HomeMy WebLinkAbout0080 HARBOR HILLS ROAD - Health 80 Harbor Hills Road
Centerville
A = 247 087
a
0,Itrord,_
NO. 152 1/3 ORA
I
4 COMMONWEALTH OF MASSACHUg,MTS
EDWXUTIVE OFFICE OF ENMONMENTAL AFFAIRS
D"ARTURNT OF Mn' RONENTAL PROT$CTION
c � I
Y-
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL,SYSTEM FORM
PART A i
CERTMCATION
hvPerty Addlesa CO&"�9/ 4'n re
Rd
Owner'sNama ,'` o 63� H`Janv7,tf9o.
Owners Address;
Date of in C o o O
6 i I
Name of (pleaserw
Company Nr � �
Maiti�Address: o .
o�
Telephone Number-
CERTMCATION STATEMENT I'
Icartify that I have pemonany inspected the saww
below is ftw,aaaaate and aanphete as at ���m�fist the'
�S and cTamm
aPP 'ed sy m the psi W flan and oe ofon site was based-an my'
Inspector pnrm to Of 17tie S(310 CAM 111 I am sI BEP 5 �I
nW
oftmwan
Net* Evalust:'an by the Local
F Aping Authoray i
Inspector's Signature;
Date: 6' /� p `
11e
system D within 30 days shall2%=
of thta won=port to the Agwnn I'
apd or ction.If the system is a shared 8o (BOiand a�Health or
gam,the inspector and die system owner shall sYs�n or has a design flow of 10,000
DEP.�e original should be seat to the system owner and o�EB Seto the PM to�� �a of the
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authority. g I
Notes and Comments
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s�•:��report�describes��On/at the
Inspection does not ad time future under the
onditionnss of use, address how the system wiR � der fife conditions at that
sme or different i
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- OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONMENZ'3
PART A FORM
CERTIFICATION(cow
A''Olka't3'Address: �� �c r ,- A� Qc/
owner. 0 of i ' 6
Date Of
mot Marys Check A^C,D or E �
--�.-� mpkte aB Of Section D
A. Sy PROM
15.3 3 or have I10 huUR 1 any won which indices that�y the
Comments: t�Anyf ��a�wed ked bdodw��in 310 C11Dt
a System Conditiapy pass,;
,4—/One or awn system � �the k
reparred The syspen� �mpletionpmeM a�co `°� ,need na or
- .as appt+oved by the Board of H�will 1�.
Amwa yea,no or not determi (Y,N,ND)in&g
explaktar the 8 eta If"not dew ply
T�sepia tank is metal or y�old•or the ether metal or
O°fS� np18°ed with a cmp ying �-mm or js immimm�m will �
A metal sepdc tack will �c tank as app vvW by the Board of i�mspecdon if the
1° 8 that the tank ideas�on n oldigs not lealong a04N�caa of Can Vfi�
ND e�rplain:
of
c bstnxt�or eq br satled or or high static levd m the dim
MPW,Fd of Board of Health); uneven d bubion box System wilipam bqfttW.if(widue togor
ob�ructiaa is Moved
s)am wed -
on box is kYeW 0r aP1�ad
ND explain:
The system reqmred
paw inspection if( PMP'Pg Of �If a Y�due to bmlaea ar obi P (s) The gm
sy will
b vkm ppe(s)are Mlaced
—_. obsftmd0a is nmoved
ND explain:
31
OFFICL L INSPECTION FORM-NOT FOR VOLUNTARY ASSE
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPE SSMENTS
PART A N FORM
CERZ'II+'ICATION(canting
Property Address; //
Owner. ►" C 00 v, a,d' 3.A,
Date of Inspection; 6 /g
Evaloadon is fired by the Board of Health:
Candid oms exist which fmrthw ftWustion by the Board ItHWth is order to detersnia if the system
isS to maw publk haft sa&ty or the amr=,WL
L system wiII pass .Board _
syseen,is not fiactiontu8 in a manner which� a0�°0e�sd CMR 13�.�03(iXb)that the
�and the fit:
— Casspooi or privy is within 30 feet of a swface water
— Ce=WW or"Y is within SO fat of a
borde*gveaetaged wetland Ora sah marsh2. �
i
m wig fag
system Is functioning Bard Of Health(and Publk Water,%ppar,if any)determines
that PrOlech the public kw*safety and a t that the
11W
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sorlaoe =A* to a Sad�°°system(�)and the SAS is witluin 100 foot of a �
— The system has s septic tank and SAS and the SAS is within a Zone 1 of a public water
_ The system has a septic tea and SAS ''
the SAS is within SO fern of a private water MV*wall.
