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HomeMy WebLinkAbout0025 HUCKINS NECK ROAD - Health 25 Huckins Neck Road Centerville A = 252 011 �'''IIII J�gECYCIEDco IIII UPC 12543 - No. 53LOR `pn.,C��s HASTINGS, MN c a?va-011 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address t Stanley Jones Trust t Owner Owner's Name information is Centerville V/ MA 02632 May 22 2020 required for every page Cityrrown State Zip Code Date of Inspection . 1 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:When A. Inspector Information /�► !ys/S' filling out forms on the computer, use only the tab Patrick T. Sullivan — key to move your Name of Inspector cursor-do not Ready Rooter Excavating use the return Company Name key. PO Box 89 -- Company Address419-1 -- Forestdale MA 02644 Cityrrown State Zip Code 508-509-0802 S112843 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. Passes 2. rl Conditionally Passes 3. Needs Further Evaluation by the Local Approving Authority 4. Fails May 22 2020 Inspecto s Signature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner Owners Name information is Centerville MA 02632 May 22, 2020 required for every page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: Septic tank and D-box installed prior to inspection. 2) 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. Check the box for"yes", "no"or"not de�rrmined" (Y, N, ND)for the following statements. If"not determined," please explain. / The septic tank is metal and over 21Yyears old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltr, tion or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is r placed with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass nspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that t tank is less than 20 years old is available. Y 8 N ND (Explain below): i t5insp.doc•rev.7/26I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner Owner's Name information is required for every Centerville MA 02632 May 22, 2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. Observation of sewage backup or brea out or high static water level in the distribution box due to broken or obstructed pipe(s)or due o a broken, settled or uneven distribution box. System will pass inspection if(with approval of and of Health): broken pipe(s) are repla d 8 Y 8 N 8 ND (Explain below): obstruction is remove ® Y N ND (Explain below): distribution box is veled or replaced Y 8 N ND (Explain below): The system required pumping more than 4 times a ear due to broken or obstructed pipe(s). The system will pass inspection if(with approval of t�oard of Health): broken pipe(s) are replaced �� Y [j N ND (Explain below): obstruction is removed Y N © ND(Explain below): 3) Further Evaluation is Required by the Board of Health: f 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner Owner's Name information is Centerville MA 02632 May 22, 2020 required for every City/Town page. State Zip Code Date of Inspection C. Inspection Summary (cont.) 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 b. System will fail unless the Board f Health(and Public Water Supplier, if any) determines that the system is func oning in a manner that protects the public health, safety and environment: 7 The system has a septic tank find 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 tan and SAS and the SAS is within a Zone 1 of a public water supply. LD The system has a septic to k and SAS and the SAS is within 50 feet of a private water supply well. Ej The system has a septic ank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water s pply well**. Method used to determine istance: **This system passes if the ell water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates bsent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, pro ded that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: / 4) 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner Owner's Name information is Centerville Y MA 02632 May 22 2020 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No 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 %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 water supply. well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. 8 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 2000 gpd- 10,000 gpd. 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. 5) 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° es" or"no"to each of the following, in addition to the questions in Section CA. Yes No the system is ithin 400 feet of a surface drinking water supply 8 the system .s within 200 feet of a tributary to a surface drinking water supply the syste is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner Owners Name information is Centerville MA 02632 May 22, 2020 required for every page. CitylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No 0 8 Pumping information was provided by the owner, occupant, or Board of Health 8 M Were any of the system components pumped out in the previous two weeks? 8 N 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, 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? WIC§tho facility own@f(and occupant§ if dift r@nt from own@r) pf®vid@d 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)] t5insp.doc•rev.7/26QO18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _ 25 Huckins Neck Road Property Address Stanley Jones Trust Owner Owner's Name information is Centerville MA 02632 May 22, 2020 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DE610N flow b@§od on 310 CMR 15.203(for oxort!plo 110 gpd x#of Wdroom@) 330 GPD Description: 0 Number of current residents: Does residence have a garbage grinder's Yes C@ No Does residence have a water treatment unit? Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection Yes No information in this report.) Laundry system inspected? ® Yes No Seasonal use? Yes No 2018= 118 GPD Water meter readings, if available (last 2 years usage(gpd)): 2019= 92 GPD Detail: Sump pump? 8 Yes H No Fall 2019 Last date of occupancy: Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner Owner's Name information is required for every Centerville MA 02632 May 22, 2020 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial 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 Water treatment unit present? Yes No If yes, discharges to: Industrial waste holding tank present? Yes No Non-sanitary waste discharged to t e Title 5 system? 8 Yes 8 No Water meter readings, if availabi Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: No previous records found Was system pumped as part of the inspection? Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner Owner's Name information is Centerville MA 02632 May 22, 2020 required for every page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: E Septic tank, distribution box, soil absorption system 8 Single cesspool 8 Overflow cesspool 8 Privy 8 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)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): Approximate age of all components, date installed (if known) and source of information: Septic tank and D-box installed 05/21/2020. Leach pit installed 09/12/1990. Certificates of Compliance on file at Health Dept Were sewage odors detected when arriving at the site? Yes No 5. Building Sewer(locate on site plan): 2.4 Depth below grade: feet Material of construction: 8 cast iron E 40 PVC other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner Owner's Name informatifor every on is required Centerville MA 02632 May 22, 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 18" Depth below grade: feet Material of construction: concrete 8 metal fiberglass El 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: 10.5'x 5.5' x 5' 1500 gallons Sludge depth: 0 Distance from top of sludge to bottom of outlet tee or baffle 0 0 Scum thickness Distance from top of scum to top of outlet tee or baffle 0 Distance from bottom of scum to bottom of outlet tee or baffle 0 How were dimensions determined? Dip tube and 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.): Inlet and outlet tees in place.Tank installed just prior to inspection. Risers bring covers within 6" of grade Recommend maintenance pumping every two years. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 tCommonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner owner's Name information is t Cenervill MA 02632 Ma y a required for every y 22 2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: concrete metal ['f erglass 8 polyethylene 8 other(explain): Dimensions: Scum thickness Distance from top of scum to/invert, e or baffle Distance from bottom of scuutlet tee or baffle Date of last pumping: Date Comments(on pumping recinlet and outlet tee or baffle condition, structural integrity, liquid levels as related to ounce of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at tim�of inspection) (locate on site plan): Depth below grade: / Material of construction: / ® concrete metal fiberglass 8 polyethylene other(explain): Dimensions: i i Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 25 Huckins Neck Road -" Property Address Stanley Jones Trust Owner Owner's Name information is required for every Centerville MA 02632 May 22, 2020 page. Cityrrown State Zip Code Date of Inspedion D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: Yes No Alarm level: Alarm in working order: Yes No Date of last pumping: Date Comments(condition of alarm and float sw' ches, etc.): "Attach copy of current pumping contract(required). Is copy attached? 8 Yes No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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.): One inlet, one outlet. H-20 DB-3, 3' below grade. Installed just prior to inspection. Riser brings cover within 6" of grade. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner Owner's Name information is required for every Centerville MA 02632 May 22, 2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: Yes No* Alarms in working order: Yes No* Comments(note condition of pump chamber,/codition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: t s x 6"w/ leaching pits number. stone. leaching chambers number leaching galleries number: leaching trenches number, length: [� leaching fields number, dimensions: overflow cesspool number. 8 innovative/alternative system Type/name of technology: t5insp.doc•rev.7t26=18 Title 5 Official Inspection Forth:SubaaFace Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner owner's Name information is Centerville MA 02632 Ma 22, 2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): 18"of liquid in pit at time of inspection. Light high water staining 2.5' below invert. Clean stone visible in side wall. No sign of past hydraulic failure. Riser brings cover within 6" of grade. 12. 