The URL can be used to link to this page

Home My WebLink About0429 OLD CRAIGVILLE ROAD - Health 419 OLD CRAIGVILLE RD., CENTERV. - T A=247.038 Slll J��o� lIII UPC 12534 No.2_ HASTINGS. MN Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-.Not for Voluntary Assessments 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information is CENTERVILLE required for MA 02632 4/10/10 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:When filling out. A. General Information When forms the I� computer, r,use 1. Inspector: only the tab key to move.your DOUGLAS A BROWN cursor-do not use the return Name of Inspector key. DOUGLAS A BROWN INC Company Name r� P.O BOX 145 Company Address (� CENTERVILLE MA 02632 Cltyrrown State Zip Code 508-420-4534 S14297 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: 0 --t ® Passes ❑ Conditionally Passes ❑ Fails'--- Needs Further Evaluation by the Local Approving Authority U r . 4/10/10 p Ln nspec ature Date CIO The system inspector shall submit a copy-of this inspection report to the Approving Athority(Brd rrn 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 1 _ Ia Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 429 OLD CRAIGVILLE RD Properly Address PAULL Owner Owner's Name information is required for CENTERVILLE MA 02632 4/10/10 every page. CitylTown 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 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: EXCAVATED DOWN TO THE INFILTRATORS STONE WAS CLEAN WITH NO SIGNS OF HYDRAULIC 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•09108 Title 5 Official Inspection Form:Subsur face dace Sewage Disp osal posal System•Page 2 of 17 p> Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information is CENTERVI LLE required for MA 02632 4/10/10 every page. City/Town 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): ❑ 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 Mine•O91D8 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 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information is CENTERVILLE required for MA 02632 4/10/10 every page. Cltyfrown 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 coliforim 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 r . Commonwealth of Massachusetts : Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments rt 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information is CENTERVILLE required for MA 02632 4/10/10 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 CM 15.304.The system owner should contact the appropriate regional office of the Department. t5ins-09/08 Title 5 Official Inspection Form:Subsurface_Sewage Disposal System-Page 5 of 17 L t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name uati is required CENTERVILLE MA 02632 4/10/10 every page. Cityrrown. 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): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 t L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information CENTERVILLE required for MA 02632 4/10/10 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1000 GALLON SEPTIC TANK D- BOX AND 4 INFILTRATORS WITH STONE 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)): 08-74/09-115 Detail: Sump pump? ❑ Yes ❑ No Last date of occupancy: CURRENT P 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: t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �Y 429 OLD CRAIGVILLE RD Properly Address PAULL Owner Owner's Name information is CENTERVILLE required MA 02632 4/10/10 every 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: 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•09/08 Title 5 Official Inspection Form: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 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information is required for CENTERVI LLE MA 02632 4/10/10 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: S.A.S INSTALLED IN 1998 ACCORDING TO AS-BUILT CARD Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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: 1 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: Sludge depth: VARYING t5ins•09M - Title-5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r� 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information for is CENTERVILLE required for MA 02632 4/10/10 every 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 Scum thickness TRACE 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? WOODEN POLE 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 (locate on site plan): DeptFi 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•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 1. Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 OLD CRAIGVILLE RD Properly Address PAULL Owner Owner's Name information is CENTERVILLE required for MA 02632 4/10/10 every page. Clty/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.): TANK COULD USE PUMPING 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 y ❑ 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•09108 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information is CENTERVILLE required for MA 02632 4/10/10 every 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.): BOX LEVEL NO LEAKAGE, SLIGHT SCUM LAYER 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: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 1 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information is required for CENTERVILLE MA 02632 4/10110 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ Teaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): EXCAVATED DOWN TO SOIL BESIDE INFILTRATORS STONE WAS DRY AND CLEAN WITH NO SIGNS OF FAILURE 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 l5ins-09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 i t Commonwealth of Massachusetts Title 5 Official Inspection Fora' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information is required for CENTERVILLE MA 02632 4/10/10 every page. Cityrrown 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•09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information is CENTERVILLE required for MA 02632 4/10/10 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 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts WEL Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name nisrequiredfor CENTERVILLE MA 02632 4/10/10 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: AT LEAST 4 FT 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: AUGERED 4 FT BELOW S.A.S NO H2O ENCOUNTERED Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 N Commonwealth of Massachusetts AIRK Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `r 429 OLD CRAIGVILLE RD Property Address PAULL Owner Owner's Name information is CENTERVILLE required for MA 02632 4/10/10 every page. Cttyrrown 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 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 f '11A I% TOWN OF BARNSTABLE \� LOCATION !I 7' (5�sQ G �.�„ x;10� SEWAGE # S 5" VII.LAGE ," ,E( o.. ASSESSOR'S MAP & LOT ]_ " INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 1 ooc�iu& LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNERo� PERMITDATE: 9 y4 e COMPLIANCE DATE: - 1 i i Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by JJ i I I . f t a No. J / j Fee . THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: I. Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Oizp0al *pgtem Congtruction permit Application for a Permit to Construct.( )Repair( )Upgrade(�cbandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 4 4jPt DV D Cr,-,-%U( Owner's Name,Address and Tel.No. Assessor's Map/Parcel � C e ` -7-®3 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3�y gallons per day. Calculated daily flow �c gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank er S. < 6?i-'t t J Type of S.A.S. ----ac cn Cc Description of Soil S�r� Nature of Repairs or Alterations(Answer when applicable)2C-_U'-�"`�-(AA eC c ..ems.-��.��'�� 2 S w�� Sprit-� �,�- 5 t lA^�S �-/��' t.t�✓ 8�-�� 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 Issued b�this oar Signed Date Application Approved by Date �— Application Disapproved for the following reasons Permit No. �� Date Issued No. J ' / Fee .�ii THE COMMONWEALTH OF MA-S&AC�IUSETTS Entered in computer: V Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Zipprication for Migoml *p!tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( bandori'1(\\) q Complete System ❑Individual Components Location Address or Lot No. y a� 0��D C r-'-Ov 6 ),Q Owner's Name,Address and Tel.No. Assessor's Map/Parcel v-17 �` �r. ��t7-03 � Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. YkA,A SO—C cA (z-e 5,0 (i ti Type of Building: Dwelling No.of Bedrooms ?: Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3"3 C_-) gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank rQ S� ` fir`Y r / Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable)jz7 J'- -- (AA \ �o✓`� �� .cT� ��, �<<r ;� �".��.-�•�`.�s�� S l�\�� S't cti� o�-- S t 1P -c',S y— ��cj�` �w�� {ti..�G-�( .. 