Loading...
HomeMy WebLinkAbout0011 RED LILY POND ROAD - Health 11 Red Lily Pond Rd. Centerville A=227-043 ///1 �Y UPC 12534 i i I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �< 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is �j�.e required for Ma. 02601 8/9/2010 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out forms on the computer, use 1. Inspector: only the tab key to move your Raymond Dumas cursor-do not Name of Inspector use the return key. Dumas Landsape Const. Company Name 564 Old Stage Rd. Company Address Centerville Ma. 02632 City/Town State Zip Code 508-778-0249 S1437 Telephone Number License Number B. Certification -� C= o 2 I certify that I have personally inspected the sewage disposal system at this address and that 99 information reported below is true, accurate and complete as of the time of the inspection. Theonspetfion was performed based on my training and experience in the proper function and maintenance omn site sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 og Title 5(310 CHAR 16.000).The system: c n ® Passes ❑ Conditionally Passes ❑ Fails W 41 W r— ❑ Needs Further Evaluation by the Local Approving Authority -a m 8/9/2010 Inspect is 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal!System Form-Not for Voluntary Assessments w 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. City/Town 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: 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owners Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cons.) B) System Conditionally Passes(cunt.): ❑ 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 t5ins-09108 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 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page, Citylrown 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 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 El ® 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 t5irts•09108 Title 5 Official Inspection Farm: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 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. CofTown 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 16,000 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 11 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. CitylTown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments z.° 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. Cityrrown 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?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ® Yes ❑ No Water meter readings, if available last 2 ears usage d 2009/22000 9 ( Y 9 (gp ))� Detail: 2009/22000 gallons 2010 7000 gallons Sump pump? ❑ Yes No Last date of occupancy: 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•09M Title 5 Official Inspection Forth: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 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is Hyannis, Ma. 02601 8/9/2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: none available 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-09108 Title 5 official Inspection Forth:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts upTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 1999 11 yrs old Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 24 inches feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: town water front left of house in crawl space Comments(on condition of joints, venting, evidence of leakage, etc.): good Septic Tank(locate on site plan): Depth below grade: 12 inches 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: 1500 gallon size Sludge depth: 4 inches t5ins-09108 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 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. Citylrown 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 Winches Scum thickness 6 inches Distance from top of scum to top of outlet tee or baffle 8 inches Distance from bottom of scum to bottom of outlet tee or baffle 18 inches How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): pumping is recomended 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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "( 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. Cityfrown 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.): no evidence of leakage but recommend pumping septic tank. No records of any pump since installation in 11 yrs. 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 t5ins-09108 UW5 Official Inspection Form:Subsurrace Sewage Disposal Systarrr-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert at level no carryover 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.): level an no signs of leakage 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: as per plan on record at BOH t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal!System Form-Not for Voluntary Assessments 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. CitytTown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: Cl overflow cesspool number: ❑ innovative/alternative system Type/name of technology: precast flow diffussors 4'x8'x18"H Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): all good 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•09/OO 