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 infl 8 Yes No Comments(note condition soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts I WTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments N, 25 Huckins Neck Road Property Address Stanley Jones Trust Owner owner's Name information is Centerville MA 02632 May 22, 2020 required for every y page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs f hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7126=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts sw Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road Property Address Stanley Jones Trust Owner Owner's Name reformation is required for every Centerville MA 02632 May 22, 2020 City/rown page. State Zip Code Date of Inspection D. System Information (cont.) 14. 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 8 drawing attached separately c� ! 01 0 1> 1 0 J 4,1 t5insp.doc-rev.M262018 Title 5 Official Urspection Forth:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 25 Huckins Neck Road `" Property Address Stanley Jones Trust Owner Owner's Name information is Centerville MA 02632 May 22 2020 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: 0 Check Slope 0 Surface water 0 Check cellar 0 Shallow wells Estimated depth to high ground water: >5 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 0 Observed site(abutting property/observation hole within 150 feet of SAS) 0 Checked with local Board of Health -explain: 0 Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: maps.massgis.state.ma.us/oliver.php You must describe how you established the high ground water elevation: Slope to West drops over 20'to pond. Accessed local ground water contours and topo mapping. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7f2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 3 Commonwealth of Massachusetts WTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - v, 25 Huckins Neck Road —" Property Address Stanley Jones Trust Owner owner's Name information is Centerville MA 02632 May 22 2020 required for every y page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed &Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6 (Checklist)completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 No THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:—s Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS AppYitatiou for Disposal *pstem Construction Permit Application for a Permit to Construct( ) Repair grade( ) Abandon( ) ❑Complete System Pfridividual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. Assessor's Map/Parcel (j \ of �,� ,� es Installer's Name,Address,and Tel.No. 7~C Designer's Name,Address,and Tel.No Type of Building: Dwelling No.of Bedrooms Lot Size sgrfk- Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 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 Nature of Repairs orAlterations(Answer when applicable) 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 Certificate of Compliance has been issued by this of Health. igned Date cS _ Application Approved by """ Date �� 2-tp' Application Disapproved by Date for the following reasons Permit No.- f �— Date Issued Zp L 0 < . Fe No. I / ,^•t- P j b THE COMMONWEALTH OF MASSACHUSETTS Entered mcomputer Ye PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01pplitation for MispoBAY *pstem Construction Permit f Application for a Permit to Construct( ) Repair(�pgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No.' S 4`�,G Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 2 'S U Sn� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: v ^� Dwelling No.of Bedrooms } Lot Size m Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 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 Nature of Repairs or Alterations(Answer when applicable) - A 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 Certificate of Compliance has been issued by this .o d of Health. / igned Date Application Approved by Date Application Disapproved by 41Zr Date for the following reasons Permit No.?���� 7 Z Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(v Upgraded( ) Abandoned( )by — f, ^` at �_ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.2f2 dated Installer Z „ e —� t ,� Designer #bedrooms } pproved design flow 'gpd The issuance of this permit shall of be co strued as a guarantee that the systeemill as • i ned': —^' Date Inspector No. Fee l� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at ,,� ,� . 4S 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. Date�� !:�02 D Approved by - k t [ - _ j 1 � © • t erg THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEA �TH Appliration for Uhipos al Works Tonstrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal System at ... ...... .............................................................•--.................._..----._...._. n- ddres or Lft No. .. eX� - x u_�.1. . ......................................... ... ner Address Installer Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ........................•----------•------------------.-------•----------=-------- ---....................... Design Flow............................................gallons per person per day. Total daily flow__._........._....._........................gallons. WSeptic Tank—Liquid capacity............gallons Length................. Width....__...._..... Diameter---............. Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................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........................ ............ = .. ODescription of Soil----------- ........................................................................................... w ----------------------------------------------------------------------------------------------------------------- - -------------------------- - .......................................... U Nature of Repairs or Alterations—Answer when applicable.________ _____1�f1.,o 0-_-_- -----------------------------------------------------------•------------•--......_........---.................-----------------------•--------------------------------------------------------•••--•---. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL U 5 of the.State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Keen issued by the board of health. Signed--} - ..._�� .• - - --------------- / ...... Date Application Approved BY �.... 00 ---- .-�`_ ...-•-------- Date Application Disapproved for the following reasons:............ ------------------------------------------------------------------------.......................... --------------------•--•---•-----------------•------------------------.-----------------------------•----------------------------------------------------------------------=-------------------•-------- Date PermitNo.................................................. Issued. ��------. .. Dom-- ------••----- --•---•---- THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA w� FE NO-------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 1. '( : . ... oF..�?C. .J..J)'::)rr h, =..........--•••-........---•.... Appliration for Uhijuvii ai Warks Tonutrurtion ramit p Application is hereby made for a Permit to Construct ( ) or Repair (;v�) an Individual Sewage Disposal System t [ < Location-Address or Lot No. • Owner Address Installer Address UType of Building Size Lot............................Sq. feet �-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) n pa-I Other—Type of Building ---------------------------- No, of persons............................ Showers ( ) — Cafeteria ( •. )\ Pa Other fixtures -------------------------------•••-•-•••------= ------------------------ •.................----.......----------------- w Design Flow............................................gallons per person per day. Total daily flow__._......•.._....._........................gallons. W Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other.Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit............_....... Depth to ground water........................ fi, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 9 D Description of Soil...................(.I.L.!{.:.i...t....." 1}'�/i,'( x .I----------------•----....------...---------------------------------...._............................................. w UNature of Repairs or Alterations—Answer when applicable.--___-_ --------a _!..................................................... r Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT112 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed... -----•-- `-•• } _\=?`' ............................... r................................ .. ......._. P Date Application Approved By........,.. 4 �._ s.. .............. Date Application Disapproved for the following reasons:................................................................................................................ --------------------------------------------------------------------------------------------•-----•---•. Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH f. .........4. ................ ...........OF........%...:...................................:..................................... Tnrtif irate of Toutplinnre THIS IS TO-CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired . j / jj- Installer r C ' 1 ' ....!................................................... i � I... . . ! , r I � . has been installed in accordance with the provisions of TITLEE 5 of The State Sanitary Code as described in the ,,application for Disposal Works Construction Permit No...g!p".9zq,7............... dated.--. .................. ` THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � DATE......'`.. .....l••=�--------•------•-------------•------------------- Inspector... = ---....... •. F THE COMMONWEALTH OF MASSACHUSETTS BOARD- OF HEALTH © ).......OF......�,.:�. :.n:.� /` lr%I-J �. �tt No..Q 9 .................................... -__ .---•.-------- FEE.......................... . Disposal Vorkv Tnnstrnrtion ramit Permission is hereby granted -1: 1- ?__fr,�t t`! i`!,�_�if'.J l !`/!° ................................................. to Construct ( 1) or Repair (,0 an Individual Sewage Disposal System -- atNo..::�. = II/!l_ Jli/` J,'.%� ;' �� � 'T< -r_I//�, -1�-/jC- --- ----------------------•••--•.•--.. •--•--•.. . ---- •... l Street as shown on the application for Disposal Works Constructio it No...................... Dated.......................................... . t0! .. � Board Health DATE...... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS TOWN OF BARNSTABLE tt�� LOCATION S i>Q p 2 e P-SSEEWAGE# VILLAGE�,b^�L� ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE SEPTIC TANK CAPACITY LEACHING FACILITY.(type) Lam, �1�, �`,�' (size) "JX e..�/sYe NO.OF BEDROOMS OWNER � ��dw PERMIT DATE: g COMPLIANCE DATE: S Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility r 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) r Feet FURNISHED BY on J 3r ` So A 73 4,1 �.„ �l LOCATION SEWAGE PERMIT NO. 07 " vekkin'C k.ec L leg 0// VILLAGE I N S T A LLER'S NAME i ADDRESS race f,),,,I bPr -4- 3UILDER OR OWNER �7 (� a e S DATE PERMIT ISSUED g _ � DATE COMPLIANCE ISSUED I� r e, ram. New Iwo