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HomeMy WebLinkAbout0036 RAINBOW DRIVE - Health �6 RAINBOW DRIVE Centerville A = 188 — 172 /// 5 M E A D® No.2-153LOR UPC 12M MadMm • Mob In USA i Q mmMn IY SFI iwwmmwmx °mx ° cen� I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Owner's Name information ks required forevery Centerville y Ma 02632 12-4-12 page, Cityr 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 A. General Information filling out forms on the computer, OF f� �� use only the tabInspector: .�����-,......ASS . key to move your 1. _•, 9y cursor-do not James D Sears �:' JA M ES '-u' use the return Name of ins edor =o= _ key.- p SEARS cn= Capewide Enterprises.LLC -*' Company NameVQ F �� O 153 Commercial Street — ��'� 5 1N 5IV Company Address Hanna Mashpee Ma 02649 City/rows state Zip Code 508-477-8877 S 1623 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 trairiing and experience in the proper function and maintenance of on site sewage'disposal systems.I am a DEP approved system inspector pursuant to Section 1.5.340 of Title 5(310 CMR 15.000): The system: ® Passes ❑ Conditionally Passes ❑ Falls ❑ Needs Further Evaluation by the.Local Approving Authority 12-4-12 i0ilpector'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. Nis re 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 wiH perform in the future under the same or different conditions of use.. t5ins•11110 Title 5 Oflidal 1I?Sub.url—Sewage R15Derat System•Page 1 cr 17 vvty V,-r r e-of V';'p r - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Owner's Name requir lfotlon is Centerville Ma 02632 12-4-12 required for every page. Citylrown 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 16.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: 0 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 0 NO (Explain below): t5i�g 11H 0 rifle 5 OQidel tmpection Form:Subsurface Sewage oispood System'page 2017 5 4 Commonwealth of Massachusetts Title 5 Official lnspection form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Owners Name iequired for is Centerville Ma 02632 12-4-12 required forevery page. C1tyffown State Zip Code Date of Inspection B. Certification (cant.) 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): El 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 15fna•i in o ride 6 OlfWal Inspection Form W=rfaoe Sewepe Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Owner's Name information is Centerville Ma 02632 12-4-12 required for every page. cityrrown State Zip Code Date of Inspection B. Certification (cant.) 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. 0 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 inspectlons: Yes No El ® 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 El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cilleff peel is less than 6"below invert or available volume is less than day.flow Pi7a- tSins•11110 Title 5 Official Inspection FOM SubfteaW Sewage Dispoaai System•Page 4 of 17 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Owner's Name require for is Centerville Ma 02632 12-4-12 required for every page_ Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ® Required pumping more than 4 times in the last year NOT due to dogged 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. ❑ 0 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 he attached to this form.] The system is a cesspool.serving a facility with a design flow of 2000gpd- �.`' ® 10,000gpd. El ® The system falls.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 I5,000'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 ❑ 0 the system is within 200 feet of a tributary to a surface drinking water supply EJ Elthe system is located in a nitrogen sensitive area(Interim Wellhead Protection Area IWPA)or a mapped Zone If 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. t51ns-i iMo Tore 5 OWel Inspection Form:Subsuftea Sewage DtgmW System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Rainbow Drive Prop"Address David Gabelman Owner Owner's Name Information Is required.for every Centerville Ma 02632 12- -12 page, Cityfrown State Zip Code Dale of Inspection C. Checklist Check if the following have been done. You must indicate Oyes" 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 NIA) ® ❑ 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)1 D. System Information Residential Flow Conditions: Number of bedrooms (design): na Number of bedrooms (actual): 5 DESIGN flow .based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 t5ins•t tH0 Title 5 0 Mdal trispeftn Fortre SubsrAeoe Sewage Disposal System•Page 6 017 VCU VY I e-VL.T I l./ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Owners Name information.is required for eery Centerville Ma 02632 12-4-12 page. cityfrown state Zip Code Date of Inspection D. System Information Description: The System is a 1500 oral precast tank d box and two pits Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a.separate sewage system?(if yes separate inspection required] ❑ Yes ® No t_aundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes 0 No Water meter readings, if available last 2 ears usage d 2010-135,000 gal 9 � Y 9 (gP ))� 2011-116,000ga1 Detail: Sump pump? ❑ Yes ® No .Last date of occupancy: presDent ate CommerciaUlndustrial 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: c5ins•1 tl10 Title 5 OOWd 61epectioo Form:Sub sufaw Sewage Dispossl System-Page 7 ar 17 UWL;V4 I L VG.'