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Home My WebLink About0627 PHINNEY'S LANE - Health (2) 462 PPHINNEY'S LANE, CENTERVILLE A= 251 009 llll �EcY«Fo No S3LOR � HASTIPt08,b9T{ TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE V SESSOR'S �&LOTAVS, ,/-0,69 INSTALLER'S NAME&PHONE NO. iz SEPTIC TANK CAPACITY MbO LEACHING FACILITY: (type) (size) NO:OF BEDROOMS - / BUILDER OR OWNER PERMIT DATE: ' .% " COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwatcr,Table and Bottom of Leaching Facility Feet Private Water Supply Well.nand 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 eaching facili Feet Furnished by e�� Mx OL2L . p y No. Fee ^�� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: " s 'PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Migoar *raem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Q5Complete System El Individual Components Location Address or Lot No.60 ';),?P 6 Nis Owner's Name,Address and Tel.No. Assessor's Map/Parcel �316`._00 C C/c`7 ap- / I LE LVYi�O� Installer's Name,Address,and Tel.No. 6 G V Designer's Name,Address and Tel.No. o S� Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures `1 C Design Flow 33y gallons per day. Calculated daily flow -1 7 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank to S Type of S.A.S. ► �.cw G L Description of Soil 0W rZ � ✓� Nature of Repairs gr Alterations(Answer when applicable) �S� -`\G�— 1=��"��' S A—g0)4 kA 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 E Code and no a the system in operation until a Certifi- cate of Compliance en issued by t ealth. Signed Date Application Approved by �t Date Application Disapproved for the following reasons Permit No. Date Date Issued w, 9'' r F No. fee �6 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: y 'PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pphration for Migo5at *p5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Womplete System ❑Individual Components Location Address or Lot No.O�7 f t IV�-�� / Owne shame,Address and Tel.No. f - i Assessor's Map/Parcel `— / 5 " Installer's Name,Address,and Tel.No. `1 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( ) 4. Other Fixtures Design Flow 33U E gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 k � 5, Type of S.A.S. Description of Soil l U►e f�Z S/' > F Nature of Repairs grAlterations(Answer when applicable) 17SM A\(, - =c�ac-�- vhS� — g07C Date last inspected: R 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 ewes Code and ce the system in operation until a Certifi- cate of Compliance hee`issued by this ealth. Signed Date a vrw Application Approved b ` Date Application Disapproved for the following reasons Permit NO. Date Issued -------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that thelOn-site Sewage Disposal System Constructed ( )Repaired( )Upgraded,( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N�'D00,01 dated h J 7 -:7� t.�. Installer Designer The issuance o-tln�e- It tall n,4t be construed as a guarantee that the s �fs designe Date �/'- ' �� Inspecto " • �� . ® ---------------------- No. Fee /' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Miopooal *p5tem Construction Permit Permission is hereby granted to Construct( )R pair( )Up rade(Abandon( ) System located at ` U 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 th it. Date: � / �� Approved `'f 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) a , hereby certify that the application for disposal works construction permit signed by me dated �' , concerning the property located at meets all of the following criteria: V This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. V• The soil is classified as CLASS I and the percolation rate is less than ore equal to 5 minutes per inch. q /There are no wetlands within 100 feet of the proposed septic system (There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed There are no variances requested or needed. fThe bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] o If the S.A.S.will be located with 250 feet of any vegetated we the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: �/ A) Top of Ground Surface Elevation(using GIS information) [t 0 B) G.W.Elevation C-x/t +the MAX. High G.W.Adjustment �� DIFFERENCE BETWEEN A and B 3 `C SIGNED : DATE: J [Please Sketch propos plan of syst&m on back]. NOTICE Based upon the above information, a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert s� � 1 D \ �� . �_. i . TOWN OF BARNSTABLE LOCATION / SEWAGE42addn VILLAG ASSESSOR'S & LOTs7 '"' 0 INSTALLER'S NAME&PHONE NO. i SEPTIC TANK CAPACITY /Jbd i LEACHING FACILITY: (type) (size) NO. OF BEDROOMS / BUILDER OR OWNER �l PERMIT DATE: �'��:% ' 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 jeaching facili Feet Famished by i • s G-' 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Address of property a 7 Owner's name u < Date of Inspection % qr �� 0 7 y �/ pxRT A CHECKLIST 1 Q' Check if the following have been done: Pumping information was requested o �'"F _ Health. f the owner, oc t, and Bo � of _/ None of the system components have been S t and the system has been receiving normal andatleast duringttwo weeks flow period. Large volumes of water have not been introduced into