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HomeMy WebLinkAbout0016 LONG POND CIRCLE - Health 16 Long Pond-Circle Centerville P 14pECYCtEpcO NU ' ��HASTINGS, MN Commonwealth of Massachusetts M4# Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 16 Long Pond Cir Property Address f•• Philip Bateman . Owner Owner's Name , information is required for every Centerville MA 02632 4-1-16 3 page. City/Town State Zip Code Date of Inspection �. C..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. A. General Information s1 �Js�l 1. Inspector: Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-508-495-0905 S13971 Telephone Number License Number B. Certification ^ I certify that I have personally inspected the sewage disposal system at this address and that the E 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 - 4-1-16 Inspector'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 is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 0 Commonwealth of Massachusetts ' Title 5 official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments, 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is requ. 'd for every Centerville MA 02632 4-1-16 I page., City/Town State Zip Code Date of Inspection r fMe 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 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: System is in good working order with no sign of failure. 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): t5ins-W 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Flame information is required for every Centerville MA 02632 4-1-16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): ty , ❑ The system required pumping more than 4 times a yeardue 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 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 r4 - . 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. t5ins-3113 Title 5 Official Inspection Forth: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 j M 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 , 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 stem received normal flows in the previous two week period? ❑ ® Y P 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? P 4 P 9 . ® ❑ 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): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments' �M 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No 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 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? I ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 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 M 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 page. City/Town 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: N/A Was system pumped as part of the inspection? ❑ Yes ® No If um,es volume pumped: ,y P P 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/Altemative 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 ` Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 16 Long Pond Cir ' Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1990's Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20"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.): Good condition. Septic Tank(locate on site plan): Depth below grade: 14"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: 1550 gal Sludge depth: 12" t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 page. City/Town 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 20" Scum thickness 1" 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 15" How were dimensions determined? Tape Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank is in good condition with baffles installed and no sign of leakage. 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 t5ins•3/13 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 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 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): I Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No 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 t5ins-3113 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 M 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 page. City/Town 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.): Good condition with water at working level and no sign of back-up from pit. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 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 M 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) . 'Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ 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.): Leach pit in good condition and empty at inspection with stain line at 18"off bottom of pit. 