+1 i.J N•" Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Owner's Name information is required for every Centerville Ma 02632 12-4-12 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: na note. tank to be maint pump Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gaaons 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 IfA system by system operator under contract Tight tank. Attach a copy of the DEP approval. Other(describe): 15ims-11110 - Tide 5 omdel t nwection Form:SuDewfaoe SewagO 0Isp03Bd Syaeem-Page.B or..1 T VCIi VY I L VG.YLI.I r.v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner owner's Name information is Centerville Ma 02632 124-12 required for every page, Cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed(if known)and source of information: 1985 Permit#85-195 new D Box 12-3-12 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 49' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: Beet Comments (on condition of joints, venting,evidence of leakage, etc.): Pipeing is 4" pvc sch 40 Septic Tank(locate on site plan): 32" Depth below grade: 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: 1600 Precast Sludge depth; - Sins•11no Thle 5 Offidel Inspection Form Subsurt ee Sewage Disposal System-Pego 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Owner's Name information is Centerville Ma 02632 12-4-12 required for every page. cityrrown state Zip Code Date of Inspection D. System Information, (cont.) Septic Tank (coat) Distance from top of sludge to bottom of outlet tee or baffle 27" Scum thickness 2' Distance from top of scum to top of outlet tee or baffle a" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-tape-sludge Judge 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 at 37'below grade w/inlet cover at 1'outlet cover at 15".Tank at working level w/in and out tees.no sign of leakage or overloading Grease Trap (locate on site plan): Depth below grade: feet Material of construction: concrete ❑ metal ❑fiberglass ❑ polyethylene O 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 tsns•11110 Title 6Miidst Inspecfion Form:subsuftes se"a Disposai System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Ow Ws Name information is Centerville Ma 02632 124-12 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan), Depth below grade: Material of.construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Capacity: gallons Design Flow- gallons per day Alarm present ❑ Yes ❑ No 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 !Sins;i 1 a TTige 5 Official Inspection Form:submsface sewage DiVosal system•Page 91 of 17 .vc.v i c vc.-rvr.+ r• •- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Owners Name information is required for every i,enterville Ma 02632 12-4-12 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note tf box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-25"below grade w/cover at6"below grade two lines out Box is new 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•11A D TWO 5 O ieW Inspectim Form:SuW08W sewege IDIVasal system•Page 12 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Owner's Name information is required for every Centerville Ma 02632 12-4-12 page- City/Town State Zip Code Date of Inspection D. System Information (cunt.) Type: . ® leaching pits number two ❑ leaching chambers number. - ❑ leaching galleries number. ❑ leaching trenches number, length: C] 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.): Leaching is two 1000 gal precast pits Pit#1 at 42"below grade w/cover at 30"2'water in pit, no sign of overloading or solid.carry over. no high stain line Pit#2 and cover at34"below grade ,18"water in pit no sign of overloading or solid carry over no high stain line 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 isms•91110 Me 5 Official IhspM.'on Form:Suomurlace Sewage Disposal System•Page 13 o117 vv:w-r i c vc.-r.+N r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabeiman Owner Owner's Name required for every Lion is Centerville Ma 02632 12-4-12 require page. city/rown 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•11f10 Title 5 otttdal hspeclion Fwx subudaee Sewage Disposal System•Pa®e U of 17 VCIi VY 1 L VG.YYfJ N• i v Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form,, Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabeiman Owner Owners Name information is required for every Centerville Ma 02632 12-4-12 page. Gitl+Row 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 PA If i o 3 /7 r R- Y- C JV= .- 'V r5ins•I v10 Tide 5 Official Inspadon Fam:Subuyfew SeaWe Disposal System-Page 1501,17 vvv v� c v�.��N r• •- Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner Owner's Name information is required for every Centerville Ma 02632 12-4-12 page. citylrown State Zip Code Date of Inspection D. System Information (cons.