The URL can be used to link to this page

Home My WebLink About0208 FIVE CORNERS ROAD - Health 208 `ive Corners Road Centerville P A 168 109 1521/3 ORA 10% P2 TOWN OF BARNSTABLE _ LOCATION (dRK&P,S P-6 SEWAGE # VILLAGE' I)I L1 ASSESSOR'S MAP & LOT MR 10 INSTALLER'S NAME & PHONE NO.'r^- `O%rv% QAC<< l` da SEPTIC TANK CAPACITY 1090 .:, P .. LEACHING FACILITY:(type) Ptam( LdVG9 FL6U) (size) 6-AL - NO. OF BEDROOMS O PUBLIC WAT�ER OR OWNER.3AC V- DATE PERMIT ISSUED: DATE COUPLIANCE ISSUED: 3 " 19 - / VARIANCE GRANTED: Yes No r , V� qq c ASSESSORS MAP NO• l PA�� Fps. 3 �� EL NO: �. � 2 v No....91.......... ... . ............. THE COMMONWEALTH OF MASSACHUSETTS / A S BOARD OF HEALTH ` ,-N �►�� TOWN OF BARNSTABLE Appliration for Utirp ottl Wor1w Towitrnrtion rvrmit Application is hereby made for a Permit to Construct ( ) ` Repair ( an Individual Sewage Disposal System at: • �o f ......-•--••••-_ .............................................................................cCJ jZ►v�.�Z-�------1�.....-------- U............................................................................... Locat ion-Address _.. �.. �Owncr Addr s W .................. ........R_kz lv.o�_�_. ..-------------------------------------------- 12<... -AA.....a- ....................... Installer Address QType of Building Size Lot............................Sq. feet V Dwelling— No. of Bedrooms._.........�-•--------------------...Expansion.Attic ( ) Garbage Grinder ( ) aOther—Type of Building -------------------_- ..... No. of persons--_------------_--_-_----- Showers ( ) — Cafeteria ( ) Q+ Other fixture ------------------------------------------------------ w Design Flow------------57_S______________________gallons per person er may. Total daily flow.._..Z..7.0..._................gallons. WSeptic Tank J Liquid capacitv/00(Jgallons Length__ '_____ Width_�J_S_._.._ D>ameter................ Depth................ x Disposal Trench—No- -------------------- Width. .__.___.._........ Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------/_ ..-.-.-- Diameter....... Depth below inlet.... ............ Total leaching area6 2X_sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------- --------------------------------------------•---------------- Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit_----------------- Depth to ground water........................ Test Pit No. 2---__---_---.-minutes per inch Depth of Test Pit-------------------- Depth to ground water....................... P4 -•----•------------------------••-••--••---•---••-•----•-----••---•--•--•---•------------• ................................................................. 0 Description of Soil-------------------------------------------------------------------------------------- --------------------------------------------------------------------------------- x w. ------------------------ ---------------------------------------------------- ------------------------------------------ ------- ----- ---------- )ffu V Nature of Repairs or Alterations—Answ a_ when plicable. W S - -d. =a ...j�t• - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code-The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed . Application Approved B Z ` pp pp y --------------� .t/1-- ------------- ----------- -1 .... ........... ........ Da[e Application Disapproved for the following reasons: ----------------------------------------------------------------------- ---------- ------------------------------------------ � yl �.. ..�.. 5..._.. Permit No. Issued .. j..... Dare TOWN OF BARNSTABLE LOCATION_' t'1 U�+� (dQyIi? R (Z SEWAGE # ,fir- L VILLAGE t1_l lJ ASSESSOR'S MAP & LOT PAq 10 INSTALLER'S NAME & PHONE NO.)n.542krp0v� Q A C V H 0crlJLU TtiN'K CAPACITY UO(J j LEACHING F.ACILITY:(type). Pt ( �Q VS-'R FLOW (size)`a'W 6-AL .: j NO. OF BEDROOMS O PUBLIC WATER j OR OWNER K i►rv�r►�b�P�nn,r4► ) DATE PERMIT ISSUEb: : 3 J/2 J 9s DATE : COMPLIANCE ISSUED .. - -T:' VARIANCE GRANTED: Yes No L 16 � d ti No...q... Fxs.....:3.��...-..... ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ;-�t- TOWN OF BARNSTABLE , pphratiott for Uiopooal lVorko Tonotrnrtion Frrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at V I v > --------------------------•-`------O-----------------------.....