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HomeMy WebLinkAbout0351 HUCKINS NECK ROAD - Health f�,351=Huckins Neck Road A.=233-041 Centetville 5 M E A D �%. 2-15"ll L R Ur`C 12534 smead.com • Made in USA ��CYC(Fp iy i r 0 t v r COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS I DEPARTMENT OF ENVIRONMENTAL PROTECTION e � � C w t \y V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 351 Huckins Neck Road Centerville Owner's Name: Ron Wilson Owner's Address: Date of Inspection: 8/16/2007 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 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: �asses Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: �C�� Date: '5 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and tlfei!,approving authority. Notes and Comments Z7,1 CD -'- ii T.t ****This report only describes conditions at the time of inspection and under the conditio s of use-A that" time.This inspection does not address how the system will perform in the future under th same or different conditions of use. �y i r Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 351 Huckins Neck Road Centerville Owner: Ron Wilson Date of Inspection: 8/16/2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sys Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: 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 proved by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for the ollowing statements. If"not determined"please explain. The septic tank is metal and over 20 years old*or the eptic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or t failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as proved by the Board of Health. *A metal septic tank will pass inspection if it is structur y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is avai ble. ND explain: Observation of sewage backup or break o t or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled o uneven distribution box. System will pass inspection if(with approval of Board of Health): b oken pipe(s)are replaced bstruction is removed distribution box is leveled or replaced ND explain: The system required pumpi more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval f the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Y , Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 351 Huckins Neck Road Centerville Owner: Ron Wilson Date of Inspection: 8/16/2007 C. Further Evaluation is Required by the Board of Hea Conditions exist which require further evaluation y the Board of Health in order to determine if the system is failing to protect public health,safety or the enviro ent. 1. System will pass unless Board of Healt etermines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner hich will protect public health,safety and the environment: _Cesspool or privy is within 50 f et of a surface water _Cesspool or privy is within 50 eet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health /within lic Water S pplier,if any)determines that the system is functioning in a manner that protects thealth,s ety and environment: _The system has a septic tank and soil absorm AS)and the SAS is within 100 feet of a surface water supply or tributary to a surface wa . _The system has a septic tank and SAS and t within a Zone 1 of a public water supply. The system has a septic tank and SAS and t within 50 feet of a private water supply well. _The system has a septic tank and SAS and t less than 100 feet but 50 feet or more from a private water supply well". Method used to termine distance "This system passes if the well water ana sis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indi tes that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitra nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of th analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 351 Huckins Neck Road Centerville Owner: Ron Wilson Date of Inspection: 8/16/2007 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to and overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than''/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 _ _,Z- 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. V Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for 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.] AZ(Yes/No)The system fails. I have determined that one or more of the above 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 fa ' y with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the foll ing: (The following criteria apply to large systems in additio to the criteria above) yes no the system is within 400 feet of a surfac drinking water supply the system is within 200 feet of a tri tary to a surface drinking water supply _the system is located in a nitrog sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water sup well If you have answered"yes"to any uestion in Section E the system is considered a significant threat,or answered "yes"in Section D above the lar system has failed.The owner or operator of any large system considered a significant threat under Sectio or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner s ould contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 351 Huckins Neck Road Centerville Owner: Ron Wilson Date of Inspection: 8/16/2007 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No __V-_ 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? Z _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up? _ Was the site inspected for signs of break out? ✓ _ Were all system components,excluding the SAS, located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different than 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 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 351 Huckins Neck Road Centerville Owner: Ron Wilson Date of Inspection: 8/16/2007 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 33 0 c Number of current residents: Does residence have a garbage grinder(yes or no):YLS Is laundry on a separate sewage system(yes or no):0C�[if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): AJCD � �• ,D Water meter readings, if available(last 2 years usage(gpd)): Sump Pump(yes or no): 3 S- P.'t�� Last date of occupancy: C COMMERCIAL/INDUSTRIAL Type of establishment: _ Design flo/escribe): on 310 C 15.203): gpd Basis of dw(seats/ ersons/sq. ft. etc.): Grease tra (yes r no): Industrial ld' tank present(yes or no):_ Non-sanita ischarged to the Title 5 system(yes or no): Water metgs,if available: Last date oncy/use: OTHER( ): GENERAL INFORMATION Pumping Records S (� Source of information: Qs c ,4— �' Was system pumped as part of the inspection(yes or no): ,Jo If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM Septic tank, 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,date installed(if known)and source of information: n �� �v-. •A\La Q �d`V �' v..