7U MOCIR has a sepk tank and SAS and the� �y well*+. used to SAS is less than 100 fat but
SO fat or�from mime disfana a
"This Eystem its if the well watbacteria ander 4
Vol"orb p mod at a 1 macaw that the ,.a.��� ,fa
Wham
failum criteria am m p��m��'D���to err less�������'and
copy the aoaiysis�be attached to
than
form. Prded that no other,
3. Other; I,
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• rn�Y�JJ l l
OX
G�
OFFISCI�ALS INSPECTION FORM—NOT FOR VOLUNTARY ASSESS
MUM
URFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A FORM
CERTIFICATION(iow
Pr+oPerty Addaas; 0 �.-4,- �/� �d
Owner. G t'c 1�00 , J
Date of:Veedow / 05
D. System Failure Cditda APPlicable to afl systems:-
You mot indicate"Yee or`ne to each of the following for H9,mspoctions:
Yea IVp /J of �
sewagehclkq or MOM CQUIPOnent due to aved
oaded or dogged
S=i
S or CesVo0j
Of to the snrfaoe of the sound or s an Ov-loaded or
ool
-�/ StItic hgmd level m the box above oudet ,
invert due to an overloaded or dogged SAS or
depth m cesspool is legs than 6"below ess than
��j
m mane than 4 times in the�A doggPd� �8ow
.� m of Me 3, ml�(s)•Number
4Anypomco
° off ar Pay is below high g+�d1 0esspoolorPrh7iswithin100fleetofssudhce ormaytoa surgace
rdon of a oes Orp�is within 50�within a ofa°faP well.n of a asspoal or pri{►y��than 100 fat�water���"�' Plivate_
supply wen with ao soaeptable water than SO fat from a
performed at a DEp ardAedy��colKorm Parma it the well water analysVr
lodlcatrs that the wen ii fitie}from popa�from that fbadelia and volatile organk impounds
nibleen and nitrate nitrogen is equal to or leq than S WA tty and the presence of ammonia
aR��'A copy of the analyst most be attached �p�ded that no other tailare criteria
described syskm ff&l have mined that one or more of the above faiiure criteria ocist as
Hen determine in 310 wits should Coutac t the
necessary to corms the owner Board of
To be bW systein the system maul
gpd. serve a tacifity with a chip How of 10,000 gpd to 11,M
(You to�llo mdgc�te��W or`yin"to each of the
'to WX Waam m addton t°the ceteria ate)
I
�is within 400 fat of a surface&riming wain�y
the system is within 200 feet of a tinbutary to a surface ddaldng water mp*
X-11�733
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11 of a WSUM s located in P�water sum en tive am d im Wellhead protection Area-IWPA)or a,in
Wyou have answeredW to any question in Section E the
"yes"in Section D above the large system has faded, The o ner aa s. a og°ificaut tires;or answered
2 Clint thr+eet under Section E or faiWunder for of M'lag considered s
]5.304,7be owner should SoctioaD shallu .the
sotto the app regime e�ice d
ofanoewith 31Q
raw Sor i i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNT
ARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
PiwedyAddnm -gig
r
e� P od6��
owner: C
Date of Inopec&m: 8
Check if the fO..110fing have been done:You mast es"or"no"as to each of the foWwin
Yes
— —c/ S Wm='an was provided by the owner,aoca�or Baaad o(Health
Were any of theqsk=O0nV0nvft I
P�Ped cot in the I
previous two weeira I
sYshm received maul am m the pm Ous two week
penal I
Have&W vdaimes of water been in< cl to the system nocendy or as pwt of this
bqcMm
Were as built plans of the system wined and examined?
(If tbW were not av18*k note as N/A)
/ Was the>hciluy or dwelling for sig u of sewage baact u
✓ — Was the site inspected for sigma of bm*
out
Were all system
T coaopoascuta.=�doding the SAS,kcafod on site i
Were the septic tank mmmho
of the ar toe4 material of wed,° ,and the inferior of the tank d for the condition
' 'dq&of hqzK depth d'shdpe aoddepm of m m
Wm 60
e of saber (&pn if �'0m omu)Povidod with Wmmatkm on the pct�per
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The sine and location of the Soft Absorption System(SAM on the sate has been
determined tarsal on:
Yen no � F�
a plan at the Board of Health. �
Determined in the fell(if any o(the failure criteria related to Pbtt
Is unmceptabie)I310 CM 15.302(3Xb)] Cis at'wuc approxiamtiaa of distaum
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Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
n SYSTEM INFORMATION
Property Address: �V Ark, yf��S
c �, Da63� �e.�-►,
Owner: l/'�1 C h on,4.1
Date of Inspection:
LOW CONDITIONS ,/ l
RESIDENTIAL �T7 A c 4,�J
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): .7-70
Number of current residents:_9
Does residence have a garbage grinder(yes or no):/+/0
Is laundry on a separate sewage system(yes or no):W0 (if yes separate inspection required]
Laundry system inspected(yes or no):�0
Seasonal use: (yes or no):-SI-OS
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy:
C OIMIMERCIALA"USTRL4 L
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 inspection(y s or no):dip
If yes, volume pumped: gallons --How was quantity pumped determined?