-----...------------------. Location..\ddress ror--�Ydt moo. '<�► y.�_.�'�.�^�. ._ _. -` `-IP ------------------- - _/v r' r Lt7 t?R %, S'y4 v�-D •-------•--.......,.... . -•----•..... ......•. Owner Addr ss l" 1,,.,.r_.►_ .2 i , t-( 13— C 12.7T 6� . S'r9 n. 0(',1 r._�...... Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms--- ___________________________Expansion Attic ( ) Garbage Grinder ( ) aOther=Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------•-•-------------------_.--------------------------------------- -----------------•----------------------•-------------------- W Design Flow............�_ ......................gallons per person per day. Total Idaily flow_._._7_._Z_v.__._.___......_..__gallons. R: Septic Tank 4 Liquid capa6ty/060galIons Length__�'''_7__._ Width.✓`...-__5------ Diameter__ _.__.___.__ Depth................ W Disposal Trench—No. .................... Width.................... Total Length_.____-.-_-_-_--____ Total leaching area....................sq. ft. x Seepage Pit No..___._/......_._... Diameter.__...'--------- Depth below inlet----6............ Total leaching area2� ..2,-Y.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------------------------------------------------------------- -•---------- Date......................... ............. a Test Pit No. I--------- ......minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 444 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 91 -----------------------------------------------------------------------------------------•-•-----------•----------•---....-----------•-----•....__...__..._.. 0 Description of Soil........................................................................................................................................................................ x V ---------------•----------------•-••------•--------•---•-----------•-------------------•-----•--------------------------•--•----•-------------------....------------------•-•--•---•--•----•----•--•---- W _ ___ Nature of Repairs or Alterations—Answer er when applicable-. ....................::.:......:.:.:::::...:. .. U - - - p PP � � �L Uw_---�-J� / �-- J s Y 1..�.�. ......� f -----•----..._/ .e.Y.1..S 7`yo G— ' ' �`. _��_.__.___..._. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—.The undersigned further agrees not to place the` system in operation until a Certificate of Compliance has been issued by the board of health. Signed .�... :__: 1 ,1r - ."'"..._ 1.?---------------- -- Dace Application.Approved By ---------- --� ' ✓"" �../ l ..--- ..�y ...... ..........._..-.. ....._..__.. ...._._.... ./...._.._.. ....._.................... Date Application Disapproved for the following reasons: ..._..... ..................... -- ............................ ............. ......... . .._...................... .. .. ............ . ... .._..........-------------------------------------------------------._..--------- ---------------------------------------- Permit No. .........%5..-...yl .. Issued .................3..." 7 ....... Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Ge>r#tftca#e of Compliance THIS IS TO CERTIFY, That the Individual Sewage Di osal S ste co str cted g y,p ��y ,- — y ( ) or Repaired by ........ -.�- . - _...._..__....._........ C_.,, (C K ►'1 Installer C 2.-t`?r at .........7 C-4..I1 - - - �-�.- ----.... _-------------------.....------------------------------------- ------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. _f r 4_0._...................... dated .Z_..-./_7--------- S S THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. r DATE..._... - L......_...)-------.�.._ /.'.. ._ Inspector .... ... _... _...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ey TOWN OF BARNSTABLE 3� a No......................... FEE........................ 19iopoottl Workii Tonotrnrtion �erintt Permission is hereby granted....... ee..A-�`------------------------------------------------------------•---------.....----- to Construct ( ) or Repair ( v an_jndividual Se7r�age Disposal System atNo........... A �.� S' rGp, ................................................... ............................ Street .