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 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. City/Town State Zip Code Date of inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09108 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 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 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 I f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 � every page. C4rrown 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: 8 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: 6/23/99 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: plan on file at BOH ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Enginnered plan 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 11 Red Lily Pond Road Property Address Elizabeth D. Stanley Owner Owner's Name information is required for Hyannis, Ma. 02601 8/9/2010 every page. Citylrown 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-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17 TOWN OF BARNSTABLE LOCATION ll /t C'!,\ Lr��t/ �� �� SEWAGE# — 3 .a VILLAGE fU iti%L''r> =�'% - ASSES SOR'S MAP&LOT_JAJ—XJ INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /, o LEACHING FACILITY: (type) �/o�,+�� /= i S'c f f (size) ,� .k J 6, size NO.OF BEDROOMS .3 T DER /fit- !\1r-11'E 7- nLil.untc On- v w tv�x �-- � � = i 4-�z r � n �/cc.V r t j �q PERNIITDATE: Je;�- 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 fee of leaching facility ���/ Feet. Furnished by1 �— � TI G �\ // TOWN OF `- �� DBARNSTABLE LOCATION jl �e o 'RO�'� �� SEWAGE# - �S 7 ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. / �n1 C h4 CZ SEPTIC TANK CAPACITY 1S6n 6ct l LEACHING FACIL]TY: (type) owi ,'��ASOr- Trep (size) D6 NO.OF BEDROOMS 3 �- BUILDER OR OWNER 1�r Z ��� S7 cc,,j r PERMPTDATE: X"—:;� '9 2 9 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) wl" Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feeMofaching facili a Feet L Furnished by " l 131 3c?- ,8�. � Fee ®e THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Migaar *potent Construction Permit Application for a Permit to Construct X)Repair( )Upgrade(x)Abandon( ) IXComplete System O Individual Components Location Address or Lot No. %/R�4ALY ®A+/A /Qp Owner's Name,Address and Tel.No.0"ZOW47W De SMA h/Y1A,VA11_Cj 07-601 rgus fir4 6W rHac S 7 v,[,6,V Fhmay pactsr Assessor's Ma /Parcel O � tY7 ller' ress, el.No. -7 444 Designer's Name,Addre s and Tel.No. 3 ��"'®5^® Rr�s v 1,D. /V7kVV0 EWe Z40 P.- . s rrd A o 7 �P��.ro s� D,V"1v/s A4 a2.6 7,o TyPe of Building: 9- ArFslaA+ �/Q 3 /6,(95.t� C�KIV�4�' Dwelling V4 No.of Bed oms Lot Size sq. ft. Garbage Grinder�V)® Other Type of Building No. of Persons Showers( ) Cafeteria( ) ` Other Fixtures Design Flow -3 3 0 gallons per day. Calculated daily flow 330 gallons. Plan Date%bAA ' /9 9 Number of sheets / Revision Date Title / �Sr-,VAI6 Size of Septic Tank SW 6 -.2 Type of S.A.S. 4 jSQW U tVIS7W,10 Description of Soil -:5AEPly z4raamE�Q R/Ll' 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 an not to place the system in operation until a Certifi- cate of Compliance has been issued by oard of Health. Signed ° Date Application Approved by Date G P:�5 -g' Application Disapproved for the folio ing reasons Permit No. &-- 3 g a— Date Issued -7--- - ~- � TOWN OF BARNSTABLE LOC1ATION39 'e5� LtLL4 SEWAGE # 9;L-21 r7 VILLAGE �`�vf��R-V� ASSESSOR'S MAP 6z LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY ( d Ono LEACHING FACILITY:(type) Tvc°-Tb,LS (size) a3 37X6 NO. OF BEDROOMS PRIVATE WEL �PB�LICWATER BUILDER O OWNER DATE PERMIT ISSUED: 3"/;7-d I92. DATE COMPLIANCE ISSUED: S' /a27 hq L. VARIANCE GRANTED: Yes No t, /FEz. - ?.0.............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Allpfiratiuu for Diupua1 Vorkg Tuustrurtiu Application is hereby made for a Permit to Construct ( ) or Repair (gp) an Individual Sewage Disposal System at: Location-Address or Lot No. ......... '...�_................q.v\�`T...................................... ........_.. _� ...........------.-------.--._.---------.............. Owner Address W `c (!Ov l s'tvz�c'tc '�o s ,c -•..1 ..- --•-----•---•. ---•••---••••-••--••-----------•---•---....-----••......_ � .. 4. ....... wA114.................... Installer Address d Type of Building Size Lot--------------------•-_--_--Sq. feet U Dwelling No. of Bedrooms...:........................................Ex Expansion Attic�-+ g— p ( ) Garbage Grinder ( ) Pk Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ W 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. I................minutes per inch Depth of Test Pit.................... Depth to ground water--_-•----__-_-__•-----_. 04 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................ 9 •-•••-••-----•--------------••---•-•---•--•••-•----•---••-•----....•---......---......_...-------•--.................................................. ••-•-- 0 Description of Soil...............................................................................---------------------------------------------........------............------.......... x (� ----•-•-••--•-••-•........--•--••---••-------••.......--•-•-•.......--•-•-----•--••••------•----•------•-••-•---=-•••---•-•------•-••--••-•-----•--•--•-•----•-••---••-•••-•------•--------•......