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 inflow ❑ Yes ❑ No t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments . 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 ' 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.): t5ins-3/13 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 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 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 >�G �� JA 1� ) it J i t t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 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: 12' 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: You must describe how you established the high ground water elevation: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 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 16 Long Pond Cir Property Address Philip Bateman Owner Owner's Name information is required for every Centerville MA 02632 4-1-16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 0 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 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TON—M OF BARNSTABLE LOCAITON: - POrt �'�" SEWAGE# VII:L:AGE C� T Iry f l e ASS8SSOWS*�i1Af'& A� fg NA &PHONE O SEM.-C-TAlgK CAPACTCX � LF ,CfIlNG f?�iCfL' 'f�.tt7lp'°) i tsue) N©. FBBT3ff�OC3MS A bUILDER OR{3 1�TER O i�4h�CF: f?1TE PBTD261TB._ NUL c7s7. Separauon Distanee=Betvr;, �e 1�Iaximum Ad1astecl'Granndvuater Table to the Bottom of�achtng FaGifity Fee Private Water SUpOIY e11 d Lac n;Frey any it i s extst uir sits or:.witlun 2t;£3 feet of ieng fhcuky j Edje;of bl and and beaching Facility(ff airy wetlands cps with�a 3ftfl feet €leaching f; ) Furnished by G � LOJ OF n- OL 6 1 r �No. � r Fee. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2ppitration for 33igozal by.5tem Cougtruction Verrait Application for a Permit to Construct( . )Repair(X)Upgrade(X)Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. f , �t7���1�, � L�� Owner's Name,Address and Tel.No. C C ►%A--V e d-t'ii�� VN,\� C • a� o�ta�4ti- �-i I zl Assessor'sMap/Parcel i �- 1R act —f a1-rL to \L 4 0 n a 5 2, i;i IAA.A a Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. J C , t4o n� c rdl Ll I I Is M A► i Type of Building: Dwelling No.of Bedrooms _ Lot Size 3`7 jP/U sq.ft. Garbage Grinder( ) Other Type of Building iXta,,,r- No.of Persons s�2 Showers(,I ) Cafeteria( ) Other Fixtures Design.now 3 30 gallons per day. Calculated daily flow 4 to gallons. Plan Date 1 O 1:2 /a 4 Number of sheets I Revision Date Title 1�p poS^p c,- , C..z Size of Septic Tank j�S Oe0 Type of S.A. . Description of Soil Natu of Repairs or Alterations(Answer when applicable) CICA.SrrviL E U . Date last inspected:T �D 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 u y t s an d bd qjf Health. Sig ne 0 Date Application Approved by Date Application Disapproved for the following rea n "'^ i Date Issued D : - y No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISIONS TOWN)OF BARNSTABLE, MASSACHUSETTS Application for a PennitAt.a'pjkt R )Repair( )Upgrade( )A n e� l`Cor MtfSys ] yidual Components Lo�C tip AsVot4liSt No. O)vV_rrSai�e,,Vdresr t 1 aIau F al�c•Q 21D 4'sse�s€QFjs 'Bc�l�el{�l�1 �S A eQ its: PA V `t 1 MR Installer's Name,Address,and Tel.No. Design�Id�TVddress and Tel.No. ko-N elk c7 / Type of Building: �,, Dwelling No'p3fledrooms Lot Size sq.ft. 1v t'garbage Grinder( ) Other / d Al e oliuilding o-of Per4ons Sho ers( ) Cafete Other Fi � sa pQ�—C7G a n — £e- I'L �S t� 1 4 P�D Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Descrpption of Soil 1 9s.S am L. c /,chi �,� • off! �5� £yc�s��� �o�ch pL- Nature of Repairs or Al`/ tiZ441swer when applicable) t � Date last inspected: Agreement: 'V The undersigned agr es_ P/e "e&,c�,'�strdc.tion a m nteuirm 5', f th�forees�ed on-site sewagv�l m accordance with the r. 'sio of itle/5 of theEn�P l df�� � �`�p vtronrnettal Co e and not.o�place the'system in operata)C/ rti i- cate of Compliance has been issued by this Bo6k Health. Signed Da,e Application AppAe,d to for the folf8wing Y sons Permit No. Date Issued 1, r v ' ——— THE COMMONWEALTH OF MASSACHUSETTS —c A hBA?NSTABLE. MASSACHUSETTS Y 4ift "" ate of C h 5 RTIFY, that the On-site Sewage Disposal System=Tu ct#- 1114T epatred ) gra ed�- ,T4V Abandoned( )by J at i �.t,� �' / k s be ms rt uct i€I accordance with the provisions of Title 5 and the for Disposal System Construction Permit�INo. - w dated ,G Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date0.