� as shown on the application for Disposal Works Construction Permit Dated....... S =_- / r Board of Health DATE............. .. ......... FORM 36508 HOBBS Q WARREN.INC.,PUBLISHERS 1 c n_ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIEONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION II ,N s`•e�' JAN 2) 2005 TOWN of{,`r, VISTABLE TITLE 5 "E--r"DEPT. OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address . bS�,e�✓ti�.-�� y E�� IPA .Ap Owner's Nam Owner's Address: �R,RCEL. Date of Inspection: "-�°--- Name of Inspect. ease print) ( [ Company Name: Mailing Address: Telephone Number:sne7i / CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reponeli 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 iDEP approved system inspector,pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes , Needs Further Evaluation by t7e Local Approving Authority ils `� Inspector's Signature: y Date: 7 la!�— 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 sha-ed system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shalt submit the repo-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 ad 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 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:Z ( ' AAD Owne C �,,�• Date of Inspection: / vs Inspection.Summary: Check A,B,C,D-or E./ALWAYS complete all of Section D A. System Passes: W I have not found anv information which indicates that ary.of the:failure criteria descried,in 310 CMR 15.303 or�in 310 CMR 15.304 exist.Ar_y failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes:. One or more system component-3 as described in the"Conditional Pass"section need to be replaced.or repaired. The system,upon completion ofthe 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 ove=23 years old* or.the septic tank.(whether metal or not) is.structurally unsound,exhibits substantial infiltration.cr 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'f it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 y--a s old is available. ND explain: Observation of sewage backup or creak 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 rr_ore 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 s, Page 3 of 1'1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owne . Date of nspection C. Further Evaluation is Require 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, pass�:Unless.Board.of Health determines ir,'accorda„ce With310 CMR'15.303(1)(b)that the system is not functioning in a manner which.will protect public'health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a.manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within;a Zone I of a public water supply. _ The system has a septic tank and SAS and the SAS is within r0 feet of a private water supply well. _ The system has a septic tank and SAS and.the SAS is less thF-n 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 er 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 1 I Page 4 of 1 l I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS +' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFhCATION(continued) Property Address: x Owner. / 9� Date of Inspection) /2 C)o L9 D. System Failure Criteria applicable.o 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 _ 1/ 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 i e s.Number q P P � Y �� P P ( ) of times pumped Any portion of the SAS, cesspool or privy is below high groundwater elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface / water supply. V` 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. [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 nitrcgen.is equal to or less than 5 ppm, provided that no other failure criteria. are triggered.A copy of te:analysis must be attached to this form.] (Yes/No)The system fails. I have determined'that one or more of the above failure criteria exist as described in 310 CMR 15.