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 . issued by this Boar eaitlt. r Signed f ,, a Date Application Approved by va Date Application Disapproved for the following reasons Permit No. S w Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance . THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired( )Upgraded(�) Abandoned( )by O—G K4 vc a,( f at G""1( has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. C <_7 t� dated Installer —De W* ner The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No. /O 'S7J =--------------------------Fee .Syi �-"'� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwiopoga[ *pztem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( 7)�Abanddon( ) System located at c` 01 0 CY 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. f Date: �� 9 Approved by F ` ti A J y ✓ % . �ii% 61 LOCATION � TOWN OF BARNSTABLE - • �. d VELLAGE SEWAGE it INSTALLER'S NAME NO. ASSESSOR'S MAP& LOT &PHONE SEPTIC TANK CAPACITY OC?r� LEACHING FACILTTy: (type) i NO. OF BEDROOMS (size) BUILDER OR OWNER PERMTTDATE: - _ _ Separation Distance Between the: COMPLIANCE DATE: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water Supply Well and Leaching t3' on site or within 2 hmg Fan ty (If any wells exist Feet 00 feet of leaching facility) Edge of Wetland and Leaching Facility within 300 feet of leaching facility(If any Wetlands exist Feet Furnished by Feet • t { : This Form Is To Be Used For the Repair.Of Failedi^ CU . . . �. $eptic Systems On y :. CERTIFICATION OF SKETCH AND APPLICATION FORUT ' DISPOSAL WORKS CONSTRUCT! PERMIT (WI DIS ENGINEERED PLANS ; s 1 here txttify that the application for disposes works by► 1 � coneming the f • won permit sig>w by the dsk , Bets all of the propettr loemw It 1 fo�ToNviet criteds: . . T�r!e we wethttds loeeted vain 100 het ofthe proposed h�ehMg tlellih► � f welb witl+M ISO fm eflhe prepexd septk � 'flrere ere ne p� ; "theta b no ham"M �f '114te are tie ie1 °r"ecd�• • wetlands,the bottoM of the� ' 1 heh wM be beefed within 250 het of e ► �if dhe t �les,then fourteen(14)Feet above the maximum adjusted proposed keeltittd AteilitX will and �, i g�,d„d,bter table eleretien. i • Plet>se.0ptete the fbhewbip e �. . . A)'fbp ePOrewrd �(eceerdint b the Bn�Meerint Dlvisien O.I.S.Mop) 9) omwwft Tebie Me"do(eeeadir+s toHeeMh Div him well map), OATS 3tOtVED "M TO"OF BAIWSTABLB MMBER tw�ctt�stro► sYsrBM n�rA i AIM If d»Nswwd h+rulh►"Oew o enlltt�A dle!etatt. ". tAPAM e,`1Aw&00 008% "yelMN. fit dde phn dMM be eubl006 L,. ,, i � 1 ,,_, •G , TOWN OF BARNSTABLE LOCATION Y,I �� Cc , SEWAGE # • S75- 43 VILLAGE L"Q,� g�y� a_ ASSESSOR'S MAP& LOT ;2— `'7. ® % INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACII.TTY: (type)_1� �✓,t� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: f q e COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �3-gO 3- No..-A ...... ......�........ THE COMMONWEALTH OF MASSACHUSETTS �. BOARD f, HEA :.. .... .-.._......_..OF......... - .................... Appliration -for M-4pofittl Worko Tow;trurtion - erutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst at: - k L�Fation-Ad ress .....Ec`-------------- h`_-------ti-• - - ................................... ............. - ---•----•-•---------•••-----•---------•-•-------------------•-- Owne Address Installer Address Q Type of Building Size Lot----------------------------Sq. feet U Dwelling&!!'No. of Bedrooms--------- -----------------------------Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ._--___- __--_---_ _ No.. of persons............ Showers (/ ) — Cafeteria ( ) Q' Other fixtures --------- W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. P: Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter---------------- Del)tll.-..-.-__-.---- Disposal Trench—No--------------------- Width-------------------- Total Length.................... Total leaching area--------------------sq.,ft`t� Seepage Pit No--------------------- Diameter-------------------- Depth below inlet-................... Total leaching area............------sq. it z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by------- --------------------------•-----•-----•---•-•----•----•---•....._ Date----•-------------------------------.-.. a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water...---------..-._-.----- 0:4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-_._-._--_-.---.-_------ 1:4 -------------------------------------------------------------------------------------•--••--•-•-•............................................................ 0 Description of Soil----------------------------------------------------------------------------------------------------------------- -------- ---------------------- ----------------- x V ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ W ---------------- ----- -------- -------------------------------------------------------------------- --------- --�----------•--------------------------------------- +� ------------ UNature of Relrirs or Alterations-answer when applicable.