(!oni. .. fi), Inspector --------------------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS p { P �LIATH1►VdSyN - Bl�I� LE,I. ��V 1 � �.. E Migposml *pgtem Construction permit Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( ) System located at _. and as described i" ap e/I cation for Disposal System Constructio e its is cog ' es his/her duty to comply with Title an the�fo'llowing local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. r« TOWN OF BARNSTABLE �L LOCATION 11o' Loner /9o-61 SEWAGE # VILLAG ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. C, 194 M9 SEPTIC TANK CAPACITY ,LEACHING FACILITY: (type) (size) �'O:O NO.OF BEDROOMS 3 �y3UILDER OR OWNE PERMITDATE: /'0-/`� O f COMPLIANCE DATE: y 'L 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 Ac-, of '�� Gam✓ '� , a ti 'Poe, . TOWN OF BARNSTABLE � LOCATION // /"�'• /�o"� C,'r�/� SEWAGE# VII.LAGE C?nT��v�./�� ASSESSOR'S MAP & LOT fl y 0 3& INSTALLER'S NAME&PHONE NO. ,T. C• A /�� SEPTIC TANK CAPACITY _ • LEACHING FAC -r Y: (ype� /% (size) NO.OF BEDROOMS 3 BUILDER OR OWNE PERMIT DATE: /0 .j COMPLIANCE DATE: y ,' 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 JicQo— of Gwr New 15"ivy t�rN 3 a a 3 y Town of Barnstable Regulatory Services Thomas F. Geiler,Director Public Health Division � R Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Pc Z ace Date: cxT. 2 o,,200q Designer: SuL.LIVI91V EIV61N6GRIN I�NG Installer: iJ. C. Aa Address: -7 PAR.14E(L QoND Address: /��, Soy( .33q 0.5 e1WILLEA /YJASS /emu s�`vns /4,11S /� ���� On le-, `y G '� C. A-► t�f� was issued a permit to install a (date) (installer) septic system at 16 L o N G fro N D C I r. CEA7rMV I LLc based on a design drawn by (address) MA SUL-LII//9Ng1yoI►V6EMIlye. INe dated to-7 —oq (designer) x I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. C�RTIF+cp'17on� I s Fvr 'TI 01V[-Y. DGEs NaTCr~rT►F%I PLUnnptivy ar E'LEc'TRicl�t- GaDs-s. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. / OF (Installer's Signature) KENN (Designer's Signature) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL_BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Desiper Certification Form r ►4 COMMONWEALTH OF KksSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED JUN 2 12004 TITLE 5 TOWN OF BARNSTABLE OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A C�nIFICA rT �r vl..T.1 . 1 1{�1 1 - Property Address: Y/n) A iOAP Owner's Name PARCEL, Owner's Address: O7 Date of Inspection Name of Inspecto please print) , T Company Name. Mailing Address: Telephone Number: fr•' '�' 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 15.34.0 of Title 5(310 CMR 15.000). The system: /passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector'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 is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I Page 2 of l 1 . OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:/-6 11'04V- 1�;& Owner: Date of nspectio11: Q 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 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 approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s).or`due to a broken, settled or uneven distribution box. System will pass inspection if(with. approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than*4 times a year due to broken or,obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health):. broken pipe(s)are replaced obstruction is removed ND explain 2 t 1 ' Page 3 of 1'1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date o.f spection: CIT 6 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 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 coiiform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria,are triggered. A-copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: � &0- Owner&& (� I Date of iispection: Rju D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes Nq V 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 li uid level in the distribution box above outlet invert due to a overloaded QQ �/ q. n ded or closed SAS or /. cesspool V Liquid depth in cesspool is less than 6"below invert or available volurne is less than %z day y flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number / of times pumped ✓,I Any portion of the SAS, cesspool or privy is below high ground water elevation. f/ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface _7 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 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. Aare.triggered.A copy of the analysis must be attached to this form.] (Yes/No)The system fails, I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no. the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 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. 4 . ti Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART B`.; CHECKLIST Property Address: j,ejOwner: Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes N Pumping.information was provided by the owner, occupant, or Board of Health L 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) L,-"_ Was the facility or dwelling inspected for signs of sewage back up Was the site inspected for signs of break out? JZ_ 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: Yes o Existing information.For example, a plan.at the Board of Health. t/ 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)] 5 Page 6 of 11 OFFICIAL INSPFCTION;FORM NOT FOR VOLUNTARY°ASSESSMENTS - SUBSURY ACE SE WAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: Owner: Date of.nspeetion: PLOW CONDITIONS RESIDENTIAL Number of bedrooms(:design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: I W gpd x#of bedrooms): Number of current residents: Does residence have.a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no).&cif yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): ... Water meter readings, if available(last 2 years usage(gpd)):0,3` >!�© Sump pump(yes,or no):Ab Last date of occupancy:Y COMMERCIAL/INDUSTRIAL Type of establishment: Desian flow(based on 310 CMR 15.203): gpd Basis of design flow(•seats/persons/sgft,etc,): Grease trap.present(yes or no): Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system (yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: V. 9� Was system-pumped as part of the in ection(yes or no): If yes, volume pumped: gallons--How was quant ty 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) _hmovative/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): S F-Approxi Hate age,of all components, date installed(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no) 6 Page 7 of I 1 ` OFFICIA.L INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 & Owne Date of nspection: � � BUILDING SEWER(locate on site plan) Depth below grade: — Materials of construction:_cast iron 40 PVC_other(explain): _ Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): SEPTIC TANK/locate on site plan) Depth below grade: Material of construction:_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: Distance from top of sludge to bottom of outlet tee or baffle: 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: How were dimensions determined: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): GREASE TRAP/ ocate on site plan) Depth below grade: 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: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): 7 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner.: Date of Inspection: TIGHT or HOLDING TANK/(tank must be pumped at time of unspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_____polyethylene otlier(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX;�(if present must be opened)(locate on site plan) j . Depth of liquid level above outlet invert: 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.): PUMP CHAMBER (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments (note.condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of I spection: SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: TypOe leaching pits, number: leaching chambers, number: 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, et .): �i s / ` CESSPOOLS: (cesspool must be pumped as part of inspect ion)(]ocate on site plan) . Number and configuration: x Depth—top of liquid to jalpt invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: CpC �S Materials of construction: U"X Indication of"groundwater inflow(yes or no): mmrents(note condition of s 'I, ions of by raulic fail re, level of ponding,Condit! n of vegetation,e c.): � � 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.): 9 Page 10 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1-0 Owner: 6)�PJYO Date of Inspection: 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. , 'T 3� l � 0 x 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: AVi94 Owner: 2�2 Date of I pection: (�G SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water �! 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 local Board of Health-explain: �hecked with local excavators, installers-(attach documentation) t/Accessed USGS database-explain: You mast describe how you established the high ground water elevation: 11 2' 4 f Permit Number: Date: Completed by: 1� j 'c #E HIGH GROUND-WATER LEVEL COMPUTATION • r E 1 � t Y e ' Y, Site Location: �� ��i�� Lot No. ,,pp ner: ] C � `f Ow � � Address: /� � 4 is fil -;Y Contractor Aqt //7 L,/� ' �r5' Address: `-/-,; d/ v�3'^)/ ,�- Notes: ,/r/I. ��✓/,-$ z}r e STEP 1 Measure depth to water table .....:...:... to nearest 1/10.ft. .............................................................................. .Date l month/day/year 3t4,, STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: Appropriate index well................. W/ ................................... ® Water-level range zone ........................................... 4 _ STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) �' 6 determine water-level adjustment ..........................................................:............................... STEP 5 Estimate depth to high %later by subtracting the water- level adjustment (STEP 4) i from measured depth to water level at site (STEP 1) �J Figure 13.--Reproducible computation form. i i .........,_...__...�.,..„�„_..:..s-., - Sl,1 fF+(�',,jai fit'��� �:i+.. •'�i't -...._................. .. ............ _► - tk No. .d..... 99— Fxs...................... . ... /0 THE COMMONWEALTH OF MASSACHUSETTS BOAR® QF HEALTH r�..�.................OF.... ..... �4a Appliratiou for �Diipniial Works Tomitrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair (< an Individual Sewage Disposal System at: - �..� °.. ---------•--- ----------------------------------------------- .-......L;.at' n-Address or Lot10�1 o. Owner dress �.. Installer Address Type of Building Size Lo ---------. q. feet Dwelling No. of Bedrooms Bedrooms.._ ---_-. Expansion Attic Gar age Grinder a Other—Type of Building ......Z& No.......of persons............................ ( ) Showers ( ) — Cafeteria ( ) Otherfix es ..-•-••••--••----•--•--.........-••---••---•......----•••-••---------------•.....•----- ............................................................. Design Flow.............. -5—_.,_.._.....__..gallons per person per day. Total daily flow-_____-_-_-_.•��Q....__..........gallons. WSeptic Tank—Liquid*capacity/VOOgallons Length-------6.. Width.....6...... Diameter................ Depth....'a......... 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. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-._---__________-------. G14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------------•-- ----------------••----...-•-•-•••-•--•--••--••--••---••-••-••••--.........--...---_..... O Description of Soil �_ .. ` -.....�-- - --------------� . ..............40... DO--._., - x ----------------------------------------------------------------------------------------------------------------------------------------------------------------- .............................. Mb U Nature.of-1R airs or Alterations—Answer when applicable....____.�! -----•-_-./ _ __.. ..........~! " =-....- `-P?Q'- ----------------------•-------....------------••-----------------------------------------•---------------.....-----------•-•---.......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITl � 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee su by boa- of l alt . y Signed-. = . ....-•-•---•-••••-- ..' CD'a' Application Approved By.. -• •-• •--• ®• .... . .._.. ....... D a e Application Disapproved for the following reasons--------------------------------------------------------------------------------------------••---•••••......._... Date Permit No._ /.. f .................. Issued........ .... .._ ... ..................... .f- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF...�� !li!E .......................................... ApplirFa#iun for DiopuoFal Works Tonotrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: _ f' �V�O l��C'.�-----•--------••---- �:�r/�-1 f:_, _U/CC ............................................................ Location-Address / or Lot No. ' �.�iY•'-//' .....e................_............._.................................................................................. /� ... Via?'. t.._... .._`��._..._.__........_.._..._.... ....... Owner Address ,-a •-----•- Installer Address cl� Type of Building _ Size Lot<_.:_�! _-_._ q. feet Dwelling No. of Bedrooms...........z;``,.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building .....r�_5_�....... No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .------•--•------------••-----------------------------.-----•-----------------------......------------------------------......--•-•-•••••.....-••-•---- W Design Flow............. 5.........._..___.gallons per person per day. Total daily flow____-___.__--3-'��.G........._......gallons. WSeptic Tank—Liquid'capacity.'G�G.gallons Length.......6.... 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........................ (3� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------•---...----•-••---•---_• •-•--•---••-•-••-•••-...----_........... Description of Soil------••--0.-- -_...- e,6,ji 1( �F5 Spa' tf� r f/f� �" O p / ' UW -•----•-•--•----•-----------•-•••---•------------------------•----•--••-•----------•--•-•-•-----------•-•-•-•--•------------•-------•----------•-•----------••-- Nature of,Pairs or Alterations—Answer when applicable._--____!A6D..