=0=,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.sysEem_must serve a facility with a design flow of 10,000:gpd to 15,000 gPd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the-system is within 400 feet of a surface drinking water supply — _ the system is within 200 feet of a tributary to a surface drinking water supply i 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 l 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART,B` CHECKLIST Property Address Owne Date of Inspectio&Uv Check if the following have been done. You must indicate"yes"or"no"as to each of the following: i Yes No AZ /Pumping.information.was provided by the owner, occupant, r.Board orHea'.th t� 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?(Iff-thiey were not available note as N/A) _ Was the facility.or dwelling inspected for signs of sewage'bac-k 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 Wthe 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 i�dintena lnce of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)or _tie site has been determined based on: Y�esno Existing information.For example, a plan.at the Board of Hezlth. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3.10 CMR 15.302(3)(b)] 5 l Page b of 11 OFFICIAL INSPECTION,FORM-NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C f SYSTEM INFORMATION Property Address: Owner.,, Date of Inspection: pS LOW CONDITIONS RESIDENTIAL Number of bedrooms(design):�� . Number of bedrooms(actual): DESIGN flow based on 310 C 15203 (for example: 11:0 gpd x#of bedrooms):c Number of current residents: Does residence.have.a garbage grinder Eyes or no): Is laundry on a separate sewage system dyes or no)/�6i�if yes separate inspection required) Laundry system inspected. e�r no Seasonal use: (yes or no): Water meter readings, if avgj1able(last 2 years usage(gpd)): 03 i. Sump pump(yes,or no): Last date of occupancy: ��✓�� / (� COMMERCIAL/INDUSTRIAL Type of establishment:. Design flow(based on 310 CMR.15.203): gpd Basis of design flow(seats/persons/sgft_etc.): Grease trap present(yes or no):_ Industrial waste holding tank present Cfyes 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 INFORMATIpN Pumping Records Source of information: Was system pumped as.part of the i _sDection(yes or o If yes,volume pumped: _ gallons--How was quantity pumped determined? Reasoh'for.pumping: TYP F 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'. opy of the DEP.approval _Other'(describe): Ap r.' ate age of all comppnents.-date.installed(if known)and source of information: Were.dwage-odors.-detected when arrving.at the site(yes or no): r Page 7 of 11 t OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTI�M INFORMATION(continued) C' Property Address: g <� Owne r. Date of nspection: BUILDING SEWER(locate on site plan)/10b 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) /l Depth below erade: Material of construction: �oncrete_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: 'S _ �cp Sludge depth--_, Distance from top of sludge to bottom of outlet tee or baffle: Z Scum thickness: Distance from top of scum to top of outlet tee or baffle: z t� Distance from bottom of scum to bottom o outlet tee or baffle: How were dimensions determined: Comments(on pumping recommencfations, irAet and outlet tee or baffle condition, structural integrity, liquid levels s lated to outlet invert,evi ence leakage, etc.): v GREASE TRAK�&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 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART C SYSTEM.INFORMATION(continued) Property Address: c-/ Owne . Date of Inspection• /�.�.C:Dod"�) TIGHT or HOLDING TANK(_ank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass__poIyethylene other(explain): Dimensions: Capacity: gallor_s Design Flow: -allons,-day Alarm present(yes or no): y Alarm level: Alarm in working>rder(yes or no): Date of last pumping: Comments(condition of alarm and floar.switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet inver� Comments (note if box is level and distsiAion.to outlets qual, any evidence of solids carryover,any evidence of —I kagQ into or out of box, etc /1 fi PUMP CHAMBE4,'1P-)- (locate on s to 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 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. Own •/ ' Date of Inspection: SOIL ABSORPTION SYSTEM (S S): (locate on site plan,excavation not required) i -If SAS not located explain why: TYPe aching pits,number: ]eachmg chambers,number: 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 pording; damp soil; condition of vegetation, etc.): gle vt CESSPOOL (cesspool must be pumped as part of inspection)(loc-ate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments.(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY(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 1 I is OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM INFORMATION(continued) f. e Property Address:. � � C� /-1- Owner. 1 -�- Date of Inspection: ��j �J0 U. 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 T.00 feet. Locate where public water supply enters the,building. o loco Y t3cv pp nn6 W low L 10 Page 1 1 of l 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(c ontinued) .Property Address: Own Date of Inspection: C SITE EXAM Slope Surface water Check.cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground wa er 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: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: , �D 11 Permit Number: Date: Completed by: aS HIGH GROUND-WATER LEVEL COMPUTATION Site Location: �g �(/�" Ca/��_S /Tip' , Lot No. Owner: a' e Address: LJ Contractor: /rc5 Address: Notes: STEP 1 Measure depth to water table f g to nearest 1/i 3 ft. ......................:......................................................... .Date 1113 �✓` month/day/year i STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine:. AO Appropriate index we-1.................................................... G�'J OB Water-level range zone ...................................................... STEP 3 Using monthly report "Current Water Resources Conditicns" determine current depth to l f water level for index well ........................... month/year STEP 4 Using Table of Water-levEA Adjustments for index well (STEP 2A), current depth to water level for index v�ell (STEP 3), and water-level zone (STEP 2B) determine water-level adjustment .......................................... ............................................... STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water fy, levelat site (STEP 1) ............................................................................................................. "'l1 Figure 13.--Reproducible computation form. 15 ..Z..4* ............. -.l'--..,.;..--,.l-;......... -------- 4v p I. OWN OF BARNSTABLE LOCATIO SEWAGE # V]1,LA.'E ASSESSOR'S MAP & LOT �O� 6 �`'�U' IXAME&PHONE N� (5 77/ SEPTIC TANK CAPACITY !J LEACHING FACILITY: (type) - `X ® ?_,��size) NO.OF BEDROOMS Q BUILDER 0 OWNE PERMITDATE: COMPL CE 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 �`� ❑ O7,Sf- No - .-- -.- Fimic ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _.._._._...Town............OF.............Barnstable ...................................................................... Appliratiun -fur Uitipustt1 Works Towitrurtiun Vrrnift Application is hereby'made for a Permit to Construct ( x) or Repair ( ) an Individual Sewage Disposal System at: Lot #3 Five Corners Road, Centerville •----------------------------•-•---••--•-----•-------...----•--•---•-----------...----------•--••- -----------•--••------•-------••-•---•--•-•-••-•-•----------•------•----------------------••-•--. James K• Smith Location.Address Barnstable or Lot No. W Vetorino Brothers Owner Barnstable Address Installer Address Q Type of Building Size Lot--------- 6 Sq. feet Dwelling—No. of Bedrooms---------------------3 --------------------Expansion Attic (no) Garbage Grinder (no) 1-4 a4 Other—Type of Building ---------------------------- No. of persons..--...............--....... Showers ( ) — Cafeteria ( ) a' Other fixtures ................................. Q 110 b..-droom-------------------------------------------------------330------------------------------------- W Design Flow--------------------------------------------gallons per�okea per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity-!_QQpgallons Length..__-8-------- Width_-A.......... Diameter----- ---------- Depth.__._---_----- x Disposal Trench—No--------------------- Width.................... Total Length--.......... Total leaching area--------------------sq. ft. Seepage Pit No----------- (----� Diameter--------�_--- Depth)below inlet....... . ...._..._. To��leaclyy�g t. offsq. it. Z Other Distribution box Dosingtank ,Percolation Test Results Performed b- .............. Date-.s1.:-7 - Test Pit No. 1...z----_...:_mmutes per mch Depth of 'Pest Pit-.._.L2�..