUSETTS
a Title 5 Official Inspection Form
_ d
eW� Not for Voluntary Assessments
V
Subsurface Sewage Disposal System Form
B. Certification (cont.)
1343 FALMOUTH ROAD
Owner's Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
C) Further evaluation is required by the Board of Health (cont.): N/A
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
indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
P g P Y
Page 4 of 16
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COMMONWEALTH OF MASSACHUSETTS
i;
Title 5 Official Inspection Form
� yey`er
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Certification (cont.)
1343 FALMOUTH ROAD
Owner's Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
0 Backup of sewage into facility or system component due to overloaded or clogged SAS
or cesspool
® 0 Discharge or ponding of effluent to the surface of the ground or surface waters due to an
overloaded or clogged SAS or cesspool .
0 Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
0 Liquid depth in cesspool is less than 6"below invert or available volume is less than
day flow
0 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 surface 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.
0 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.]
YES No
The system is a cesspool serving a facility with a design flow of 2000 gpd-10,000 gpd.
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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
5.a Subsurface Sewage Disposal System Form
B. Certification (cont.)
1343 FALMOUTH ROAD
Property Address
CENTERVILLE MA 02632
Cityfrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
E)N/A-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
0 the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-
I
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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
COMMONWEALTH OF MASSACHUSETTS
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. Checklist
1343 FALMOUTH ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
Check if the following have been done. You must indicate"yes" or"no" as to each of the
following:
Yes No
0 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?
✓� Q 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?
QWas the site inspected for signs of break out?
✓� Were all system components, including 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)].
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
COMMONWEALTH OF MASSACHUSETTS }
a
Title 5 Official Inspection Form
Not for Voluntary Assessments
Vey`
Subsurface Sewage Disposal System Form
D. System Information
1343 FALMOUTH ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
Residential Flow Conditions:
Number of bedrooms(design): 5 Number of bedrooms(actual): 5
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system?[if yes separate inspection is required] Yes No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): 26500
Sump pump? ❑ Yes �✓ No
Last date of occupancy:
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.)
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ® Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings if available:
Last date of occupancy/use:
Date
Other(describe):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
1343 FALMOUTH ROAD
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
General Information
Pumping Records:
Source of Information: BOARD OF HEALTH
Was system pumped as part of the inspection? Yes No
If yes,volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank, distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
® Shared system (yes or no)(if yes, attach previous inspection records, if any)
Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract
(to be obtained from system owner)
Tight tank.Attach a copy of the DEP approval.
Other(describe):
Approximate age of all components, date installed (if known)and source of information:
THREE YEARS
Were sewage odors detected when arriving at the site? ® Yes �✓ No
COMMONWEALTH OF MASSACHUSETTS
r.
Title 5 Official Inspection Form
Not for Voluntary Assessments
" Subsurface Sewage Disposal System Form
P Y
D. System Information (cont.)
1343 FALMOUTH ROAD
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
Building Sewer(locate on site plan): N/A
Depth below grade:
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.):
Septic Tank(locate on site plan):
Depth below grade: 42"
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:
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle
Scum Thickness 1"
Distance from top of scum to top of outlet tee or baffle 4"
Distance from bottom of scum to bottom of outlet tee or baffle 17"
How were dimensions determined? RULER
COMMONWEALTH OF MASSACHUSETTS
r Title 5 Official Inspection Form
o
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
1343 FALMOUTH ROAD
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid
levels as related to outlet invert, evidence of leakage,etc.):
CLEAN, NO NEED FOR MAINTENANCE PUMP.
Grease Trap (locate on site plan): N/A
Depth below grade:
feet
Material of construction:
concrete ❑ metal fiberglass polyethylene other(explain)
Dimensions:
Scum Thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid
levels as related to outlet invert, evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): N/A
Depth below grade:
Material of construction:
EDconcrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
1343 FALMOUTH ROAD
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
Tight or Holding Tank(cont.) N/A
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 a copy of current pumping contract(required). Is copy attached? Yes No
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert WORKING LEVEL
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.):
LEVEL & CLEAN
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes No
Alarms in working order: ❑ Yes No
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
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COMMONWEALTH OF MASSACHUSETTS
W Title 5 Official Inspection Form
d
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
1343 FALMOUTH ROAD
Property Address
CENTERVILLE MA 02632
City/Town State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
R leaching chambers number: 4
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.):
NO WATER IN CHAMBERS.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
COMMONWEALTH OF MASSACHUSETTS
a
Title 5 Official Inspection Form n
W� for
o Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
1343 FALMOUTH ROAD
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NO
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
Privy (locate on site plan): NO
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
COMMONWEALTH OF
MASSACHUSETTS
d
Title 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
1343 FALMOUTH ROAD
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
Sketch of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at
least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where
public water supply enters the building.