Reason for pumping:
TYP SYSTEM
_ eptic tank, distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
—Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components, dale in alle if known)and source of information:
00
Were sew .sewage odors t g detected when arriving at the site(yes or no).
Ti*Ic S IncnArt;nn 17^—lii siinnn 6
OFFICIAL,INSPECTION FORM—
NOT SUBSURFACE SEWAGE DISPOSAL SYSTEM ARY ASSESS)IIENTS
-PART C ECTION FORM
p,�,..,�, .Q SYSTEM EVORMATION
"�'s7 Ad1 C! O G�� A��S
or
Owner: 6�� i
Date of
I
BUILDING S
EWalt 11oc�te on siteplan)
Depth below grade; 0
dials atco ;a�--7�
ywcj—
cmmeed((n coca mm Off joiaw vm of ear
I
SEPTIC TANK._Occaftan sine Pam)
Dqgh below aterial llrada
M of mn&achon;_
—ot� —���_polyethylene
If tm*is nm:w
_ h —d b .a
x / 0 nOC(yes or no):_( a dopy of
edq�th: a
Dimaaae �opa,f'Scum didom- LQs of odld tenor be e:
Distance fmm.boet=& ��of°�tee or bed:
How`verse �aatlet tee a baft; •�'-
Co (on p mwg nencladogM inld and Rq
reLVd to o�rtlet mve� tee of bdk condition, j
r �tegriiy;liquid levels
R✓� Ati AP �r 7ti vr/e
.ems. S /✓� 4o Dv, aN
GREASE TRAP.-IC(�Cate as site Plan)
materw Of oo —fie
(�): medl--= _polyethylene—
Scam tluclmem._
Distance Sum two of O boMm tee a bade:
Date cf last pmpeng of oatkt We
or be®e; j
as mlated to°ntlet'woertg evidence dc.) sold tee or ba>Ue conditioq
�h',hqod levels
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OFFICIAL INSPE
CTION FORM—=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(aa�tmve�
nWily Addrm-. eo lqa,Zo A;Ilr kl
Owsea:
oa 6j�t-
Date of Iaspe ,a. 6 c
TIGHT or HOLDING TANIL 143tm*mnst be pub at tiro of ..Xbate on site plan)
Depth below grade:
Material ofo
oonmte metal fibergl-W l3►ethylene °duf(expbln):
--------------
Ded8n Fkw. ~day
Alarm present(vea or no):
Alarm level:
Alarm
Date of last pnmphw in wig order owor no):
Comments(COOMi m Of aim=and fk)W switches,etc.):
DISTRIBUTION BO. (jfPwcWmom be
oPM-*b-te on site plan)
Degh of hqmd levd above outlet invert:___Ql o!
Comma(note if box is kvd
l or out cif box,etc.): to°utlM �► ooe of soBda cmyover,m,m id of
PVW CHAMW&-V(1 on ske per)
PUMP in waddag order(yes or no):
� k (yea or no):
mmeft note afPmp dumber,oond dl a[
Pimps and Vpwmamcck etc):
• o"TCL"MPECTrON FOJtM_
•• SUBSURFACES NOT FOR'VOLIINI'ARY
EWAGE-DEPOSAL SYSUM INSPE
. PARTC... INSPECTION FOR
SYSTEM MOMMAXON
PrWMAMwem
Owner: 0,2 G 3�
Date of / v
:'WM ,M"T""SUM'MA4-._(bob aw sifr piano ftQwa*w jw.
If SAS not locaw t;v why.
Type
-740�/���
--
kacmu
w
fift Spa
°M1" ►C
'p 7e
caspoM& amg be pm"d as pert af a Ga Site
Pam)
Dqxhof so&.*
Dimawaft off i
Mat iala of
Indicadw aj '(Y=ar
conimuft �
e Ind afVmft d ��
PRIVY: /(./�ocatenQ�P�?
li
Dcp&of aoi&
CDO=*s*°` �• lmd aft boa afs e�
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Pale 10 Of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSI WW,
SUBSURFACE SEWAGE DISPOSAL SYS
TEM INSPECTION FORM
PART C
SYSTEM PU0JtMTj0jq
Property Address: av` Ors l j�S
Owner.
