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HomeMy WebLinkAbout0160 GUILDFORD ROAD - Health 160 Guildford Road Centerville p A = 171 069 No. 4210 1 f3 ©RA 40 1000 ,U(9 ........... ..au,.- - -- - -�-'^ """ r� - -- l !e � � a 1- Ilk s AL DATE 1 /23/02 PROPERTY ADDRESS: 160 Guildford Road --Centerville,Mass_- �1��-(,�1 02632 ` ------------------------ On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. Baffle Tank 2 . 4-infiltraors. ( Stone Dry ) 394 GPD 3 . 1-Distribution box. Based on my Inspection, I certify the following conditions: 4 . This is a title five septic system. 5 . The septic system is in proper working order at the present time. 6 . The septic system was upgraded two years ago. ( Per Owner ) SIGNATURE:f J. Name: J . P . Macomber Jr�____-_ Company: Jose.2h_P_ Macomber_& Son , Inc . RECEIVED Address; Box 66 -- _. CEVED Centerville , Ma_ 02632-0066 EJAN 2 4 20 o,N EOLTHNTF6 Phone; 508_775-3338 A pr. - THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachflelds Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r DEPARTMENT OF ENVIRONMENTAL PROTECTION o i TITLE 5 OFFICIAL INSPECTION CE SEWAGE DFORM —NOT OR VLUNTARY POOAL SYSTEM FORM SUBSURFACE PART A CERTIFICATION Property Address: 160 Guildford en ervi e,Mass. Owner's Name: Richard Cazeault Owner's Address: Same Date of Inspection: 23 02 Name of inspector: (please print) Joseph P Mar.om er Jr. Company Name:J.P.Macomber & Son Inc. Mailing Address:Box 66 ('on�crvillc Mace 02632 Telephone Number: S08-775-13-4$ CERTIFICATION STATEMENT 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: tl� Passes _ Conditionally Passes Needs Furthei Evaluation by the Local Approving Authority Fai Inspector's Signatur?bmit Date: P The system inspector shall 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, d Comments Notes an . ""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 6/15/2000 page I Page 2 of i 1 s OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 60 Guildford Road Centervi e,Mass. Owner: Richard Cazeault Date of Inspection: 1 /2 3/0 2 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 1 have'not found an informatio hich indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 C R 15.304 exist. Any failure criteria not evaluated are indicated below, Comments: The septic system is- in proper working order at the present time. B. System Conditionally Passes: A)n 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. _tZL 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(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: Za 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: Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . PART A CERTIFICATION (continued) Property Address: 160 Guildford Road Centerville,Mass. Owner: Richard Cazeault Date of Inspection: 1 /2 3/0 2 C. Further Evaluation is Required by the Board of Health: Vd 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 envirorunent. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b) that the stem is not functioningin a manner which will protect public health,safety and the environment: ,VO Cesspool or privy is within 50 feet of a surface water ,07 Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. Svstem 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. �,1e) The system has a septic tank and SAS and the SAS is within a Zone I of a public water supple. 1-_4 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. IV The system has a septic tank and SAS and the SAS is less than 100 feet bu j50 feet or more from a private seater supple 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 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: 3 Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 160 Guilford Road CentervJlle,-Mass— owner: Richard razeaul t Date of Inspection: 1/?a/(L2 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 tLi;d*stribution box above outlet invert due to an overloaded or clogged SAS or /cesspool C ►OA? 7 Y iquid depth in ee"peol-is less than 6"below invert or available volume is less than 1/2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped () . �y 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. ny 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, perfarmed 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 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 now 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 11 of a public water supply well P 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 I 1 , r OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 160 Guildford Road Centerville Mass. Owner:Richard Cazeault Date of Inspection: 1 /2 3 /0 2 Check if the following have been done You must indicate"yes"or"no" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks _ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection ? Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,A-Acluding 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 ? ZWas 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. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) (310 CN R 15.302(3)(b)) 5 Page 6 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 160 Guildford Road Cen ervi e,Mass. Owner: Richard Cazeau t Date of Inspection: 1 23 02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): �J DESIGN flow based on 310 CAI 5.203 (for example: 110 gpd x# of bedrooms):30/ Number of current residents: A _ Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system es or no):W- [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)): 2000=58, 000 gallons=1 58. 91 GPD Sump pump(yes or no):ND 2001 =77, 000 gallons=21 0 . 96 GPD Last date of occupancy:lT� COMM ERCIALXOUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): W,9 gpd Basis of design flow(seats/persons/sgft,etc.): tJV Grease trap present(yes or no): M Industrial waste holding tank present(yes or no): .f Non-sanitary waste discharged to the Title 5 system (yes or no): '60 Water meter readings, if available: Last date of occupancy/use: ,}J OTHER(describe): .IJA GENERAL INFORMATION Pumping Records �/ - Source of information: Alt° 144 Was system pumped as part of the inspection(yes or no): If yes, volume pumped: D gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, distribution box,soil absorption system WSingle cesspool IOverflow cesspool Privy D 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) 4k Tight tank 4 Attach a copy of the DEP approval k6 Other(describe): App oximate ase of al c mpon ts,date installed (if known)and source of information: Were sewage odors detected when arriving at the site(yes or no): 1614 6 s s Page 7 of I I i OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 160 Guildford Road Centerville,Mass. Owner: Richard Cazeault Date of Inspection: 1 /23/Q2 - BUILDING SEWER (locate on site plan) Depth below glade: �_ Materials o(consrrvction:�cast on 11,410 PVC Lf�other(explain): /1�� Distance from private water supply well or suction 1ine:i��1` Comments (on condition ofjoints, venting, evidence of leakage, etc.): Joints appear tight.No .evidence of leakage.The system is vented through the house vents. SEPTIC TANK: (locate on site plan) 1110e %A2at�-7 Depth below grade: /01✓ Material of construction: ►'concrete.( metal.gLfiberglass,U�olyethylene 40 othcr(explain) Ald — If tank is mcul list age:" Is age conftrmcd by a Certificate of Compliance (yes or no):"/(arch a copy of ccnificate) , ,� Dimensions: �6 y�� Aide S'r%sf Sludge depth A, Distance from top 2.L,5,luege to bottom of outlet tee or baffle: /,&z4(L Scum thickness: /�td Distance from top of scum to top of outlet tee or baffle: Distance Qom bonom of scum to oo(jom of outlet tee or baffle: How were dimensions determined: A444/ ) Corr_mcnts (on pumping recommendations, inlet and outlet tee or baffle condition, structural integTiry, liquid levels as related to outlet inveri, evidence of leakage, etc.): Pump the septic tank every 2-3 years.Inlet & outlet tees ire in place Tank Has inlet baf l e The tank is structurally sound and shows no evidence of leakage.Liquid level at the tt�� }}� nnyy���� �r GoREATRAYilLuitl,�oca Sonse plan) Depth below grade: Material of consuuction:4G�concreted rnctaI44 fiberglass�r polyethylene other (explain): ZA Scum thickness: n __� Scum thickncss: Distance 6om top of scum to top of outlet tee or baffle: ,tY Distance from bonom of scum :o fro..^.om of outlet tee or baffle: Date of last pumping: __a . Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integTiry, liquid levels as related to outset tnven, cv:_er.ce or. leakage, etc-): Grease trap is not present, 7 Page 8 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:1 60 Guildford Road en ervi e, ass. Owner: Richard Cazeault Date of Inspection:1 /2 3/0 2 TIGHT or HOLDING TANK4�W�,(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: VA Material of construction: A)j concrete 06 metal fM fiberglass Zl/4 Polyethylene��other(explain): A4 Dimensions: jlJ Capaciry: 'M gallons Design Floe: A/4 gallons/day — Alarm present (yes or no): Alarm level: VI? Alarm in working order(yes or no): Vlf Date of last pumping: _ Comments (condition of alarm and float switches, etc.): Tight or holding tanks are not present. DISTRIBUTION BOX: Z/ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: t/CI 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.): Distribution box has one lateral.No evidence of solids carry , over.No evidence of leakage into or out ot the box. PUMP CHAMBER4,4/f,(locate on site plan) Pumps in working order(yes or no): ,V4 _ _ __ ___ ___ _ ___., _ _. Alarms in working order(yes or no): 14 Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.): Pump chamber is not present. 