�cC� <. C. ..��sitativc� b�g� Were sewage odors detected when arriving at the site(yes or no): p Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 351 Huckins Neck Road Centerville Owner: Ron Wilson Date of Inspection: 8/16/2007 BUILDING SEWER(locate on site plan) Depth below grade: a'� Materials of construction:_cast iron�0 PVC other(explain): Distance from private water supply well or suction line: ---T ,rt..,�.�,,d,, u-,e_-S.1 �� r Comments(on condition of joints,venting,evidence of leakage a c.): SEPTIC TANK: (locate on site plan) Depth below grade:t," Material of construction:-V'concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: (" q Distance from the top of sludge to bottom of outlet tee or baffle: Scum thickness: I( a h Distance from top of scum to top of outlet tee or baffle: + Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determinefi—\,sne -t �p Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): ` n GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_ tal_fiberglass___polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to toJdations, tee or baffle: Distance from bottom of scum tf outlet tee or baffle: Date of last pumping: Comments(on pumping recomm inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evideage,etc.): f Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 351 Huckins Neck Road Centerville Owner: Ron Wilson Date of Inspection: 8/16/2007 TIGHT or HOLDING TANK: 76talfiberglass umped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete _polyethylene_other(explain): Dimensions: Capacity: yAl= s Design Flow: s/day Alarm present(yes or Alarm level: g order(yes or no): Date of last pumping: Comments(condition switches,etc.): DISTRIBUTION BOX: (if prese must be opened)(locate on site plan) Depth of liquid level above outlet in ert: Comments(not if box is level and istribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): PUMP CHAMBER: locate on site plan) Pumps in working order(yes or no): S Alarms in working order(yes or no): 5 Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): C " S Q f Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 351 Huckins Neck Road Centerville Owner: Ron Wilson Date of Inspection: 8/16/2007 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: _k,t-leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): CESSPOOLS: (cesspool must be pum d 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 in ow(yes or no): Comments(note condition f soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of s ' ,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 351 Huckins Neck Road Centerville Owner: Ron Wilson Date of Inspection: 8/16/2007 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. w� 6—t- 5 o � se( Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 351 Huckins Neck Road Centerville Owner: Ron Wilson Date of Inspection: 8/16/2007 SITE EXAM Slope V— Surface water+f Check cellar Shallow wells Estimated depth to ground water 3 feet Please indicate(check)all methods used to determine the high ground water elevation: ,/ Obtained from system design plans on record—If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _LZAccessed USGS database-explain: a,,,� You must describe how you established the high ground water elevation: TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION - a33 Map Parcel 04 Application # 0 6 1 Health Division Date Issued Conservation Division ,!� Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address �i �'� +�5 kdc y, ob Village Owner 13,zoca 1�'/{4 oiAp—I Address Telephone �0- a�� -3�r3 A4/ad; Permit Request w 2C4 zvd "q if xg —r 4 o �. AS f2k 2,wta)5 T Square feet: 1 st floor: existing 22�e�proposed 2nd floor: existing proposed Total new Zoning District �, 1 Flood Plain Groundwater Overlay,©n e op ate? Project Valuation Construction Type Lot Size 24,1ia t S Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: J. Yes ❑ No On Old King's Highway: ❑Yes �o Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) i A J ��`Basement Unfinished Area (sq.ft) Y Number of Baths: Full: existing new Half: existing b4 new Number of Bedrooms: A existing _new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: I Yes, ❑ No Fir aces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garu, l.� ;.:i: ting new size Pool: ❑ existing ❑ new size — Barn: ❑existing ❑ new size_ Attached garage: ❑ , :sting ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑ Yes dNo If yes, site plan review# Current Use 7LE FA�Paj G4-1- Proposed Use DQ)9-4-w n APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name f3aad p, WAA ern Telephone Number Address )/A/ �i���� Pr License # Home Improvement Co ntractor ontractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING.FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE G No.. ....._L3 Fas.. ..:........... THE COMMONWEALTH OF MASSACHUSETTS � � BOARD OF HEALTH TOWN OF BARNSTABLE rr Uiripnial Wnrk.6 Tomitrnrtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: L n-Adflress or Lot No. tier Address ... ....... ...... -- ------ ------------------------------------------------------------------------------------------•-•..--- taper Address Q (Type of Building Size Lot............................Sq. feet aDwelling— No. of Bedrooms-----3------ ---------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons-----.--..---------_------- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ----------------------------------------•----------•--------- W 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. l................minutes per inch Depth of Test Pit...........--....... Depth to ground water........................ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a ---------------------------------------------------•-----...------.........-----•---................................................... ------------- 0 Description of Soil.................................................................................................................................................. ------...--- x U .......................••-•--------•----------------•---------------------••-•-....-----------------------•-------------------------------------•----------------...................................... W -------------------------------------------------------------------------------------------.................... U Nature of Repairs or Alterations—Answer when applicable.------ -•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia e has been issued b he board of health. Signed ............ ...... .... - -------- . ........................... � � Dare ApplicationApproved By .............. .. .-•= ..----------......---------.... ..... ............................ ..$..-.' , Dace - Application Disapproved for the following reasons: .......... ........ . ... .................................. ..................-- -- ........................ ................................................................. . . .... ............................ ... ..................................................................................... ........................................ U Dare PermitNo. ....... ......(_� ........................... Issued ....................................................................... Dare tr, ��ti-_•.--�-..�.�• �--�- .-.- . .-_. ..�ty___ � ....._-ti-w•• -._.-.�_...�.... ...-_.,...s. r. ti. ...- -, �.._. .�.... _ .-.....n..-•_ _� cam.:--Y-....., -- ^'�._•.+;..-w tJ,:+�.a'�.:a...y*�.;i THE COMMONWEALTH OF MASSACHUSETTS� BOARD OF HEALTH ' TOWN OF BARNSTABLE 14 7 .2 ppliration for Di!ipmial Workii Cnowitrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at:: .....--••--••-?- j...&(_'�---/,, . .............................................•---......----...._....-------------•---....----•-... L 9ress or Lot No. 1=0:;hUW ........................ -•-----•----•--.......----••----------^------•-----•-----.....---.......--•------................ W -ner Address t taller Address dT. e Building Size Lot............................Sq. feet �-. Dwelling— No. of Bedrooms-----j---------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building -.--_-.--_-__---_---._-___ No. of persons______________________--.-. Showers ( ) — Cafeteria ( ) dOther fixtures ..................................................................................................................................................... Design Flow_.........................................gallons per person per day. Total daily flow-------------------------------------_......gallons. W Septic Tank—Liquid capacity............gallons Length--A.----__.___. 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ri .............................•.. -••------••----........---•---•----..._............---•-•------....--•---•--..................._.............. --••--- 0 Description of Soil.............................................................................................----------------------.._..--------------•---...... ....... U W ----•--- ............ n......_ ..................... U Nature of Repairs or Alterations—Answer when applicable.------------------------ ---i% ._._ ,�..__Ct �._...______. -•-•-------------••••-----•---•-•------.......-•---•---•-•-•--••-----------•-•-•-•-•-•----•-----••-.....-••-•-•---• Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the ` stem Y in�o erasion P <until a Certificate � s �CoaPNance has be.... issued b he board of health. Sand� - .................... Date Application Approved By .............. .<.-,`5.......-.......................- -.... ........................ ..g....... .3 Date Application Disapproved for the following reasons: .... ........................................................ ........................................ . . ...... ........ ................................................................................ ................. ..... ... . .. .. ................................................. ........................................ u Da Permit No. 9�j '- -t-_ �.......................... Issued ........-.......-.-.... . ................ Dare � THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�Erttf rate of C�omialiance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (^ -) ..................... 'c_ .by ti�.-� ... ...-.... ................ ... .........-..........-........-............................................... (,� - i�,t:�ilbr at ..............................3. �- -(y�� .-... Q �._ .lie. :. ...... n....,...? p. n.. ........................ �� ..... . has been installed in accordance with the provisions of TITLE 5 oyL The State Environmental Code as described in the application for Disposal Works Construction Permit No. -------1 � Y/, .7_ dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................. ...-.. ....�9 ----------.-....---------- Inspector -- ............. . .:............... .-... ............ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No....... ..-... � -- FEE ................... . �• .� .. �i��r,a�tt1 �r�� �vra��tr�stilan �rrutit y Permission is hereby ,granted------------ to Construct ( ) or Repair ( ) an I�idual Sewage Dispo�al System atNo. VA -- `t Y ..................................................... ...f. street as shown on the application for Disposal Works Construction Permit o._�Y-.V7 Dated........................................... ------..---•.-----------� : �- ..... DATE_ •`s J v Board of Health FORM 36508 HOBBS&WARREN.INC..PUBLISHERS r� TOWN OF BARNSTABLE LOCATION 337k —\c���`.�j 1��c>� o SEWAGE# Y3 7 VILLAGEASSESSOR'S MAP&PARCELS- C�4{ INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY \ X)cp ` �A - QC) LEACHING FACILITY.(type) 3..,-!P-, (size) NO.OF BEDROOMS OWNER PERMIT DATE: Wa 3 49 a COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY ,� he z,r ,,cam•...—" <s� k��s-e-� t%vc�`h r TOWN OF BARNSTABLE LOCATIONP A 4:gz2s SEWAGE # 92'11-97 VILLAGE j ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. dgbg SEPTIC TANK CAPACITY (owrloz LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER e DATE PERMIT ISSUED: �f,io DATE COMPLIANCE ISSUED: VARIANCE-GRANTED: Yes Vo f f. 0o e �1 60 u3 �a 0 . oa tee ' en v 4 j �[ S' zo cqg TOWN OF BARNSTABLE LO��ATION SEWAGE # JVILLAGE ASSESSOR'S MAP Cz LOTc�3- 0y/ INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY ,1621a d LEACHING FACILITY:(type) 4/ �) (sue) 6X/0 NO. OF BEbROOMS PRIVATE WELL O PUBLIC WATER BUILDER OR OWNER ,CO/L) �GSD� DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No ,,. �p�T Q/� �/Ca�S� E i �� _, �e G �` _/ ` c C-0 6( In : . . - q. � t. '.:. •• ' . - Breakfast gtdrerr . . � .. .• .' .. •' •, Ba Bed } Entry 0 :-M.sea'. �. O Batt, ■ o- r �OC _ _ O Z cti living O y'_� : Bed Dtrilng : �'• ■ �.� LO Q .pop:,. . '' � � - '•- ..- : � - - Fatuity'� . . - ... '. : ,• .. ft" de0dwards. . AR'a HI TE cTS tAiting Floor Plan .• rv�ozp/gv.o-ss.a .. - -.:. - •v a .1 SCALE 1/4' — .�•�`:•