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells ,✓� Estimated depth toFh ground water: feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked, date of design plan reviewed-, Date El Observed site(abutting propertylobservation 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: T.H. per Plan at 33 Rainbow Dr 94-12 no G.W_at 11+' lot high Before filing this inspection Report, please see Report Completeness Checklist on next page. t5ins-11Ji0 Tide 5Offidal Inspection Form:StfDsiarace Sewage Disp System•Pape 16 or 17 o Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 36 Rainbow Drive Property Address David Gabelman Owner, Owner's Name information is Centerville Ma 02632 12-4-12 required for every page. Cityr town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary.A, B, C, D,or E checked ® Inspection.Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 16 or attached in separate file t5ins•11110 Tile 5 Official Inspection Form Subsurftm sewage Disposal system•Pape 17 of 17 No. ®�Z_ 30 W Fee 100 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yor Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ftpYitation for Misposal *pstem Construction Permit Application for a Permit to Construct( ) Repair(>�_ Upgrade( ) Abandon( ) ❑Complete System -®-Individual Components Location Address or Lot No. 3(, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel t -6 $ l Installer's Name,Address,and Tel.No. IJ-3 Designer's Name,Address,and Tel.No. c4tz,w,i e �,k�P s�� Y Z i'l� Type of Building: {Dwelling No.of Bedrooms °'' Lot Size ��6 — sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided N gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: le.(_ Z©cZ 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 Certificate of Compliance has been issued by this Board of Health. S' ned Date ( ;L. '� — 'L ',Z Application Approved by e Date / —Z Z Application Disapproved by Date for the following reasons Permit No. 7-PI-2— Date Issued j 0�ClYhSll'U. Date ! 0-1 � �� No.2.0 Fee-* �o w THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS MisposaY 6pstem Construction permit Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( ) System located at 3 (0 12y,,1,, (o,) and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. I Provided:Construction must be completed within three years of the date of this permit. Date 17 c7 7 Approved by No. 20 iZ % b Fee o0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes g i 21ppliLatlon for MispoBal 6pstem (Construction jermit i Application for a Permit to Construct( ) Repair(yQ Upgrade( ) Abandon( ) ❑Complete System ].Individual Components Location Address or Lot No. 3 b Owner's Name,Address,and Tel.No. ` Assessor's Map/Parcel Installer's Name,Address,and Tel.No. �s 3 C � Designer's Name,Address,and Tel.No. Y71 g877 Type of Building: Dwelling No.of Bedrooms t.� Lot Size �`6 OC9 o - sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) tj A gpd Design flow provided �� gpd Plan Date Number of sheets Revision Date Title i Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 untiLa,;Certificate of Compliance has been issued by this Board of Health. -• ffS1ed Date I ;L Application Approved by / Date / ! Z o Z i ` Application Disapproved b Date for the following reasons Permit No. ,?_61 3,( Date Issued /_T�Z o t Z �-- 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_� � G, ,� , e i t at t ►Z ln^ C Zn has been constructed in accordance i with the provisions of Title 5 and the for Disposal System Construction Permit No.Zora —3RL dated Z o 1 Z Installer l ,. ,, „ ,� �, )=Z,r o•b .r, Designer #bedrooms Approved design flow gpd The issuance of this permit shalt d as a guarantee that the system will function'a`s c�'i_ed: Ad i a .7 LOCATION pm pf)4 SEWAGE PERMIT NO. 40 VILLAGE I N S T A LLER'S NAME i ADDRESS K • 111C V-F,Y S U I L D E R OR OWNER DATE PERMIT ISSUED 2 �5 DATE COMPLIANCE ISSUED 7 /�E; � � - x� . ., • - . . �'��� No as Fps. ............... THE COMMONWEALTH OF MASSACHUSEETTS BOARD PF . ------- AH � ..........OF........ . . ... ..... ......... ................................. Apptiration for %yugal Works nitrurtiurt rrutit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: - .................... .&.. ....67.... ....... ...... "I 1,.(1411h 2/luloV, ....................................................... - " or Lot No. r -•-•-.----._ .. .......... - ............. .............. er L dress a ---------------- z� , / ...... ............................ ---- .---------• ------•-----•--.......-•---- � Installer Address p a/® Type of Building Size Lot___.._ }________________Sq. feet Dwelling—No. of Bedrooms.............. .................•--_-_•-__Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------- ••-•-----•---•---•----------•---••----•--•-----•--------•--•------------- �y W Design Flow............ ......... .........gallons per person per day. Total daily flow____..____ Cam.....................gallons. -- 9 Septic Tank—Liquid capacitQallons Length................ Width---------------- Diameter................ Depth................ W Disposal Trench—No..................... Width_ __ ............ Total Length.._____. _____...._ Total leaching area__---_--•-__.-----sq. ft. x Seepage Pit No--------------------- Diameter....... ---------- Depth below inl et._... ........... Total leaching area.c;.L.00....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~' Percolation Test Results Performed by................................................... Date...............................:...... Test Pit No. 1.......0*-.minutes per inch Depth of Test Pit.....12...._... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_................. ------------- a Description of Soil--6/= '� x .