-----— _s-_ �..........,h 0....... . . ....... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System.in accordance with the provisions of Article Xl of the State Sa Code—The undersigned furth agrees not to place the system in operation until a Certificate of Compliance s been ' sued b - board 4 Si �•�_ e ,.....e R St ..... = ---------------- - .. ` Date Application Approved By---------'------- Date • Application Disapproved for the following reasons:----- - =---------=----•- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- De Permit No......................................................... Issued------ --'• `S •----•-- Date - al? LOCL,TION ' V 5EW&CIE PERMIT UO.I IWSTALLER5 1 &NlE ADDRESS BUILDER 5 Q L MF- &.DORESS Dtl^TE PERWT ISSUED �= 7 D ATE,',COP/IPLI &t`lCE ISSUED; r /ads g,q L No....�I f --•-- Fmc THE COMMONWtt �LTH OF MASSACHUSETTS BOARD O HEA T .� firtttia�t ` >ar Diigv 4W Works ( owitrurtion Prrutit Application is. hereby` made'for a Permit to;Construct' (: ) or Repair. ( ) an Individual Sewage Disposal Syst at ••• -",•J� top r - ! anon-Ad ess or Lot o. W Owner Address,_.4 Installer Address Type of Building Size Lot............................Sq. feet Dwelling•AeNo.. of Bedrooms---------- ----------------------------Expansion' Attic ( ) Garbage Grinder ( ' ) Other—Type 'of Building _ .-____.-�-_____ persons-------------No. of 7-- Cafeteria r�t. ._- Showers ( I) ) Other fixtures --_----- . ....... _: W Design Flow.......:...................................gallons per person per day. Total daily flow....,_____.________.._....._,..--------------gallons. WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter-----........... Depth.-_._-_._._-.... x Disposal Trench—No-__________--------- Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area------- -------._.sq. ft. z OtherDistribution box. (" ) Dosing tank ( ) a Percolation Test.Results Performed'bY•----: -.---•------------- --•--•-------------••--•-------------•------- Date_.--•----••--------=------- -------- Test Pit No. d-----------------minutes per inch .Depth of Test Pit....................... Depth to ground water..__--_____:--__-___--- f14 Test' Pit No. 2................minutes per inch Depth of Test Pit...................... to ground water........................ W , . Descr tion of Soil---'---------- --------- - U •-•-•------•------ ---------------------------------•-------------------- --•--- --•-----------------------------•--•-----------•----••-----•------ W ------------ ---------------- -------------------------------- -----=--------ram---------- ----...-------------------...---------- ---- �- -------------- Nature of Rep irs or Alterations— nswer when applicable...... - �F ------------ = - -----_'------- -- ..................................................... ................ Agreement b The undersigned agrees'- to install the aforedescribed Ind, idual Sewage Disposal System in accordance with the provisions of Article XI of the State Sa Code—The$_ndersigned furtlle grees not to place the system in operation until'a Certificate of Compliance s been sued by board e t Sig ; --' Date Application Approved BY----- - ------ ------------------ � ",' 7,�/ 1' PP, Date A lication Disapproved for the following.reasons:_._..._..'----------------------------------- --------._...-- ....._._. 1 . k. Date PermitNo. ------------- -- 3 Issued.......................................................... Date `gR ... 4 - THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH . OF.......... ............. .. .......... Trrtifirt > f ;f��rmialittnrr •` »° T S 1 QPro C RTIFY, That,tyk Individual Sewage Disposal System constructed ( ) or Repaired YInstaller V. has been instal din accordance with the proKisions,..of Article XI of The State Sanitary Code as described it(the 4 U_ � application for Disposal Works,Construction Permit %NQ..,. �'''..._... dated--..�.Z +_ "... •......._-... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT.BE CONSTRAJ D AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION .SATISFACTORY. DATE. - Inspector. ector.v _- , THE COMMONWEALTH OF MASSACHUSETTS BOARD ' O HEALTH d�'Lt No------j �...{7•....... FEE--- iR > 1. 0 kil i#rurtivii ikrmif Permission 's hereby grante e to Conarjor Repa•r,`,(; n Individual Sewage isppsaI Sys r ` •--•• --- Street as shown on the a lication for Disposal Works Construction P I -No._. Dated__f_ "' .PP P s ��t �{ r ...... .... 7 Boar o Health J .. DATE....�. .. ---------------- --- 'FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS