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Home My WebLink About0325 GREAT MARSH ROAD - Health 325 GREAT MARSH ROAD CENTERVILLE A = 210 005 e //// aEcYuFo ti UPC 12534 No. 2 153 OR gPosr-coNS�`� HA$TIN06, MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ^M 325 Great Marsh Road Property Address Michael E..& Patricia A. Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 5/12/2011 every page. Cityrrown State Zip Code Date of Inspection 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: A. General Information When filling-out forms on the. l r computer,use 1. Inspector: I ►`y/) only the tab key to move your Raymond Dumas cursor-do not Name of Inspector use the return key. Dumas Landsape Const. Company Name 564 Old Stage Rd. Company Address Centerville Ma. 02632 Cityrrown State Zip Code 508-778-0249 S 1437 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 5/12/2011 Inspector's 6ignature 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Dispo 1 System•Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 325 Great Marsh Road Property Address Michael E. & Patricia A. Dumas. Owner Owner's.Name information is required for Centerville Ma. 02632 5/12/2011 every 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: El 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): t5ins•09108 Title 5 Official Inspection Forth: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 wM s 325 Great Marsh Road Property Address Michael-E. &-Patricia.A. Dumas. Owner Owner's Name- information is required for Centerville, Ma. 02632 5/12/2011 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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: El 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•09/08 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 ;M 325 Great Marsh Road Property Address Michael E. &_Patricia A. Dumas Owner Owners-Name information is required for Centerville, Ma. 02632 5/12/2011 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. El 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 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 1/day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 325 Great Marsh Road Property Address Michael E. & Patricia A. Dumas. Owner Owner's.Name. information is required for Centerville, Ma. 02632 5/12/2011 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes. No. El ® 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. El ® 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 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary_to correct the failure. E) Large 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 325 Great Marsh Road Property Address Michael.E..& Patricia A. Dumas_ Owner Owners-Name information is required for Centerville, Ma. 02632 5/12/2011 every page. Cityrrown 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? El ® 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? E ❑ 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): 3 Number of bedrooms(actual): 1 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i I ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 325 Great Marsh Road Property Address Michael.E. & Patricia.A. Dumas_ Owner Owner's.Name- information is required for Centerville, Ma. 02632 5/12/2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: 1500 gallon tank, 4 bio defusers (12x35x2 ft deep)and a d box Number of current.residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required]_ ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑_ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: 2010 69000 gallons, 2009 47000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: now Date Commercialllndustrial.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? 0 Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts f Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 325 Great Marsh Road Property Address Michael E. &Patricia.A. Dumas. Owner Owner's.Name- information is required for Centerville, Ma. 02632 5/12/2011 every page. Cityrrown 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: 12/2005 as per owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping_ routine maint. 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) El 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): as per as built attached to report t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M 325 Great Marsh Road Property Address Michael E..& Patricia A..Dumas Owner Owner's.Name- information is required for Centerville Ma. 02632 5/12/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (Pont.) Approximate age of all components, date installed (if known).and source of information: Installed 2/15/2001 Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 30" inches feet Material of construction.:. ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: 12 ft across basementfeet Comments(on condition of joints, venting., evidence of leakage, etc.): good Septic Tank(locate on site plan): Depth below grade: 15" below gradefeet 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: none t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M s 325 Great Marsh Road Property Address Michael E. & Patricia A. Dumas Owner Owner's Name information is required for Centerville Ma. 02632 5/12/2011 every page. Cityrrown 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 none Scum thickness Distance from top of scum to top of outlet tee or baffle 10" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? tape measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees at level 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 325 Great Marsh Road Property Address Michael E. & Patricia A. Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 5/12/2011 every 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.): pumping not needed at this time 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 copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•09/08 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 °M 325 Great Marsh Road Property Address Michael E. & Patricia A. Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 5/12/2011 every page. CityrFown 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 at 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.): D Box level no signs of leakage or carryover 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: as per plan t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °M 325 Great Marsh Road Property Address Michael E. & Patricia A. Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 5/12/2011 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® 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: 4 bio defusers Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): all good 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 I - Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M s 325 Great Marsh Road Property Address Michael E. & Patricia A. Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 5/12/2011 every 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•09108 Title 5 Official 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 °M 325 Great Marsh Road Property Address Michael E. & Patricia A. Dumas Owner Owner's Name information is required for Centerville Ma. 02632 5/12/2011 every page. Cityrrown 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 Z drawing attached separately t5ins-09/08 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 325 Great Marsh Road Property Address Michael E. & Patricia A. Dumas Owner Owner's Name information is required for Centerville Ma. 02632 5/12/2011 every page. CityrFown 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: 14+ feet 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: hand auger 5 ft below bottom of leach field no water Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09108 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 325 Great Marsh Road Property Address Michael E. & Patricia A. Dumas Owner Owner's Name information is required for Centerville, Ma. 02632 5/12/2011 every page. City/Town 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 P TOWN OF BARNSTABLE f j� LOCATION 3 Z'S : 6-Fe-pa- mnrs pi izb- eran}F;v;11 SEWAGE# VILLAGE �� y jib - ASSESSOR'S MAP & LOT ?//()-UOS INSTALLER'S NAME&PHONE NO. Lk `r-I r SEPTIC TANK CAPACITY }S T LEACHING FACILITY: (type).- 0 i>tFVLStzF,;- (size NO. OF BEDROOMS i BUILDER OR OWNER M1CKnr_L i= Ihl"l�S PERMITDATE: 2 1`3` O 1 COMPLIANCE DATE: Z I SY v I Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 1-1 ,S L �E C k jz a7 ,�oi� 115 C) 0 a s :7 No. r —I �� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplication for Disposal 6pstem Contrurtion permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon A ❑Complete System ❑Individual Components Location Address or Lot No. 32f G/'ca-Tti ctfj4 fk;a/. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel jo� ��1t /Vj"&,44 ba"9-S Installer's Name,Address,and Tel.No. / //�_ Designer's Name,Address,and TA.Y2 Type of Building: f Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) IU gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 6�__ A( Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the con ruction an aintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the E ninental Co and not to place the system in operation until a Certificate of Compliance has been issued by this Boar o. - r Signed Date �� 6 Application Approved by e- Date �'� _�� Application Disapproved by Date for the following reasons Permit No. Date Issued g No. Fee THE COMMONWEALTH OF MASSACHUSETTS _Entered incomputer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for Disposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon ❑Complete System ❑Individual Components Location Address or Lot No. _?Z-S- (reo-7"MaUl, Owner's Name,Address,and Tel.No. 01=Af 4✓;III MA . 