--.._------ --•- --•• ---- --. •. --• -------------------------•......-------------- -- ------------------------------------------------------------------------•---- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------------------------------------------------------------•-----•----•--------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ii'lYLE 5 of the State Sanitary Code— The u sig further agrees not to place the system in operati - until to of Compliance has be n i ed by ar health. ined.. __ ....... •. ---- ............... /�,ate •. . nA Y D Applicatio .... _-�"�'............ ........... eat �� Application Disapproved for the following reasons------------------------------------------------------------------------------------------------••--------•..._.. •-----------------•----------•--------------------------------------------------•--------------------------••.._..-•---•-•----.---•-------••-----••--------•-•-•--••---------•----•-••--•-------._.... Date PermitNo......................................................... Issued........................................................ Date a N,o.. .........)TY FEs.............................. THE COMMONWEALTH OF MASSACHUSETTS 11 BOAR® 9F H H ApplirFatiou for Disposal igork.6 omitrurtiou ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: �< - � ' /jf///jQ � ........................................................ p e, •........... ................!wn- ...-I �w.... ------ --.-... .�_. -� -;a{or Lot No- ---•-•---•----•-•---------..........-•---- er dress W � '. ---------•-- ...... � � . � Installer Address 40YO Type of Building Size Lot... ....Sq. feet aDwelling—No. of Bedrooms......................................Expansion Attic ( ) Garbage Grinder ( ) Pk Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------------- ... W Design Flow............ .'_-------.-_•...........gallons per person per day. Total daily flow---------- .....................gallons. WSeptic Tank—Liquid capacit� allons 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-C � ....sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by...................... ... Date....................................... aTest Pit No. I.......r.—..minutes per inch Depth of Test Pit.....1. ......... Depth to ground water_______________________" Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ ---- --•- - ... ,.. .. ...........................�^_.....-------•----.....--•---•-----•---- O Description of Soil.- /_ = ;:.-c -----------------•-----••-- ......................................... I ----------•- - - --- --- --- •- ---- -----------------------------•-----------•--•- W -r ------------------- - - - ----- UNature of Repairs or Alterations—Answer when applicable------------------------------------------- .11 . Agreement: . - r The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iiTILE 5 of the State Sanitary Code—The u j ig further agrees not to place the system in operatiQ�until a �erti" to of Compliance has ben i ed by ar �f health. r ��`,� i ned-•• . . .......... ......... ,---- ----- ---------•------ ...... -- -�.... ate Application Approved BYE L ; Date Application Disapproved for the following reasons-----------------------------•-------------------....--------------------------------------------------.......... •------------•-----------------------•---.....--•----------------•---------------............------......-----•---------••---••-•----------------------------------------.............................. Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD,. F H AkTj+I 1 (Q� ..........O F..................................................................................... Tertifirtt#ie of Tnaatpliaatrr THIS IS TO CERTIFY, That e Ind;7 a age Disposal System constructed ( or Repaired ( ) by........•.......................... . =•--./.�_ .----- �..'..---� t ler••--------•-•------•----- -------•----•--`.._. ...._.._.......-•----•-• has been installed in accordance with the provisions of r" j of The State Sanitary C e as described in the application for Disposai Works Construction Permit No.-g _-_I__1711------------ dated_...._ '._ ..__ __..... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL F N TION SATISFACTORY. DATE....... Inspector -- &' -• .......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD „ ,F HE LT.H <--- oF..... ................ No... FFE........................ it permit Permission is h y granted------.... -----••••-•......--......... ............................................ ....... to Construct ( or epair ( l an Indi.Xidual Sewagej.....imosal stem - at No. �? �.�� c Street ' c••.f^" /,9y `s as shown on the application for Disposal Works Construction Permit No------------- r J --------- Board of Health DATE . . --- .................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r 1 A/O /ZSo CON L7 =✓O� Ix/�L� -�1��-4- - 3710 >C z S /coo GPI? `,\ ,��✓�—��,� /d' \ To Tom- •�Es/G•t/ :. /o�� G.�?1.--. ICES/G�/ P�,�Col�4T1U�/.e�ITL a !7 r 1A Of i>l�S '•'. r��Ij2i7tfi�Mq Intl FHCHARD � `t" Pf:TER - :a A. �1 o SULLIVAN f 0 BAJ(TER Na 24*048 -No. 29733 SS ���5T£ ®e• Dt �O(o• � V F TEST f/a�.E / ?'a /07.o •. /Cc�C` /.Y1/ sox /N✓. G.4L. /ate. ,' LC-A Gil• P/-r kY/--2 e T /,vl/• /Nx/ 3/lj 7a*- /Cc,,7- /00. 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