HomeMy WebLinkAbout0129 GREEN DUNES DRIVE - Health 129 Green Dunes Drive
Centerville
A = 245 - O11
, CYCLFp
UPC 12534
No.2� 153LOR
MAOTMOS,YM
� t
COiVIMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
A �c. DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTIOP11 FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM FORM
PART A
` CERTIFICATION
Property Address: aloe?
ILIA
Owner's Nam • O I
Owner's Address: . c @ o
Date oflnspection: ,dnbtLi
Name of lea o e InsP EP a
int erJ =�
Company Na
Mailing Address: 9-e
Telephone Number: r Q
CERTIFICATION STATEMENT , -�
I certify that I have personally inspected_ the sewage disposal system at this address and that e information Feported
below is true, accurate and complete as-of the time of the inspection. The inspection was per ormed based on ny
training and experience in the proper function and maintenance of on site sewage disposal s .stems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
/Passes
Conditionally Passes
eeds Further Evaluation by the Local Approving Authority
F Is
5
Inspector's.Signature: , .S _.---- Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority Board of Health or
Y P PY. P P PP d Y
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.13ystem owner and copies sent to.he buyer, if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/20.00 page I
„A .
Page 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued).
Property Addres*Check,
/ �4p
OwnerDate of InspectioInspection Summ , , or E./ALWAYS complete all of Section D.
A. B�System Passes:
W I have not found an
y.information which indicates that an of the failure criteria described 'Y to 310 CMR
15.303 or in 310 CMR 15.304 exist.An failure criteria not evaluated ted are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional:Pass”section.need to be replaced or
repaired.The system, upon completion of the replacement or repair;as approved by the Board of Health, will pass.
Answer yes,no or not determined(Y,N_ND)in the for the following statements. If"not determined"please.
explain.
The septic tank is metal.and over 20.years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank As approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s):or due to a broken,settled or uneven distribution box. System will pass:inspection if(wiff.
approval of Board of Health):
broken pipe(s)are.replaced
obstruction is removed
distribution box is leveled or replaced' ,
ND explain:
The system.required pumping more than'4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is.removed
ND explain:
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Paee 3 of 1 1
s
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(contin--i:ed)
Property ddress: �,� /f(.ra
Owner: }.
Date of Inspection
C. Further Evalu ion is Required by the Board.of Health:
Conditions exist which require further evaluation by the Board o=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
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 ta(ik and soil absorption system (SAS).and the SAS is within.100 feet ofa
surface water supply or tributary to a surface water supply.
The system has a septic tack and SAS and the SAS is within,a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.-
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility.and
the presence of ammonia nitrogen and nitrate nitrogen is equal tc 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:
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Y
Page 4 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A.
CERTIFICATION(continued)
Property ddress: /
/Lt!,4
Own eriIWOA
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 N-9
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
1 clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded.or clogged SAS or
,l cesspool
_ 1✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than %z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ Any portion of a cesspool or privy is within 50 feet of a.private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 5.0 feet.from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds.
indicates that the well is free from pollution from that facility and the presence of ammonia,
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
:i are triggered. A copy of the 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 15.303,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-
You must indicate either"yes"or"no"to each of the following:
(The following.criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a.surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
— _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is con idered 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.
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Pase 5 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property�pddress:
Owne
Date of Inspection.
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Pumping information was T�rovided by the owner, occupant,o-Board of Health
_Were any of the system components pumped out in the previous two weeks ?
H-s the system received noJmal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection ?
Were as built plans of the system obtained and examined?(If.they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site
Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil Absorption System (SAS) on the site has been determined based on:
Yes no •
` Existing information. For example, a plan at the Board of Health.
V
Determined in the field(if,any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
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Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 09A 310,4.7 , A
Ownek: ,,^ c
Date of Inspections r
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:_
Does residence have.a garbage grinder(yes or no): '
Is laundry on a separate sewage system (yes or no): [if yes separate inspection required]
Laundry system inspected(yes,or no);
Seasonal use: (yes or no): /
Water meter readings, if available(last 2 years usage(gpd)): ��:/Z ozy- �
Sump pump (yes orno):
Last date of occupancy:
COMMERCIAL/INDUSTRIAL�C�
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(yes or no):_
Non-sanitary waste.discharged to the Title 5 system (yes or no):_
Water meter readings, if available:
Last date of occupancy/use:
OTHER.(describe): _
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the i spection(yes or no): U
If yes, volume pumped: gallons-=How was quantity pumped determined?
Reason for pumping:
I
P 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):
pp o imate age of all components, d,to in talled(i kno n)and source of information:
Were sewageodors detected when arriving at the site(yes or no):
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Page 7 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYS'TEM:INFORMATION (ccntinued)
Property ddress: .
Owne". Ik2AI�9 ,1
Date of Inspectio
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron 40 PVC other(explain):
Distance from private water supply well or suction line: r
Comments(on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TAN : zoocateon sitePlap)
Depth below grade: frete
Material of constru tion: o _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) C a
Dimensions: K
Sludge depth-
Distance from op of sludge to bottom of outlet tee or baffle: 36�
Scum thickness: /r? r /�
Distance from top of scum to top of outlet tee or baffle: y //
Distance from bottom of scum to bottom of outlet tee or baffle: 1
How were dimensioins determined:
Comments(on pumping recommen tions, i et and outlet tee or baffle condition, structural integrity, liquid levels
related to outlet invert, evidence of leakage, etc.):
GREASE TRAP•' (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 I
OFFICIAL, INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C f
SYSTEM INFORMATION(continued)
Property Address
Owne
Date of Inspection:
of
P
TIGHT or HOLDING TANK'tank must be pumped at time of ins ection locate on site plan)
P P P )( P )
Depth below grade:
Material of construction: concrete metal fiberglass. po?yet}iylene ` other(explain):
Dimensions:'
Capacity: gallon.
Design Flow: sallons/day
Alarm present(yes or no): V
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX:Z(ifent must be opened)(locate on site'plan)
Depth of liquid level above outlet invert
Comments(note if box is level and distri ution to�outletual, any evidence of solids carryover, any evidence of
eakage into pr out f bo et
, — Zr) Qw'ao e,,e 2 a-ae—/
PUMP CHAMBER: % tI
"locate on site plan)
Pumps in working order(yes or no): �.
Alarms in working order(:yes or no):
Comments(note condition.of pump chamber, condition of pumps and appurtenances, etc.):
8
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Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION.(cc-ntinued)
Property Address•.
Owne //�f7
Date of nspection:
SOIL ABSORPTI(4YST M (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
T�' leaching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number, dimensio'is:
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,
e 04_ &W,
rr 7 s,
CESSPOOLSJ&(cesspool must be pumped as part of inspection)(]o;.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.):
J
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Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTh;;M.INSPECTION FORM
PART C ;J
SYSTEM INFORMATION(continued)
Property ddress:
Owner, T ��
Date of Inspection: �J
i
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.
�C� Cyr
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10
Page 1 I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
S STEM INFORMATION(continued)
� �Property ddre�ss:`���?'-�=� - �?�.: ";
Wt-
Owne
Date of Inspection: r Z.
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 water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
— hecked with.local excavators, installers- (attach documentation)
_1! Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
13, 'ice✓ a)
11
-f
Permit Number: Date:
Completed by:
HIGH 3ROUND-WATER LEVEL COMPUTATION
Site Location: ZF 6eelly 4Wwe
Lot No.
Owner: f � . Address:
Contractor: �� � �� Address:
Notes:
STEP 1 Measure depth to water table
to.nearest 1/10
...................... .Date
month/day/year -_-
STEP 2
Using Water-Level Range Zone •
and Index Well Map I�cate
site and determine: "° `•'<
OA Appropriate inde:.ry
ell........................................:..........
CWater-level range -cne ........................................:............
STEP 3 Using m report. rren
_ g monthly rep �i, t
Water Resources.Cond-ions"
determine curre.nt.depth to -
water level for index
month/year ="
'STEP 4
Using Table of Water- Eeel Adjustments
for index well (STEP 24), current -
depth
to water level for index
well (STEP 3), =_" __-
and.water-level z -
one (STEP 2B)
determine water-level adjustment .......................:......................................................... .. L N
STEP 5 Estimate de h pt. to high waiter
by subtracting the water-
.level adjustment (STEP 4)
from measured depth to water
level at site STEP
( 1) - ........................... •'=`: _ " << =''
Figu;e i'13.—Reproducible computation form.
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PL 1569q,D
2001 KC 12 PM 3: 30
CB f d F A I R V I E W (30' wide Private) STREET ,
broken N17"12'41"E `:...�,�..—_. n --
- L AS
EDGE OF CART PATH 175.00 --,
I I LOT 33
MAP 245 PARCEL 011
CURRENT OWNER
r I I WILLIAM J.JR&JOSEPHINE K.CLEARY
AREA:38,157 t S.F.
r+----}------------------- - -----------------------------------------
BUILDING SETBACK LINE (TYP)
APPROXIMATE '
o LOCATION OF
I
SEPTIC SYSTEM ^
m PER AS-BUILT N ,
CARD
LOT 34
I I I I
r µ' STOCKADE i
LOT 32 > 4 PROPOSED FENCE I MAP 245 PARCEL 010
MAP 245 PARCEL 012 i N F
ELLEN D. KUNKEL v i PROPOSED CANDACE I. OOMOS
lN 1 EXISTING KITCHEN I y
v I I m I FLAGSTONE ADDITION Z I
5 C I I PATIO N
a I I
o EXISTING
67.5' BULKHEAD I N (n
SHOWER I a
0 a 48.8' I m
12.0 w13.8 iv
I V. 1 0 - ^j
I P' 2 STORY y
1 29.0 N AOOD FRAYS v✓ 23.6i 1
ro'2 .0/ A p 2
N /1.6" CONCRETE
I I I
N v ELECTRIC z APRON
BRICK METER c
N
I I PAD(TYP) POST & REAL
1 z FENCE ,
--------------- -- --------------- -- ------------------'�
I I ALK FLAGSTONE
22 _.
' I CBDH
'-- 175.00' < - '� naa
CBDH S1715'55"W
Li
CATCH GREEN DUNES (40' PRIVATE) DRIVE
BASING ❑ EDGE OF PAVEME T
Current Zoning Information
Zoning Classification: RD-1
Zoning Definition: Residence
Building Setback Requirements
Observed Required PROPOSED
Front Yard Setback 31.4Feet 30 Feet
Side Yard Setback 57.5Feet 10 Feet 67.5 Feet
Rear Yard Setback 65.6 Feet 10 Feet 111.7 Feet
Bulk Re uirements
Observed Required
Max. Lot Cover N/A N/A N/A
I CERTIFY THAT THE STRUCTURES PLOT PLAN
SHOWN ON THIS PLAN ARE LOCATED 129 GREEN DUNES DRIVE
AS SHOWN AND TO THE BEST OF MY MAP 245 PARCEL O 1 1
KNOWLEDGE COMPLY WITH THE
DIMENSIONAL REGULATIONS OF ZONING (WEST HYANNISPORT)
BY—LAWS OF THE TOWN OF �Ii,uA BARNSTABLE, MASS.
BARNSTABLE. ►�'�.��NOF sa�
A�ti�` SCALE: 1"=40' DATE: 12/04/2007
TIMOTHY
� R. H ►
DATE: 3N68�56 4k ; BENNETT ENGINEERING
A6Ep ` LAND SURVEYING,ENGINEERING,&DEVELOPMENT SERVICES
►S�ON�I L N� ��A
PO BOX 297 TEL.(508)888,4868
PLAN REF: 15694—D Sh 2 SAGAMORE BEACH,MA 02562 FAX.(508)eB&4867
CERT. 177907 0 40 80 120
JOB N0: 1189
f (Zd� OWN OF BARNSTABLE
=l; ATION SEWAGE #
VILLAGES 1�� Q' R S MAP & LOT , � /°
L�7`{s{QGO� S:NAME&PHONE N o "
SEPTIC TANK CAPACITY :
LEACHING FAClL TY: (type) �ac.� U (size) CA' )(6
NO. OF BEDROOMS 3
BUILDER OR�`6)
PERMITDATE: 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
i
(Po I SAD II�n
1-an
�a
k (o Lem
C, TOWN OF BARNSTABLE
LOCATION Vie., Q�t5 SEWAGE
VILLAGE ASSESSOR'S MAP & LOTx lS=a//-033
INSTALLER'S NAME & PHONE NO.Q -1-bCc W7
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 1-f>T7- (�/f (size) 6>f 0 ,
NO. OF BEDROOMS .. PRIVATE WELL OR UBLIC WATER
BUILDER OR OWNER C�Jl `9
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: 73
VARIANCE GRANTED: Yes No
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH APPROVED
TOWN OF BARNSTABLE C Mnl6m Department
Appliratiun for Disposal Works TourDate
Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal
System at: v, C.e�
......:1 ...... �W IL/lE - -• - .........-
-------------
catio or Lot N
.----------/ .........495V ..J.----, t�xJ s......................................................
W Oar
�_ Addres
s
/
Installer Address f
U Type of Building j Size Lott�.1__-..Sq. feet
�-, Dwelling—No. of Bedrooms................._......................._Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures ..---•--•-•-•-•----•------•---•---•--------•--•----•--•------•-•-•-•------•--•--.......--••-•--••••-•-•-
W Design Flow................. ...............gallons per person per day. Total daily flow...... ..................gallons.
WSeptic Tank—Liquid capacity<!012..gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width..Q......_._.... Total Length.._............t... Total leaching area....................sq. ft.
Seepage Pit No-----------Z..... Diameter......_.__..... Depth below inlet............... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_-----_____-__•--_---.
Gr. Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
-----------------------------------•---....---•------------•-------.......---•-••-•---•......_---•--.........................................................
0 Description of Soil...................-•-•••-••-----------•---•----•-••••-------•------•-•--•-•--------•------------•••-•------•--•••------•--•-•••••••-••••----------••------------------
W
V •--------
•-------------------------
•------------
••---------------------
•-----------------
•---------------
•-------------
••-•-------------------------------------------------
------------
•---------------
W
x -
U Na lure of Repairs or Alt ations—Answer when applicable..&'✓✓.�!o_._�__��(---C.F-CS�UCS_.._-..^rS7T-
.
oe
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 s b en i sue by e b ar of health.
Signed ......... . -- ...... --- - ----- --- ................ /" '
re
ApplicationApproved By -- -------- ------- -------- -- ....... ...... . --- . ------ ------ -- ............................... ---....................................
Date
Application Disapproved for the following reasons: ................................................
..................................................-
........... ---/
------------- ------.... .
Permit No. ....... ..- /
Date
..-- L Issued -------- ....------ --
Da e
f
/0 6 /f - 6 /
•- ,I�g ----•-a---...� Fps...... .6..0.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN'OF BARNSTABLE
A liration for Ui ooa1 orkii Tonstr dt an~remit c)-z
Application is hereby made,for-a-Pe rt to Construct (_ ) or Repair (�� an Individual Sewage Disposal
System at: L�
................g.....��1�E� IDu►U�s 0�Ive ..__.
---- ---- .............. . .........................
Location—Adds or Lot No:
-----... ... .......................... ---------------- -------- ..--------------•---------•----................
Owner Address
a ---------------------------------------------•----------------.....------.............------.._... ..................................................
Installer Address
Type of Building 3 Size Lot�:.10U_� _-_..Sq. feet
�-, Dwelling—No. of Bedrooms_________________v_______..____..__._._.....Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a YP g --•--•---------------•-•---- P ( ) — Cafeteria ( )
Otherfixtures -------------------------------------------------------------••••---------•---------------------•----•-----------------------............--.....-----
w Design Flow................ ................gallons per person per day. Total daily flow___........ �� a__--... I...gallons.
WSeptic Tank—Liquid capacity v..gallons Length................ Width................ Diameter__- `..... Depths:?.............
x
Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area........._?.....Sq ft.
Seepage Pit No-----------�----- Diameter------�o__..... Depth below inlet.......-_-..... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by......................................................................... Date........................................
1
Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
G%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
M ----------------------•-•-----•-•--•---...----••-•--•-------------••------------•----•-••----.-----•.......................................
Descriptionof Soil-----------------------------------------------------------------------•---•------------------------------------------- -----------------------------•----------------
x
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UNature of Repairs or Alt�ations—Answer when applicable_�k VvOfo-_.__ ___�- G t___�_�_Cs C45- ���Gl
_ _
.------
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 b en i sued by t e board of health.
Signed .. '/, .... �.J
,�~�y Dace
Application Approved BY .-..- 1.��.. ? 'G .
Dace
Application Disapproved for the following reasons- .............------------------------------------------------------------
-- -------------- --------- ------ ------------------...-.....------------------------------------------------ ----- -- ------------- - ------------
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Permit No. ---------- Issued ............ .. -. "/
.-- Date Date....--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Tex#tftca e of Tontylinurr
THIS IS TO CERTIFY, That-the Individual Sewage Disposal Syste constructed ( ) or Repaired (X )
Y --... ----------------------------------------Ca CI 1?e0AJ
---------------- --------------------------------------------------------------
Installer
at ..... .......... ......................... ��--------�'2��.�..... ; U...........5------.��..�/1�......--------W..----�`/��..�..
has been installed in accordance with the provisions of TITLE 5 f The,SS to F vironmental Code as described in
the application for Disposal Works Construction Permit No. ....... . . .............. . ......... dated ...................................------------
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................. ......1. -------------------------------------------- Inspector ---------------- -----ter' '------...................................... ...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
�� 'r-
No..T......- FEE....r. ..............
Uhiposat Works Tonstrnr#inn Permit
Permission is hereby granted...................�c7T�t7---------CQ;JST,
to Construct ( ) or Repair O an Individual Sewage Disposal System
at No...........................................Ti�1......... j� ' '�Us'U---�---- Z916 / -------------�--- /����GG��
Street
as shown on the application for Disposal Works Construction P-mit No..p_.,,-;---� -• Datedll _._ `..__�!..-.
. v - -
Board�f
DATE................�...... .................................................
Health
FORM 3650a HOBBS&WARREN.INC..PUBLISHERS
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