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Home My WebLink About0015 JAMES OTIS ROAD - Health 15 JAMES OTIS ROAD, CENTERVILLE A= 171 162 n � CQfCYCIFO �11LGa p 2� °ym UPC 12543 o.53LOR ',�srro�a PASTMOS,CAN Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments CLAM 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is required for Centerville MA 02632 May 31, 2011 ------ --------_ --- -- every page. City/Town State Zip Code Date of Inspection 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: A. General.Information When filling out forms on the computer,use 1. Inspector:only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name r� 189 Cammett Road Company Address Marstons Mills _ _ MA 02648 City/Town State Zip Code 508-428-1779 _ _ S112855_ Telephone Number License Number B. Certification 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: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority C"'' a May 31, 2011 Job# 11, 4 L= r_:) V1n _e-=c::t:�ors Si natu a 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 is a shared systeor has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit to report to the appropriate regional office of the DEP. The original should be sent to tht systemQ ner o and copies sent to the buyer, if applicable, and the approving authority. 1 tV ****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. t5ins•11110 Title 5 Official Inspection Form.Subsurface SewVjs,,sal System• age 1 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is required for Centerville MA 02632 May31, 2011 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310.CMP, 15.303 orin 310 CNAIR 15.36-4 exist. Any failf-,re criferia not evaluated are indicated below. Comments: Tank is not in need of pumping at this time, leaching system had no standing water or signs of surcharge. B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 2 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 James Otis Road Property Address Beverly Bennett _ Owner Owner's Name information is Centerville MA 02632 May 31, 2011 required for ------- --- - every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): I ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ 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. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 151ns•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is Centerville MA 02632 May 31, 2011 required for every page. City[Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for 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 must be attached to this form. 3. Other: 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 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is required for Centerville MA 02632 May 31, 2011 - every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 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 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. L,5,ns1I70 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 James Otis Road Property Address Beverly Bennett -- Owner Owner's Name information is required for Centerville MA 02632 May 31, 2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 -- Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 l5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 c Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is Centerville MA 02632 May 31 2011 required for every page. City/Town State Zip Code Date of Inspection D. System Information Description: 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Unknown Date 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 Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: 15ins•11110 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is Centerville MA 02632 May 31, 2011 required for — every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below). General Information Pumping Records: Source of information: Tank pumped 6/2003 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) 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). t5ins•11/10 Title 5 Official Inspection Farm.Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is required for Centerville MA 02632 May 31, 2011 --.-- - -- every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Leaching system installed 11/6/98. Tank is original. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): — Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 16" feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ 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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 2- l5ins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 James Otis Road Property Address ------- --------_—_---- -- — Beverly Bennett Owner Owner's Name information is y required for Centerville MA 02632 May 31, 2011 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 — Scum thickness Trace Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" _— How were dimensions determined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Baffles were intact and clear, liquid level was found at bottom of outlet invert. Tank is not in need of pumping at this time. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle -- ------ Distance from bottom of scum to bottom of outlet tee or baffle — — Date of last pumping: Date l5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is Centerville MA 02632 May 31, 2011 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Capacity.. gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No 0 Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is Centerville MA 02632 May 31, 2011 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): No solids or high stains present. liquid level was found at bottom of outlet pipe. Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is Centerville MA _ 02632 _ May 31, 2011 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators. ❑ 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.): Infiltrators were found empty with no evidence of surcharge. Cesspools (cesspool mist 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 inflow ❑ Yes ❑ No t5ins•1 MO Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is Centerville MA 02632 May 31, 2011 required for Y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 15ins.11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System.Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 15 James Otis Road _..... Property Address Beverly Bennett ---- - - -. - - ---- - --------.__.._. Owner Owner's Name information is Centerville MA 02632 Ma 31, 2011 requiredfor -_..._-....__...._._.........._..... .. ..._..... .. ----- —y---- --- every page. City/Town _ __— State Zip Code Date of Inspection D. System Information (cont.) 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 ❑ drawing attached separately 47 31 41 49 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 15 James Otis Road Property Address Beverly Bennett Owner Owner's Name information is Centerville MA_ 02632 May ,31 2011 required for _ every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15+ 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 ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: ❑ Checked with local excavators, installers - (attach documentation) ® Accessed USGS database - explain: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 30 and topo map shows property at el. 50. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 15 James Otis Road _ Property Address Beverly Bennett _ Owner Owner's Name information is Y required for Centerville MA 02632 May 31, 2011 every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater Z Sketch of Sewage Disposal System either drawn on page 15 or attached.in separate file ` t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 r V o c ... _ TOWN OF BARNSTABLE ........ .._. LOCATION VILLAGE C�e q1 C r-u (1 SEWAGE # ASSESSOR'S MAP & LOT INSTALLER'S NAM1r&PHONE N( . SEPTIC TANK CAPACITY ) 00 C LEACHING FACIl.1'','Y: (type) I ►'1.`�i ( Q,/ (size) NO.OF BEDROOMS,. BUILDER OR OWNER PERMTTDATE: COMPLIANCE:DATE: —Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of. eac faci ' Furnished by Feet No. Fee r 5t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Mi-4poeal *pztem Cott.5truction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot Ngg. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 1' 7 tot, Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. l�f c4 er 5 w C{ !/zdjlS . Type of Building: Dwelling No.of Bedrooms _3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1000 Q Type of S.A.S. Description of Soil Nature of,Repairs or Alterations(Answer when applicable) 4( �r� - c(7`r4z 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 is s e by thi o ealth. Signed "' Date rtl Application Approved by Nils Date 1, Application Disapproved for th following reasons Permit No. 71 Date Issued _ No. 28 — I ` _ Fee _ THE COMMONWEALTH'OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS /� 2pprication for 33i-4pool 6pgtem Construction 3dermit 76—7'poication for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot Ng. � S� Owner's Name,Address and Tel.No. di Assessor's Map/Parcel ( 7 1 - 1 1,2 Installer's Name,Address,and Tel. O 2 Designer's Name,Address and Tel.No. M I 1,/e L ecG,'' /lf,�c4 er ��,WYV 5 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 D gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of�Re airs or Alterations(Answer when ap licable) Date last inspected: Agreement: 'I 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 iss e by thi o ealth. Signed _ Date Application Approved by %. �" Date 1 w — �g Application Disapproved for th following reasons Permit No. — 7 / Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( .�,e)Upgraded( ) Abandoned( )by lac, at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. g--7t dated Installer Designer The issuance of this per/nit s all jot be construed as a guarantee that the system will function as designed. Date Inspector " r No. -------------------------Fee `7 G) THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS xi6pogar *pg;tem Construction permit Permission is hereby granted to Construct( )Repair(5.4 Upgrade( )Abandon( ) System located at is- ("o ,_ + 0,0 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: L Approved by— f V 1 10/9/97 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 ENGINEERED PLANS) hereby certify that the application for disposal works construction permit signed by me dated r< , concerning the property located at f �- S meets all of the following criteria: • There are no wetlands located within 100 feet of the proposed leaching facility • There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. • If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will=be located less than fourteen(14) feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Elevation(according to Health Division well map) �d SIGNED : DATE: LICENSED S PTIC SYSTEM INSTALLER IN a TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert 1 �� iN�� n � i �� t ,��: TOWN OF BARNSTABLE LOCATION �1 _I 5 J��s CT►Cc--., 2S SE"d�E# (\S reel ton 1.-VILLAGE y1fi-e rV;ILQ ASSESSOR'S MAP&PARCEL NAME&PHONE NOS r:Ll� C�ti'1►�,f 1 I. I��^ 1'1'1°i SEPTIC TANK CAPACITY kCX)O C'p, U LEACHING FACILITY: rt ATvrs (size) NO.OF BEDROOMS OWNER Y\ �- PERMIT DATE: CDATEh�;� 31( 11 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 wet& exist within 300 feet of leaching facility) Feet FURNISHED BY f f !�l•F f r r`•f Div fvf ? f f fvf`J F J`/ ? F J`JVJ`r ' 4+4+• t 414�4 4 4 \ 4 4 4 t 4 4 \ k 4 4 4 r r ♦ r f J ♦`? f ? ?` ♦ r J4r ♦�r� I•J`r`r f� �r r r ♦ J r t \ • 1 \ 4 \ v t k 'v \fv 4 \ v \ • v v • ' - f ♦ r'r r f f I r r' r f Iv r J` `?M1f ♦ J_r J`?vf vr'- ♦-I.4I . - - 1 4 t t 4 • t 4 4 • 4 � 4 t 4 'v v. k •. • 4 t • �. r ♦ r F F F r ♦ r J I ♦ r r r f J ♦ J r J r r r F r ' • t 4 4 • t 4 4 4 4 t • k 4 4 t 4 4 4 • t \ 4 _ J r r I J r f r r ♦ r r r ♦ I r r r r r''f ♦ ♦ r f r .. 4 • • t t 4 k \ 4 • • 4 t \ • • • t t • • t t 4 f I r l f f f I ? ♦ i r ! I I r I ? f f f f J`f r f f f r t • t t t t • t t t • t t t t t • • 4 t t 4 4 4 • • t 4-• 4 • . f ♦ r I ♦ r r r r F r F r r ♦ r f r ♦ Ir r r r r I r f .J I..r - . t t 4 4 4 1 • 4 4 t t t 4 v. 4 4 t t k 4 t t t t 4 • 4 • \ • t - - r i J J ♦ ♦ r ? • J ♦ r r r r I r f r ♦ ♦ r r ♦ ♦ r r r r I ♦ 4 '. 4 4 • t 4 \ • \ • • 4 \ • 4 \ 4 4 v. • v • \ t k • • \ 4 47 31 f, 41 _ 49 TOWN OF BARNSTABLE I;CX�ATION �t �� 1 _ SEWAGE # VILLAGE_ f p ASSESSOR'S MAP & LOT'� INSTALLER'S NAME&PHONE NO. � 'r 2 2 SEPTIC TANK CAPAcn-Y. I 000 LEACHING FACII.T''Y: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE:: _ 6 COMPLIANCE DATE: l I 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 Facili (If any wetlands exist within 300 feet of a faci ' Feet Furnished by ti. �A C No. ....... ........ FiLic.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD QF HE LTH '.---...........OF....... I . ...... .......................................................... for Elhiposal Works Tonstrurtion runfit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal HE Sys �6 t ayt 7-67 ....... ....... ........ . ........ .... ...... ........... Lo -A dress r'Lot NV......................................... ... . ............................. ..................... ..... ...... . ................................... 00 nor_, Address .... ......... .... Installer Address s ............................... Type of Building Size Lot./A-f..40. ......Sq. feet U Dwelling—No. of Bedrooms-3----------------------------------Expansion Attic Garbage Grinder (ILI Other—Type of Building ............................ No. of persons__..._...._.......__._.._.__ Showers Cafeteria Other fixtures ....................................................................................................................................................... Design Flow..... ...................gallons per person per day. Total daily flow........._:_ ............................gallons. P4 Septic Tank—Liquid capacitAe—_"_g-'allons Length................ Width._-............. Diameter______.......... Depth.............._. Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.__ .. Diameter.................... Depth below inlet.................... Total leaching area..................sq. f t. 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.....................__. Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground water...................._..- .........................................................................................o...........................................................I......... 0 Description of Soil........................................................................................................................................................................ X U ........................................................................................................................................................................................................ ...................................................................................................................................................................................................... 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 TLITiLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'sued by the boa of health. .......... __4.......................................... .. .. ..........S ... .. .. ... .. Application Approved By................. ...............................................................................1 Z;7�................. wing reas ons:............................................................................................Date............... Application Disapproved fort 1 ......................................................................................................................................................................................................... Date PermitNo.......................................................... Issued............... Date A& No.k-.,t r. [v ........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF t t t',r'. A ApplirFatiou for Dhipv i al Work.6 Tomitrurtitun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: Lo�c�a6gn Address /71 or Lot No. ................................ .. I? .. 1. / r . /. ............................... �•r.. t_. tJ.�F.L.._...J!:�t.:... f r .a Omer Address W 'ty f r Installer Address QType of Building Size Lot_ . . .�:..._..Sq. feet Dwelling—No. of Bedrooms. ......................................Expansion Attic ( l) wy Garbage Grinder aOther—Type of Building ___________________________• No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures ------------------------------------•---------•--•...........----•-.....__.............._.....--..................................................... - WDesign Flow......_r ...... .......................gallons per person per day. Total daily flow.._.........._...._:..................gallons. WSeptic Tank—Liquid capacity`:_`:.t: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........................................ a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ rX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -••-••'---••-----------•--••---•....................•---'-'---""'.............--•--'-•--------............................................. --------•------- 0 Description of Soil........................................................................................................................................................................ x U •--•------•----.....---••----•.........................'-------.....------.........•---------•'--•--....------...................'--••'•---......----•---........-'---......._......•--•-•"------------ W VNature 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 TIT1L 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. Application Approved B -------- --- Date Application Disapproved for th 1 wing reasons:---.......•---•---••--•--•-•---•---•'---••-----•--•---.....--•-••--•..........................•"'-............ ------•---•-••-••.....'••-"................•'•••-'•---•-•--•----••----•-------..._..._......-------'-•-•.......--•------------•-'----•------••-•----•-•---------••---•-- ...._....-"'-'--•"'"•-•-••- Date PermitNo......................................................... Issued-................--•---•--.............................. Date'' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................O F..................................................................................... Trrtifiratr of Bunt plittnrr Tl 0 CERTIFY, That the Individual Sew, e Disposal System constructed ( or Repaired ( ) at by. .......� ..-- ......................'-----------------------......-----------..............--------....._---•-' has been installed in actor cc with the provisions of TITLE 5 o State Sanitary Code as described in the application for Disposal N, or ors Construction Permit No..__ ''_ _......... dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. � 8/9y 2.DATE...................... -.--•-- --- ----..... Inspector " .............................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 'n OF.......................... No.,I............ .. FEE ......... iu�ruku Tonu#rurtion rrmit Permission is h granted•--•2V�• ..=".....-'-•--•-----•' ---- _•-•-•...............•---••..................•- to Construct or epair (// )/anI ' ual Sewag 1s ystemat No.. -- --- frJ_ .. .. .!..... --• ' ... --- ---------------------'------------•-......--------•----- •---..-•-- Streetas shown on the application for Disorks Construction Permit No.__ �-�'' Dated.......................................... ..� /z �y ®1 Board of Health DATE........................................................- ..................... FORM 1255 A. M. SULKIN, INC., BOSTON I ,IQGLCC FAMILY - 3 BcugooM WO PGAIiBAGE 6Q'wDE2 �-� / CZ8 ..' oialLY Ft-OW AlItoX 3 - 33oG.PD, Ioa vr' 5EPT%G TAtiK = 33oxISo'/• = -49%&.PC) USE- l000 GAL. / I-• `F v5E ►ao 0 GAS_. , Dt5Po5�►- PIT 5►DC-WALL AP-SA, erR '. . . . .�.�.� TO REAt o , , . �pfa ► gOT M A � 6 F - 5� S.F X 1� 0 � 5p G.Pca• � 1 , �.� -TO-CA U>E.•SIGN s ,4.25 G.P. D. p p t.l i -TOTAL DA►►-Y F*•-�v,! = 33o G,PD, • o . 7*^49. 0 PE2coLATION RATE ; 1''IN ZMIN ol`Lr=55 rev v z OF �) RI HARD tiG o DA.IR �� "jj' r, F +-p.± �n � C. cn A. a z THUUN M I SI OLa L7 i � .' o BAXTER V" cp> No. 29976 c; M "" I" ' po 4ND,SUR��{0 Fs . NALE�� 5019 TEST P-Z�gl� �G;S/ r1r TOP FWD i� EL, 57 Y� INv. s� loot/ INJ• Sy�S GA►-• < S✓9SDIt. D►ST• c,CG DUX PT► INV. INV. w tI r u s5�Z, s �/ ►'/3/4.1 /z I WASKGD i,; C.E wr I F l c o P42UFI1. 1.o44'> ►oN CEt.rIE7_VI( .;-a ELI _ 44 /3 No 5CA•LE 5c_ 1►1 D Df''T-� 4-23-B- I �•- p L_p.I•� R E P E 2.E N GE•G E IzT t Y THAT -T\4E t"Dv�DA1'lo,4 SKo wN HEREON COMPt45 YJITH"THE S 1 o1rL1t-1 E-- - 7 6-7 AUK SETe0l.GK 6G7vtR.�MEN1'� F �µ� -To w►,A O F J3,arNT A►3c AND I S I.ICrC LOGA•TED -WITNI .r 6 FLOOD PLv.IN �L • �L, 30�1i. ;"'PG: ?� : DA'T Ir 4-Z'3-9k� B A)(T E iZ. C. QE6 I�Z V-: QG"D'I.AN D s u 7-Y EY�es -TUtS PLAN 15 KlorT 4n5c o ob AW OST A E2-VILL (>JS-r?-uMENT 5v9-vc-Y �'TNE !_�I-F.SETS 5uoutl f No-T DE 'VSEDTCO DETER/11\i)-I L•c-T -It-1F--j APP�-ICA►-I I_ SMALL" L-Q C A T ION" I 16 SEWAGE PERMIT NO. L n7 a10? CZglnes oTi 6 je(13�� VILLAGE GkA.)TO? MST ALL ER'S NAME & ADDRESS R . 3. ook 9 ire U I L D E R OR OWNER i4''k&,Aj (."4 _ k`DATE PERMIT ISSUED 43 DATE COMPLIANCE ISSUED -zle e �'�-I� F -\ y `{\ F a� . a� ��