4 Assessor's Ma /Parcel r Ih� P �, Installer's Name,Address,and Tel.No. Designer's Name,Address,and T Nam.. � Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinders( ) Other Type of Building No.of Persons Showers( ) Cafeteria( _ ) Other Fixtures Aft 44 Design Flow(min.required) IV gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer�when�applicable) Date last inspected: Agreement: The undersigned agrees to ensure the constructi"r on d aintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Wr Coand not to place the system in operation until a Certificate of Compliance has been issued by this Boar o eSignedDate '�� Application Approved by Date �`� — f Application Disapproved by ` Date,' for the following reasons Permit No. d Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(^ )by at d has been constructed in accordance with the provisions of Tit 5 and the f 0trn'Disposal System Construction Permit No G( Q3dated Installer T/` Designer #bedrooms Approved design flow gpd The issuance of this permit shall,not be construed as a guarantee that the system will fimcti desig ed. y Date IS ` Inspector,, � '� ----------- ------------------------------------ No. D(` / 3 Fee �S _ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal bpstem Construction Permit Permission is hereby granted to Construct Repair( ) Upgrade( ) Abandon System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit.e Date roved A a 4 � PP b Y ,�la�l�� e�`' S�' No. CiC/ t'/�O a .. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01 pprication for Mig og Y *pgtem �Congtruction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. vo2� ///?l ' ( Owner's Npa�m�e,Address and Tel.No. Assessor's Map/Parcel t Y .� Xeld" � �� 1�C / o sly old 1'T9te � Ce4wa40,11, iva. oz�? Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. l?'9yA4olto /::_7- /w"/-73 02h3 5_ / Type of Building: Dwelling No.of Bedrooms c� Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank f s v° jyppe of S.A.S. Description of Soil ,,2 7 X li ?eZ i�,-. /a `% / N' S d.M ';cam Nature of Repairs or Alterations(Answer when applicable) / S cfstz ��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 iss by this Boar of alth. Signe Date Application Approved by Date Z 0 Application Disapproved for the following reasons Permit No.7,4ld j —0 Date Issued Z O No. C� v�� i .., �, Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Mizponl 6pe;tem Construction Permit Application for a Permit to Construct( )Repair( 4pgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �jo?� /�/lyiv�i Owner's Name, Name,Address and Tel.No. Assessor's Map/Parcel t ��"�`/� "8UAo4 S r12/ 00` S-60 O/d f?/?GE 'Cal CeFz tarvi Installer's Name,Address,and Tel.No. Designer's:Name,Address and Tel.No. j�f►ywr are 1_DuAf4S 0l03 Slo Gll �i l/� i9. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 5 " Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) S �/ 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 is s e by this Boar f=- Signed Date C2 Application Approved byLN'L,= Date Z—/q Application Disapproved for the following reasons Permit No. .rT?9 -O 7J Date Issued Z / 0 --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (!ij Upgraded( ) Abandoned( )by P at 3.2 S iza has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 7-40 I-07-3 dated a Installer�� 'I- Qu.r Designer The issuance of this permi shall not be construed as a guarantee that the syste i funct'•n,,a� signed- Date Z-VW Inspector --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS Fee Z/U-G0�PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Migogal *pztem ngtruction Permit Permission is hereby granted to/Construct( Repair( Cade( Abando ( ) System located at 3��U�{� � a_-j I t �� 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 b completed within three years of the date of this PUMA. Date: Z''/11;�Q� Approved by— `c'-� �k1a7 '� e"'' ° � u� —� - ! TOWN OF BARNSTABLE LOCATION 3 ZS. 6rexr 1` nrsH RD._ SEWAGE # 7XV 1-0 VILLAGE C�.1JT �i l(lam - ASSESSOR'S MAP & LOT -0—U0� INSTALLER'S NAME&PHONE NO._41yM0QP_> F. SEPTIC TANK CAPACITY �`S F'' LEACHING FACILITY: (type) �q JgJ0 (size� X `� �2 NO.OF BEDROOMS BUILDER OR OWNER MiC,�AF_L t by�,rjAs PERMITDATE: .COMPLIANCE DATE: 2 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 a 0 0 j 1/6/99 NOTICE: This Form Is To.Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) 1, O pw/l4Ad� hereby certify that the application for disposal works construction permit signed by me dated a J I y�o/ , concerning the property located at 3A S 6�, � meets all of the following criteria: • This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • There are no wetlands within 100 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation..[Adjust the groundwater table using the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen (14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation (using GIS information) B) G.W. Elevation +the MAX. High G.W. Adjustment . _ y. DIFFERENCE BETWEEN A and B %y SIGNED : 1A DATE: of 1 q— b [Please Sketch propos d plan'of system on back]. 'NOTICE Based upon the above information, a repair permit will be issued for �bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert CD W> e.d 0 r i ZS. TOWN OF BARNSTABLE 3 LOCATION G�-eAT Mta�s H �D ('_�A+F �1 SEWAGE # ? 1 C E1J TE.i l l i�_.. VILLAGE ASSESSOR'S MAP & LOT 2/ C) —00� I INSTALLER'S NAME&PHONE NO, P,YPetc 1> F. 3—"61,m'a S SEPTIC TANK CAPACITY 06 LEACHING FACILITY: (type) (size�: •� NO. OF BEDROOMS BUILDER OR OWNER MUGHAF—L E. ITV r lt�S COMPLIANCE PERMITDATE: zI F�IO DATE: i Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 i BAC- 14��s� _ r _.. yDE it it DECK - S ! n �1 v 13 %z)