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COMMONWEALTH OF MASSACHUSETTS
d
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
D. System Information (cont.)
1343 FALMOUTH ROAD
Property Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
SHARON & DEBRA KNIGHT
Owner's Name
September 20, 2007
Date of inspection
Site Exam:
Slope
Surface water.
Check cellar
Shallow wells
Estimated depth to ground water:
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:
Town of Barnstable
+ �p 114E raY
Regulatory Services
snxxsrnsie Thomas F. Geiler,Director
1639. �0�
9 Public Health Division
AtfD��p
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
�?7
No. �4/ ^03 Fee So
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
, Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Rpprication for Mizpozal *pgtem Cottgtruction Permit
Application for a Permit to Construct( )Repair( grade( )Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No. �a�' — OgS' Owner's Name,Address and Tel.No.
/ C���e r-►
Assessor's Map/Parcel rx
cel /Yldl/-�'� �_ �?S,^ /�/ rC 7
Installer's Name,Ad s,and X.No. Designer's Name,Address and Tel.No.
147 yc
'77S` c�8vo 7�/
Type of Building:
Dwelling No.of Bedrooms :5 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow Ji � gallons per day. Calculated daily flow Z5 S^� gallons.
Plan Date ! `r` Number of sheets ( Revision Date _4 f/4
Title
Size of Septic Tank /_S�U U Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) -2 6� f� e�Lln
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 Board of Pkalth.
Signed Date P C, '
Application Approved by Date r 0
Application Disapproved for the following reasons
Permit No. _G-3 Date Issued to q
w No. CCev --03
`-'
THE COMMONWEALTH OF MASSACHUSETTS Entel'in computer:
PUBLIC HEALT .=DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes
H,
A ZIppl cation for Digozal 6potem Construction Permit
Application for a Permit to Construct( )Repair( grade( )Abandon( ) O Complete System O Individual Components
Location Address or Lot No. x)9 — 09s Owner's Name,Address and Tel.No.
i'7o � 1
y � Assessor's Map/Parcel ��y3 F,-o1*70t/-f h 2�
Installer's Name,Address,and k4.No. Designer's Name,Address and Tel.No.
r f-�_/'7 cr
r' 77 S c)gOo 7
Type of Building:
Dwelling No.of Bedrooms S Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. daily flow S�-s S�
g p y y gallons.
Plan Date Number of sheets Revision Date 'y
Title
Size of Septic Tank /S U U Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of alth.
Signed Date //� 6 I
Application Approved by Date_/ I (4
Application Disapproved for the following reasons
}
Permit No. a CC-)L. —G 3 Date Issued D c5 y
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
y
Certificate of Compliance j
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired(graded
Abandoned( )by
at �J? C �A /-1'7p 417' CAv f/vi/ has been constructed inf accordance
with the provisions of Title 5 and the for Disposal System Co'struction Permit No. �c �l-�% gf dated 1' 61 U�I
Installer r)egionPr
The issuance of this permit all not be construed as a guarantee that the sysste will fdnc/tion as des'gned.
Date )U 1 1 u Inspector
No. G3� --------------f ----------Fee �U
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSEVS
ZiOpogar *pgtem Construction Permit
Permission is hereby granted to Consist( )Repair grade( �`bandon( )
System located at ��y� � C'
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of thedate of this permit.