___.._.. ----------------------------------------------------•-------------------------------------------------------------••-•......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLT% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be r-iss d by th�boat of 1 eal h. Signed__ J 'c �' __.. . =j _1 qVaApplication Approved ----------- -=--o__lr .. 7_.� ..... -------' . � Application Disapproved for the following reason •-•--------•----------------------•---.............-----------...---------------------------•-•--•---••--..._.. ................................... ------------------------------------------•••--••--•••---•••......-•-............_•. --------- ---------•----•--------- q �> �• AV Date Permit No. -•. ................ - -Issued . ----••-•----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J�liU (...............OF.....It � ......... 0aL..�.................................. OprrtifirFatr of Toutplitanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired �) by •' . - -- 'f nJ�- -----------------------------------------------------------•--...---...........__ Installer r at................. 6�----•--•--.-- _---•----......' �Uf) ----C-'°-....-=- ----- -lr_� /GL has been installed in accordance with the provisions of TTTIZ 5 ofP State Sanitary as e c ed in the application for Disposal Works Construction Permit No.___ _ _.. ____. dated_-.. _ _ _�................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARA TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................... ......I_7.Ac........................ Inspector................... .............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OFHEALTH No.! i`I O F..�F--,.!r'v1� �. l:'l`.................................../................................. 7i FEE ..._.._.. Eliopoal Works Tunotra ion rrutit Permission is hereby granted...............eE_;:_0j(�7Q 60'r� /i to Construct ( ) or Repair; an Individual Sewage Disposal System at No..................... ............• -..z-:2--••--- CCU �'" rD .' /CL�� Cl ' AJ7 (, I Street as shown on the application for Disposal Works Construction ermlt No i_ D ed _-----_____________ / a d of Healt DATEg l- D.. -•----------------------------------------------- FORM 1255> HOBBS & WARREN, INC., PUBLISHERS TOWN OF BARNSTABLE R >, LOCATION li�o' &0AU- e'76,u4O <Z,, SEWAGE # VILLAGE � C�2GL ASSESSOR'S MAP 6z LOT c5� O3 INSTALLER'S NAME &,PHONE NO.,&A706077 e- O 77/ -,—Fj t . SEPTIC TANK CAPACITY I;EACHING FACILITY:(type) (size) 6 ., NO. OF BEDROOMS PRIVATE WELL O UBLI �WAT�ER'�, BUILDER.OR OWNER_ ` = A—Z:152 DATE PERMIT ISSUED: j`�`�.DATE COLIPLIANCE ISSUED: _l 7-U Y VARIANCE GRANTED: Yes No j I __ { f «, F �, v _r � � �. ��\ �` � a 6 i • �� 'ay RemodelingProposedand Addition Plans for Pond Circle,16 Long Centerville, MA Designer, Builder& Owner: Philip C. Bateman 39 Tower Hill Road, Unit 19A Osterville, MA 02655 Telephone: (508)420-9122 Cell No.: (239)898-0224 H GREAT MARS A.M. 209140 SHEDS NEIGHBOR'S Ro uTE 28 CBrbH LOCUS �40� _ ,ALq ENT EDGE - CB/DH _ 125.00, 5�4w 9 �1g i 1V84-30'407 m A.M. 209139 40� w HE p o O CENTER VILLE LOCUS MAP PARCEL 2 -� CB/DH PLAN REP 1051125 0 co 129. 76 DEED REP 7986/119 v; PROPOSEDI _ CB/DH� S85.27�30" b ZONING. "RD-1" z �I GARAGE I ____ - !� SETBACKS.- 30-10-10 Z _I -` CB/DH Q GROUNDWATER PROTECTION ZONE.- "AP" __ •, PROPOSED � " B T ADDITIONS b ' b O ::��33.2'�:�. 20O PARCEL 1 ,p -----,--- - o PLOT PLAN OF LAND -,-- d PARCEL 3 ... 0 l3.O •,----,.ti � � W � LOCATED A . 23. •----- i 0� "-"""-'•191 ' 16 LONG POND CIRCLE ..-.-......- O PLFN I �V HOUSE.... OiCENTER VILLE MA. "s;"s"s;#1s;;;"s;"s... 12° A. M. 209138 C� p -.,co PREPARED FOR• AREA=35,396-' SF ~' 29.9 ---- .0 BA TEMAN LAW OFFICES C� I� AUGUST 13, 2004 CB/DH p N SCALE•• 1"=30' i 126.30 ( REV.• N85'27'30"E 126.47'(CALC) II II ►��A AA REV c,� _ ► �tN o•i.usss REV „W 126, 78 ; STEP EN f ' YANKEE SURVEY CONSULTANTS IRON PIPE 10. S84'30'40 pov� UNIT 1, 40B INDUSTRY ROAD AM 909137 e ~_ P. 0. BOX 265 MARSTONS MILLS; MASS 02648 ��✓fir TEL• 428-0055 FAX 420-5553 SHEET 1 OF 53735 GM f CP Lon 10E3j • Can -LD C 14 ID rQ T:'r 77 (� Lrjn� ���( v �E t-I Lar f �: tp OM j ��"`f S a o D C l�rQ.0�� -D o oc V o � �4 PPS F o Win. _ Iq s� o i - - � Gtcrat o O o pR G A� H t �!� Mf H A�.►- to PVT ` II D c C. t - � i - b4 alp �- = rI w � o i r I I i 7LA�7 �� �� ► j .a Y- D kLv \✓ cam . 6"' P G ( I I I U LA h� E 7� g r P G RCC. C Lc��n �t�-(i C_ � � c ! I I ! i ! � I a b4 ✓fir l a Ci- J a \ Ll of, (" - L� � I �� I L I-Z s �-L�- 4PG Sla, - 3 7Z711, ,moo�m sal s ta.Lc °� wL. a J o �s-rs ►(� @ C -IDC- S�C�C iLo 5. • I I CQ �o � \o R� C�_,2__�_C� i LA �/aLJ \ 1 17 \ J I' I, I 'i I. 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