Date at Iaspectio,; tar
a
SIICTCH Of SZWAGZ DISPOSAL SYSTrX
Provide a s'izkh of the sewav dispose(89sem bduding ties 10 at least two
bmxbmrkL Locate all wells widen 100 feet Locate where puhtic water supp enters the Nd&War
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edge 11 of I1
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS
SUBSURFACE SEWAGE DIS POSAL SYSTEM PART C INSPECTION FORM
SYSTEM INFORMATION(co>mmmo
Property Addrem vi W- A, 12d
�0
Owner.
Date of inapeetion;
I
Srrz EXAM
Slope �r
Surface water �—
Check ocuw
�, a
Shallow wdbEstimated d*&to pound wow d9ufoft
'
a
Please indite(check)all methods used to determine the bighgmund water ei ►atian:
li�v=,m
(abutting P��rooard-Mcbec> date of detdga plan mvkwcd
y bole within 1st)fact ofW)
ocatBoodoaFHealth-explain;Chedmd
AccemdSM d� -(aaach aoaumenta6on)
Win:
You meet a ya, the
0-1 �v ater ekv
g� c
Qa Ir id i is r
/oar 'S 0 v�
t ,
l A
a
C
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Jam
No. -e
_ Fee r- e
THE COMMONWEALTH OF MASSACHUSETTS Festered in compuW 4�
PUBLIC HEALTH DIVISION-TOWN OF BARNSTABLE,MASSACHUSETTS Yes
OfppCitation for Miopozal Opoem Construction Permit eW7.Prl
Application for a Permit to Construct( )Repair( )Upgrade rv,")'Abandon( ) VEomplete System 0Individual Components
Lmation Address or Lot No. Owner's Name,Address and Tet.No.
Assessor's Mapftmel •" l4K+s�tQ "TrAywf e.k.
Installer's Name.Address,and 7W.No. Designer's Name,Address and Tel.No.
I s ovi s
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 —3 30 gallons per day. Calculated daily flow 3%kCi gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1h
�-00 Type of S.A.S.
Description of Soil 4LZ
Nature,of Repairs or teradons(Answer when applicable) :7_0-9 ( (Sdb
-'C=Q6ejLjAi& X ,_e-aGt�7�i_.j2e—vei�T��,TnOS f /t./ STdr�C.uv .SiOr1'
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 the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has n issued by this
Signed I Date Z7-60
Application Approved by Date
Application Disapproved for the following reasons
Permit No. ZOO—eq/o Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
QCertifitate of compuante ✓
THIS IS TO CERTIFY t the On-site Sewage is osal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by — L
at i ati tl�s OR �(n cons c ordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. led 37? un''d
Installer Designer
The issuance of this pe s all t be c trued as a guarantee that the s fu1►c�ipn�ps gn
Date InspectorA in AM
--------------------
THE COMMONWEALTH OF MASSACHUSETTS
-Z y1,Q� -7 PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal bpstem QConstruttion Permit
Permission is hereby granted to Conwuct( ) epa�y( )Up ( Abandon( )
System located at 0 b"
VA
and as described in the above Application for Disposal System Construction Permit.The appli ant recognizes his/her duty to
comply with Tide 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this
Date: �Y�� �� Approved by �iQ
TOWN OF BARNSTABLE
LOCA110N Q yarbor-AllsSEWAGE #
NMLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACELITY: (ty ) q`N -CG&4I i�Tin C► PrViiV5-k(1(size) J I'X�S'
NO.OF BEDROOMS 0
/,J)
BUILDER OR OWNER �/�
IM / J
PERMPTDATE: COMPLIANCE DATE: 0
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
� Reef �� D��II►�9 .
413,
�,rd
LOCATION OWN OF BtNSTABL�SEWAGE
VILT:AGE Cw► 4eiV7! y I' 11 ASSESSOR'S MAP OT
Hai&T I�NAME&PHONE NO. �h� A (J��/
SEPTIC TANK CAPACITY
LEACHING FACIL=: (type) (siz )
NO. OF BEDROOMS
BUILDER OR OWNER ®�
PERMITDATE: COMPLIANCE DA :
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
95
93-
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No. �� � ..,� Fee
<' q& THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Migool *potem Cow6tructiou Permit s r�1,�-�
Application for a Permit to Construct( )Repair( )Upgrade Abandon( ) ];!�Eomplete System ❑Individual Components
Location Address or Lot No.<6_0 % Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installeer''s Name,Address,and
�Tel..NNo.}-� Designer's Name,Address and Tel.No.