the system. recently or as part of this inspection. As built plans have been obtained and examined. Note if the available with N/A. y are not The facility or dwelling was inspected for signs of g sewage back-up. The site was inspected for signs of breakout. A1*1 system components, excluding the SAS, have been loc site. ated on the N,e�_ The septic tank manholes were uncovered, opened, and the interior the septic tank was inspected for condition of baffles or tees, of material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the SAS on the site on existing information or a has been determined based approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of' SSDS. I — s C SUBSURFACE SEWAGE DISPOSAL SYSTEH 'INSPECTION FORM PART B SYSTEM INFORMATION / FLOW CONDITIONS If residential 4— number of bedrooms number of current residents . 40 garbage grinder, yes or no' YKs laundry connected to system, yes or no Nv seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: yy = lb�� a`��' �,411--q i 000 � u Last date of occupancy GENERAL INFORMATION Pumping records and source of information: /Y o. A57 U At i r /t bur a l` FS System pumped as part of inspection, yes or no if yes, volume pumped _ 4060 Reason for pumping: ' Type of system Septic tank/distribution box/soil absorption system Single cesspool 02 Overflow cesspool of Privy Shared system (yes or no) (if:. yes, attach previous inspection records, if any) * Other (explain) Approximate age of all components. Date installed, if known. Source of information: IA I' - Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:—�/—/9 (locate on site plan) depth below grade: material of construction: concrete metal FRP other(explain) 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 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, ev-idence of leakage, recommendations for repairs, etc. ) DISTRIBUTION ,BOX: 141A (locate on ,site plan) depth of liquid level above outlet inver t Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, recommendation for repairs, etc.-) PUMP CHAMBER: (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc. ) i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION coatiaued SOIL ABSORPTION SYSTEM (SAS) : N (locate on site plan if possible; excavation not required,. but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number Comments: (note condition of soil, signs of hydraulic failure, level of pondin condition of vegetation, recommendations for maintenance or repairs,etc. ) CESSPOOLS (locate on site plan) : /s number and. configuration depth-top,of liquid to inlet invert S � depth of solids layer `-V �7'H depth of scum layer NoAi a H dimensions of cesspool aT materials of construction indication of groundwater ` inflow (cesspool must be pumped as part of inspection) ` r ),4 Comments: (note condition of soil, signs of hydraulic failure, level of condition of vegetation, reco endations for maintenance or repairs,letc. ) ' ��h,A ia)wS Gt cl., ti �v G L•� bo N �vc(/�; G r� �"o-c-. x•"}o('_ o. / W a 5 p-J, �� cti L�l b • ^ �. r� S / K ccfyPov � 4s n cL� o� (locate on site plan) w } a �� `t s �"'»,P d �( co- +-� H / L materials of construction J�� 5� dimensions depth of solids Comments : (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) • 11 SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE L:SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within loo, S �1 3a� � 5�,7 ff DEPTH TO GROUNDWATER �,. ��, -}' L4,,,-dV7 ti L "j depth to groundwater method of determination or approximation: . J A-. .1 - ti J ' S 1. 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / FAILURE CRITERIA l Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined", explain why not) N Backup of sewage into facility? IL Discharge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? .� Liquid depth in cesspool <6" below .invert or available volufRe< 1/2 day flow? N Required pumping 4 times or more in the last year? number of times pumped JA Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below. the high groundwater elevation? _V within 50 feet of a surface water? .� within 100 feet of a surface water supply or tributary to a surface water supply? within a Zone I of a public well? within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? w within hin 50 feet of a private water sup ply well . less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis? If the well has been analyzed to be acceptable, attach copy of well .water anal}{ . for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEX INSPECTION FORM PART D CERTIFICATION Name of Inspector ►'0� + Company Name �— Company Address o U�� /3�s s ✓t - �� , s!� ►7 �L NL M. S /v I K Ce f i rrahi Vt4tement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Cheqk one: I have not found any information which indicates that the system to adequately protect public health or the environment as defined ins 310 CMR 15.303 . Any failure criteria not evaluated are As stated in the FAILURE CRITERIA section of this form. I have-determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303.. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature 51n,cr) Date / / / L/ original to system owner Copies to: Buyer (if applicable) Approving authority �aP27 /��- ��y3 L