8 Paoe 9 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1160 Guildford Road Centerville,Mass. Owner: Richard Cazeault Date of Inspection: 1 /2 3/0 2 SOIL ABSORPTION SYSTEM (SAS): locate on site plan,excavation not required) 4—High capacity infiltrators in series. 4 ' of stone. If SAS not located explain why: Located; See page 10 Tyke /t/ - eaching pits, number: Z - eaching chambers, number.I-High capacity Infiltrators. 11 'X24, 41d leaching galleries,number:Q t'P leaching trenches,number, length: leaching fields,number, dimensions: � overflow cesspool, number: '!� ZZY innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Loamy sand to boney fine sand.No signs of hydraulic failure or ponding. Stone is dry. Soils are dry. egetation is normal. CESSPOOLS (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: 61 Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: 4) 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.): Cesspools are mot present. PRIVY44%/t (locate on site plan) Materials of construction: Dimensions: 1 Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy is not present. 9 Page 10 of I I OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 60 Guildford Road en ervi e, ass. Owner: Richard Cazeau t Date of Inspectioo: 1 23 02 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> A i - 2cl �l 3- 33� 10 Page I 1 of 1 I 0 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 160 Guildford Road Centerville,Mass. Owner: Richard Cazeault Date of Inspection: 1 /23/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 7d feet P Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design lans on record - f checked, date of design plan reviewed: 1 bserve st e a utttng nioe bservatton hole within 150 feet of SAS) ticked with local Board of Health-explain: 13b7_,J44f d ArS �'eFI.�7" _ ecked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Ved; Gahrety & Miller Model 12/16/94 Ground watc-r ahovP sea level : USGS;Observation well data June 1992 USGS;Ann^a' ranee-, of qr ind watpr 1 v 1 92-0Q0-1 Plat-P ##2 Tup of r un A—High Capacit Infiltraors . Groundwater eet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frim ter Method J P P Therefore, the vertical separation distance between the bottom Of the leaching pit and the adjusted groundwater table is AI.V feet. 11 �a•r+'t}rwr-nfre+—.rf—.rnrafn•n�rwrs�en,�nrfrrnrt�rrrf-�frrrrfrref•f.rr,nffrn�u r,s7sTfl,tffPPf •rn-rr-r-r�r—'...• r- TOWN OF Barnstable BOARD OF HEALTH SUI)SURFACF SFKA(IF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION �0•••T•1.7' •.••.:.—T,1fI�.rTT1.rtT.f.1`nrlrf rafrrrTrf„-rri'r-'tr•71fTw1 a1TR1R�'•r1'fR.CAf/Rl..l.,!'A',R1 ,tR„i ..-.rrr•r•�• —. -TYPE OR PRINT CI.EARLY- PIIOPERTY INSPECTED STREET ADDRESS160 Guildford Road Centerville,Mass , 1 -069 ASSESSORS MAP , BLOCK AND PARCEL # 171 -069 OWNER' s NAME Richard Ca2eault PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & sQ'n Inc COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 Strvvt Town or Clty 9taty LIP COMPANY TELEPHONE (508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 fR CERTIFICATION STATEMENT - I certify that I have personally inspected the sewage disposaj system at this address and that the information reported is true , accurate , and omplete as of the time of * inspection , The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and' experience in the proper function and maintenance of on- site sewage disposal systems , ' fi i Ilfcifl Check one : -/ System PASSED , The inspection which I have conducted has not found-any information - which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 - 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA sectioll of this form . System FAILED* \ The inspection which I have con ircted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form , Inspector Signature Date �� - ne copy of this. & rtification must be provided to the OWNER, the BUYER ( Where applioable ) and the I30ARD OF HUAL'I'll. * If the inspection FAILED, the owner or'"'4erator. shall upgrade ' system within one year of tl)e date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 15 . 305 . partd .doc No. d Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 0(pplication for Mtgogo.Y *pztem Conttrurtion Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.r �Q G v Z ;56T ST Owner's Name,Addre5sar4Tel.No. Assessor's Map/Parcel `") I —& Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow _J S O gallons per day. Calculated daily flow 3"fi gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank `l c--v 7,�-- k0747 Type of S.A.S. fAti l 1, Cct CA-t `- Description of Soil Yy-10_ -- S KV0 � G U A P ky� Nature of Repairs or Alterations(Answer when applicable) �-{` S�lk�. O I14 tt tJ ak � 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 E ' onmental Code and not to place the system in operation until a Certifi- cate of Compliance has been ' y this B a Signe Date Application Approved b Date ' s Application Disapproved for the fo owing reasons Permit No. Date Issued 9 No. �''/ Fee - THE COMMONWEALTH OF MASSACHUSETTS En eared in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUS - S Yes Y 0[pprication for Oi5pogaf *p!gtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No.t �Q G �,�OY(� ST Owner's Name,Address,. d Tel.No. v Assessor's Map/Parcel —6/0 t G Installer's Name,Address,and Tel.No.1 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms L Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) ;e .. Other Fixtures Design Flow �J 0 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank !Z - tC-010 Type of S.A.S. la y t�k, CrateL- Description of Soil r c Nature of Repairs or Alterations(Answer when fapplicable) ( 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 i ,d'6^y this at Signed Date Application Approved b _ Date Application Disapproved for the fo lowing reasons Z Permit No. '" l Date Issued •�--. ' - '��f' ———————————————------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (tertificate of (Compliance THIS IS TO CERTIFY, that the On e�ewK'Q a Disposal System.Constructed(_ )_Repaired( )Upgraded Abandoned( )by -� O` L iA t� \ f � . at �7 rk�7, iF7 leU has been cons�cted in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No dated _ Installer Designer The issuance of this permit shall not be con trued as a guarantee that the syste�Willfunction as desi.�g. d. Date l � Inspector ._� � � --------------------------------------- No. / Fee -i-�-✓7J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Migoogar *roem Con.5truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade.(�Abandon( ) y System located at 1 (0 U I`�r1 r;��. ��" �� �� and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of thi a t. Date: " / Approved _ --- r` 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) hereby certify that the application for disposal works construction-permit signed by me dated S—c�3_9� , concerning the e A. property located at ko b 6 U A�}�(Z 0 SI C'e meets all of the following criteria: �/ • e failed stem is connected to a residential dwelling only. There are no commercial or business � system 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 • ere 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. mum-adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] B z • 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) � O B) G.W. Elevation +the MAX. High G.W. Adjustment,7 _ -7 i DIFFERENCE BETWEEN A and B 7 '— SIGNED : DATE: —3 y0 [Sketch proposed p16n of system on back]. q:health folder:cert 4b TOWN OF BARNSTABLE _ _Z 2— n le I LOCATION / U / / %L�-'' '' CJ ���'� SEWAGE # VELLAG ASSESSOR'S MAP & LOT!ZZ --7� t INSTALLER'S NAME&PHONE NO. /"/0 i1 A(L S��� f_ _7 SEPTIC TANK CAPACITY /s U U LEACHING FACILTTy: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER / PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the.Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (ff 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 G i Acrj i 43 .f I ,31 23- !: Q3 [33.�� !. is TOWN 0 BARNSTABLE LOCATION ! &y Guly/d,Xarrd SEWAGE# VILLAGE C? lid�.�eall . f� ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. M l le14 4 e S'C a f%c 7 2 S G ,Sl� SEPTIC TANK CAPACITY %s. G U LEACHING FACILTI'Y: (type) f Q Z-1i/1614 rd/L S (size) // X 2 NO.OF BEDROOMS r,,BUJLDER OR OWNER LPERMUDATE: j COMPLIANCE DATE: 5 29- 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 �� �' � �� `tom .�•r 43to )33 ifs f f 1— 16 TOWN OF BARNSTABLE LOCATION - SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Y SEPTIC TANK CAPACITY 1 LEACHING FACILITY: (type) ze) NO. OF BEDROOMS BUILDER OR OWNER 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 Lea king Facility(If any wetlands exist within 300 fee f 1 cility) Feet Furnished' s 1 . 201 2- 31 Z- V r 4 7-4 3 3' 31 '