__---. Depth to ground water...-----rtone �14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-._..-.._.._.._......_. 9 .............-----------------------------------------------------.......................................................................................... 0 Description of Soil......9.-2411.Loam and subsoil• 2410-1.4410 Medium Coarse Sand x --------- --•-------------------'-------•--------------------------------------------------------------------------------------- ------- --- UW ---------------------- ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Article YI 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 board of health. Sign d � Date Application Approved By....... - ------ --a ---------------------- --------------------D--ate------------------ Application Disapproved for the following reasons:----•................................•--•---•--.........-----------•-------•-------------------•------------•--- ............................................... --•------•..................----•-------•---------•---•.........-•-----•--------------------------------...-•------------------•----------------------- ate 7 cr Permit No......................................................... Issued.----.7-- '`--7-y Date --------- -J No.7� �� r ;� ►r` -•a*---- -- Fim THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Tom...... of ............Barnstable .... ... ........................................................ Applirtttion -for Di-uviial Workii Ton,15trurtion Vrrmit Application is hereby'made for a Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal System at: Lot #3 Five Corners Road, Centerville •--•----•-----------------------•--•---••----------•--------...----••-------•••-•-•--•-•----_-•-•- ..............................................................___........................... James K• Smith Location-Address Barnstable or Lot No. W Vetorino Brothers Owner Barnstable Address F] ---•••-------------•-•-•--••-•---•---------•-•--••-•-•----•-•---•-•-•-•-•-----•-•---- Installer Address UType of Building Size Lot---------159746 - S feet Dwelling—No. of Bedrooms_____________________3___-___-___----.."_-Expansion Attic (no) Garbage Grinder (no) Other—Type of Building ___""_______________________ No. of persons_.-_____----________--___.-_ Showers Cafeteria a ( ) Other fixtures --------------••••-------------- 110 dl�oM----------------------------------------- ----------------- W Design Flow------ per lea per day. Total daily flow............330------------_------------gallons. W Septic I'anlc—Liquid capacity_1000 gallons Length-----$____----- Widtll___4 ......... Diameter________________ Depth_...__._"._.... x Disposal Trench`—No.____________________ Width-------------------- Total Length--_--___-_._______ Total leaching area--------------------sq. ft. Seepage Pit No__________ ________ Diameter_____--_-___-_-_---- Depth below inlet.................... Total leac 1_.2�_.._____sq. ft. Z Other Distribution box ( ) Dosing tank ) f Q 1 `-' Percolation Test Results Performed by............... .^� -___ 6_t .............. Date--________-___._____--_"_. -704 Test Pit No. 1... n one ___________""minutes per inch Depth of Test Pit-.........._........ Depth to ground water.._--"-.-_---.--._.____- f4 Test Pit No. 2................minutes per inch Depth of Test Pit.-.___-__-._________ Depth to ground water--.-.--._-__"-.-----._.. •-•-------------------------•_-_----- •------ -- ---------------------•----- --•-•-= ---------------------------- O,••..,s Description of Soil"_.._0-24n Loam and subsoil;_-W-14V Medium Coarse Sand -------------------•--•-•----------•--"- ------•-------•••--•--------------._.-•-----------• •------------------- ------------••--------------- W ` U Nature of Repairs or Alterations—Answer when applicable----------------..--------------------------------------------------- ..-.._...___.__"_..--.._. x Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI 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 board of health. Signed....••. Date Application Approved BY7 of f-----••----•--•------ -"------------- Date Application Disapproved for the following reasons---------------------------------------------------------------------------------•------------•------------------- --••------------------------•---•------------•-•-•-•--------...--------•--------------------------•----•----------- ---------•---------•-------•--------•••-•------------•---------•---------------- Date PermitNo.......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............Town.................OF..........Barnstable .. .. ................................................ Trrtif irtttr of Tnmpiiattrr THIS ISV O C f OTBrY That the Individual Sewage Disposal System constructed ( X) or Repaired ( ) rs by......................•-•-••-•----•••-------...••--•--•-•-•---•--•-•-•-•-•-•••-•--------------- In taller Lot #3 Five Corners Ro ad, Centerville at---------•-•--_----- --_--•-•-•-•-------•----•- has been installed in accordance with the provisions of Ar XI of. The State Sanitary C le a descri e in the application for Disposal Works Construction Permit No... .....�� ..+__.___.:__ dated....�p `.:.. "._ ............ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR-ti ® AS A GUARANTEE THAT THE SYSTEM. WILL FUNCTIONS ISFAC- TQRIf! DATEt�/-__ --------"------� -----•------ rispector v _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable OF...........................`...._._............. No FEE___ ' _ i� gi�tt�erin�oters tr�Yrttdlltrrmtt Permissionis hereby granted----------------------------------------------.........".......--------------------••-•-"-----------___---------•-•---_•-- t :. to Construct (.xiotr g.�airF iv� Corners Road q ale tern i Disposal stem �3 at No.................... -•--••-•-•--••--•-•----••••••--•-••••-••---•--••••-•---•--- Street as shown on the application for Disposal Works Construction Permit __. Dated---- -------- dam-�__ •.<-..-.--_-_--•-- ................... d of Health DATE---•------------------------------------------------------------------•••. ... FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r� LOCATION;�_ S E W A G E RMIT NO. z-of .3 VILLAGE INSTALLER'S NAME & ADDRESS R.,U I'l D E R )OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED 7 7. 0 �" � 1 �� ' i �� f � � ' �' i �, 37 , � a�� : -�� 5 �'� �. �� a .. _, ` yyam�. TEST HOLE 4.r 0 MARCH a.j, I976 P&AloomL MURRAY - .�NSPECroR LOT 3 ELEV, /e, 3 �y� 15746 # I_0.=. .. LOAM ANO SUDSJfL PROP. WATER RESERVE /8,0 + LINE t .4 - 144 ME D/U/►? - \ MIN MI5?., 4 C0,4, S,E 5i9ND 1� vz IS" 10' BOX +- , b W /o i , A a+3 LEACH PIT s _ ELEV, 6. . . TEST 30,, ( HOLE NO U)RTE•R ENC0vNT ER F.D Ll �� f r r LOT '4 .\ � TocvN C..1RrE'R /.s Ay4,f M/A-1/M G/!t/! , a u/Z-ZWAAS; S ET'L5A1 C� e�QU/, �ME�/TS S C.A L E Q L F20N T Si P2o,ao SE17 SE P T/G S y5 TAM CONS T2 UG TlON � E3 E..D/zOOMS ENV/.2O�v/yC-n/T�L. COOS. T/TLC Jt ,� f agRly TA A//A/ 11AICN, Alt Th/ � <�UL,4 T/U/VS RFQ. t7t�r� .;:.'r"}t� �• ✓ _ l '""` mod._. :�. .. ,. .,.._._.,._.-,..._: .___.,_...._..._ ._T_._... _ ....__.-,.a,_....-..-.,..__...n .. ._.,,_�_.,__-,-. �? 1., ��t� _ ..-�•, .. _-417 G Div P cis-.••� ,`J �"/ SazN�tE MA ^,HOLE �CCU✓E,rz 70 EX TEnlD 'TO ✓MpC,�✓/OC/SC-0 VE.2 YV1 7-s-//n/ P OF F/A//5s-I E,D GIZA DF- TO .a2E✓eA.17- -5 f P20M /NF/L T2,4 T/AA:5 5 2 4"co 1/G-rZ.S S TOnJE /0 ! D/S-T. /0 ` nn / N. rw / GOVE..z G°ia r u BOX I Z/"WiDL- R+aDE 7/A/ __ .., - '3"MAN o v ; 6 M N y 3•.MiA/ 9...D/A. Tb�7 / P T �Fcor�u �, E— rGLr 4" o1A ? /OLCgCAl /O"MnV AN �TCN 2 P/T/4" ArXFoo7 Mini r�ircfl D/A. L�' or .r1zooGALLO„/ cpST0n/ECA pA C/ TY /N✓E 2T AE/->7`/G TAA/•- A2 O Un/O I `� ELEV.t WATG�T/G,5!7) 1 `_ $oTTOM O /N VE,QT /iV VIEA0T (�C' Pir'�/ ' NO GA28AGL C /n1E� `` /4./ c -- 20' n-7/.v!M UM Cf� ✓ fJ ;.< 6 PL A'" PR0P1,-)SZ ,L0CQ T/O/V/ f3 R N IC NT Wz 2 E.�E 2 EnfC E3ELN6 Q-r 3 ' If1f TA&IAf I�/ST.eiBUT/ON 80 ' RoAt1�tI9 v OClT[ ETS� AND /cO,� �` ' ARTHUR.' BE OJ` .�EiNFO E�CED COti/CTZETL� `a G#F.fORP u" a.& ? C A/C,e TE ST,2G.VGT, 3000 P,5/ M/N. _ = f"l l # S �tT �D TEFL 20000vt „ C :, � .T .'/� Q -/Q LOAD/n/G �✓' DkE!/VE VVA)l &/pT To P,�• Low 7-,r-D ov�e SYSTEM (Jn/LE55 .f/- ZO S/GA/ L 0<1 C)/AvG /S uSEIU.S CERT.IFf! T#hT T//Z hOUNDAVON 5,410Ut,�N DN THIS PLAN 15 cEa�ce %t`t .AS -V 0t)JV AND IT LOW,is. y OCR, ��