Date: //��k`/ Approved by .�
TOWN OF BARNSTABLE
LOr,ATION /2�� �,�ILj�'6u SEWAGE # (J
VI LAGE_�t.JU�F/2 I���L� ASSESSOR'S MAP &L T p
INSTALLER'S NAME&PHONE NO. f9IA OfAIOL_0 `775 b d
SEPTIC TANK CAPACITY
LEACHING FACIL=:,(type) �d��1�L��r �s (size) }' ,X
NO.OF BEDROOMS
BUILDER OR OWNER O
PERMIT DATE: a 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
#/3�13 r/�tMovrf/ Xo#i)
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PuCOH
1
(� TOWN OF
BBARNSTABLE
LOCATION /�/� /�JQu7/ Ablo SEWAGE # ^d
VILLAGE_�f., % /2 ASSESSOR'S MAP &11 8L T
INSTALLER'S'NAME&PHONE NO.
I.
• i SEPTIC TANK CAPACITY
LEACHING FACI�ITY: (type) (size) 'r
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: o U COMPLIANCE DATE: AQ
• 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
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1
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ASSESSORS MAP : NOTES.
TEST HOLE LOGS
PARCEL : d
1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH
fit FLOOD ZONE : N0� RAZARd> SOIL EVALUATOR : �= r ? R'��, c5 .
u . THIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF
4 7 � Vt
1/�NSTr1-e BOARD OF HEALTH REGULATIONS.
WITNESS :
gaff REFERENCE : P�`�- DATE: M6E2 'j 'la)z 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES,
II --
;� a � �f� �3$ PERCOLATE ON RATE :,,' 4 2tv"t1 I 'I,t SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO
c /1 INSTALLATION.
:
a
TH
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'
i
TH-2 3
THIS PLAN SHALL BE USED FO
R SEPTIC SYSTEM INSTALLATION
3 — ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE
DETERMINATION.
_ --_. ILltrd. Iz SN y� -'3�•7�0 4) ALL PIPING TO BE 4" SCHEDULE 40 @ 1/8 "/ FOOT. (UNLESS
4 doYl�yL SPECIFIED
r ECIFIEDOTHERWISE)
LOCATION MAP N'T 5` 'In
5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A
GARBAGE DISPOSAL. -
6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED)
MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON
ABASE OF 6,OF CRUSHED STONE.5y 6/' ,3.0� -7.) 2-u—m t->.L�.�--jP-13s,W- aptf ou T-
I32 30.2l
\\ �� NO Gw
-SEPT I C S Y S T E-M DESIGN
.0?J 5 tl-F- PP-IVA'{ &-_WeLu, its 13 �r6 At�Do _.
FLOW ESTIMATE �o. �4 Dlff C �_:.pl?1N'dt VJ?fiiK , Wr1-LS
\ v — S BED 300MS AT I d GAL/DAY/BEDROOM50 �SU _0r- P 0POSF-
S GAL/DAY a
" Ner ►(� ►�Ova '---tJ N �.11 _0_�L�Z. .A�? v►)
t"' 't° SEPTIC-TANK
._
GAL/DAY x 2 DAYS - I IG GAL
S� 2Enndv -fi° \ Y �� USE GALLON SEPT i C TANIf aEv)
Pawl - ` I
►v
SOI
L ABSORPTION TAP C LA ►2. \\ 9�C j�J- w�c,c, ;�, � �n� a RPT I N SYSTEM
ham,
z LA)Y- Z r iZ)
S;I DE AREA: �2 Z-�- t3 2. � Z x C7: 7'�/ _ 162 Z. 6
BOTTOM AREA x d 3 � D.�y =- oE 1
46 \ 19 SEPTIC SYSTEM SECTION
CL
Is "� TP, •c- Tad
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s
�v w/p
42 J Jill .3 yr, D11 00 Xe
/ GAL y Wct f Y3 t
38
SEPT I C TANK 350
i
(I � 3/y'-�2'' Dtrutot<e n
�I; INasc�Q cStoH
y2IL X I
w
of �BND d�\A OF qqS .
or— 7iEsD) - L ?O-Z
D R EN SITE AND SEWAGE PLAN
PoN U A
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tangy LOCATION : /31-13
crsT � CeIE'.I/I LC t✓ /L'j,¢
gnrITAR!�`''
PREPARED FOR :
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W DAREN M. MEYER, R.S. scALE : "'- �fo
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43 VINE STREET DATE: / G
OP t,
Pt,P�rJ D, BEs� hat.ux�l Cu�v. JXB tJ RY, MA 02332
z �A Ff. 2�, I qsb DATE HEALTH AGENT (781) 585-0293