I
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 —3 10 gallons per day. Calculated daily flow ���C"I gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. c
Description of Soil ain 0
Nature of Repairs or Alterations(Answer when applicable) 370-51 fU
iA s&. c"o-,GT Lt [5 -4-C, &iv 50i0e
i�k l Ja�r�✓ el�z��
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by
Signed Date `"?"�✓U
Application Approved by Date "7— �
Application Disapproved for the following reasons
Permit No. 'ZACUO —�L/y0 Date Issued
No. �y / �,. Fee
a THE COMMONWEALT 'RAASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYication for Migw5af *potent Couttruction Vermit
Application for a Permit to Construct( )Repair( )Upgrade(V )Abandon( ) ;!�Complete System O Individual Components
Location Address or Lot No.<?o SI Owner's Name,Address and Tel.No.
(�
Assessor's Map/Parcel ^� C.14....� *.
I
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
i At o—Gw - S-� C
s- `OQ
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 �✓3C7 gallons per day. Calculated daily flow 3 �C( gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. t cctP"C'7 -
Description of Soil S
Nature of Repairs or Alterations(Answer when applicable)
Cz� Cc, 0 AC.T7 LAFt(.-TItiTGe- CAA Lt T J T i- CA- tf
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 provisio itle 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this o al
Signed _ Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. �Z100 U l y O Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY at the On-site Sewage Disposal System Constructed( )Repaired( t )Upgraded(Y )
Abandoned( )by t
at c.6-K..45 RO 2 ( has been constructed in-a cordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. M — /Yo dated _ � zrv-o
Installer Designer /_ t" An M (��A
The issuance of this permit srhall not be construed as a guarantee that the systemfw'11 funct'ion;#-s designee
Date_ / �/� � Inspector �/ i r'�UDt_._._ �.,i i�
VV
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Fee _S
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwiopozar *psstem Comaruction Vermit
Permission is hereby granted to Construct( )> epair`( )U gr de( Abandon( )
System located at t> ;® G"G Gr t,%4 ,
n
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.
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Provided:Construction must be completed within three years of the date of this t.
Date: —Approved J U Approved by --/ � FAG-
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..; 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
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construction permit signed by me dated �3-T7—6 , concerning the
property located at 02r,-T— 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.
t/• 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
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, •/°There are no private wells within 150 feet of the proposed septic system
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.
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There is no increase in flow and/or change in use proposed
• ere 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
icable]
If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed I
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)
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B) G.W. Elevation +the MAX.High G.W.Adjustment./
DIFFERENCE BETWEEN A and B J
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SIGNED~ A DATE:
[Please Sketch propos 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
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TOWN OF BARNSTABLE
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LOCATION —20 PQr6or t l ills Ralqn SEWAGE #
VII-LAGEiS ASSESSOR'S MAP & LOT N
INSTALLER'S NAME&PHONE NO.AJ rr^�5�,�tc -LI499 J
S#
SEPTIC TANK.CAPACITY IS009p Ir
LEACHING FACILITY: (ty ) -�� -CG ��% ��k (size)
NO.OF BEDROOMS 0
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: dS O
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet .
Private Water Supply Well and LeachingFacility.
ty.(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
I, Furnished by
140c-
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bU�II�M/l �9 JY��
IMET Town of Barnstable ,
�s
13nxrtsrns Department of Health, Safety, and Environmental Services
MASS. Public Health Division
1639. ♦0
AT�D"A°�A P.O. Box 534, Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
August 25, 1999
Michael Corrigan
3050 Bristol Street #9P
Santa Ana,CA 92704
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ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 80 Harbor Hills Rd.,Hyannis was inspected on August 25,
1999,by a Massachusetts licensed septic inspector Donna Miorandy of Town of Barnstable.
The inspection of your septic system showed that your system has failed under the guidelines of 1995
TITLE 5 (310 CMR 15.00)due to the following:
• Raw sewage was observed overfloving onto the ground.
You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram of
a proposed system to the Town of Barnstable Health Division Office(Town Hall,367 Main Street,
Hyannis)that will bring the septic system into compliance with 310 CMR 15.00,The State Environmental
Code,Title 5 within(14)fourteen days of receipt of this notice.
You are also directed to bring the septic system into compliance within thirty(30)days of receipt of this
order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic
system to prevent discharge of sewage or effluent into the buildings, onto the surface.of the ground,or in to
surface waters.
Any person aggrieved by any order issued by the.local approval authority may appeal to any court of
competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
WomasMcKean,R.S.,C.H.O.
Agent of the Board of Health
q/hrbrhlls/ord.let. -k.s.
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