---_.. W U Nature of Repairs or Alterations—Answer when applicable__t!M- ------(+S oo-_----_5��� �? ---••--•-••-•-•--•-------------------------------------------------------------------------------------------------••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compkance has been issued by the board of health. Signed ------- ---- ---<_--- - -------- --- ------- 6/g Z Date Application Approved By ............ r Application Disapproved for the following reasons- --------------- -- -------- ----------------------------------------------- ----------------------------- -- ----------- . - . Dace PermitNo. �?a....-...i.i..7-------------------------- Issued -- -- -- -----...................--- ---------------- -- Date 17 F�s....�©..... ..- r THE COMMONWEALTH OF MASSACHUSETTS ( BOARD OF HEALTH' TOWN OF BARNSTABLE ApplirFatinn for Disposal Works Toustrnrtion prrmit Application is hereby made for a Permit to Construct ( ) or Repair (SD) an Individual Sewage Disposal System at: -------- ----•-••-•.........................................•--....------•---..........----...........--... Location-Address or Lot No. W Owner Address ...00")%�ioc\row 38 Ko-A-K_ � �f2tN�✓IS... -- -----......- Installer Address Type of Building Size Lot............................Sq. feet V Dwelling No. of.Bedrooms___••-•-.---•--------•----------------------Ex anion Attic � g— p ( ) Garbage Grinder ( ) aOther.—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) � 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 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........................ (X4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -•-•----•••-•-----------••------•-•-•----•-•----•-••---•................................••-•-.•--•--......................................................... 0 Description of Soil.......................................................................................................----------..-----------------------•----•-•---._..........._.. x U •-----------------•-•-•••••--•--•-•-•-----••-----•--•--------•---•....•-•--•------......---••••-•--•.....------..................................................-..................................... W x U Nature of Repairs or Alterations—Answer when applicable._�'!''s�'_-'.`_�--_--. o0o ge ......................a. p` ------.... `� .- !w�\1 -\V^, o•tom 5 t -----------------------------------------------------•---------•-----------------------------•................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli nce has been issued-by the board of health. ......� Signed ........... `�- Date ApplicationApproved By .............. ----------- ------------....-------------------------------------------------- ........1)-a�-G-.�_.a Dare Application Disapproved for the following reasons: ........................................--------- ------- ...............----- -- ---------------............................. .- . . ----- ---------------- ----------- --------------- ------- -------- Da[e PermitNo. .. 7........ --. Issued --------------------------------------------- ------------------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C rr#tft.ett#E of Graylianre HIS IV TO C RTI L That the Individual Sewage Disposal System constructed ( ) or Repaired4_<:�') Insta-Ilex at ------- -- ----------------------- --------------------------- --------------------------------------------------------------------------------- -------------- ------------------ --------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ---------.. ......I..I... ........ dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----- - ---------------T .. �. .. �......----------------------------- Inspector ........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE DispoR al Works Tonstrnrtion an it �e.l4_e-cj Dow s� Permissionis hereby granted...---•-•----------------------------•.....--------•----•---------------•-•---------------------•--....-•----------......................--- to Construct ( ) oV�,, � epair (eT an Individual Sewage-Disposal System atNo............--............................................................................................----------•---•.................•••-----••••.....----•-•-----•-•••--•-.............. Street �l as shown on the application for Disposal Works Construction Permit No._ `-iN7 Dated.......................................... ----------------------------- ., �- - .................................................... G M Board of Health DATE.................... -.1� ..-. ,/•.. .....-----.....-•---• FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS TOWN OF BARNSTABLE LOCATION 1f /l c'J� L���(/ /'A0�.1 SEWAGE# AM VELLAGE `/ ��- ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. _ Ict `r�-S hQ(;z SEPTIC TANK CAPACITY /5-7n LEACHING FACII.TTY: (type) F�o� i /= .�5'c! (size) NO.OF BEDROOMS 13 DUILLDA VA VYYIVZA y- 1- IT!JZ/ / "Qt C 1 PERMITDATE: '" r ' COMPLIANCE DATE: Separation Distance Between the: c Maximum Adjusted Groundwater Table and Bottom of Leaching Facility _ O °' '` 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 fee of leaching facili �� / Fee Furnished by ter — i 1 r ; L7 I I SysT,� sq,S_.� x W/T'H 4 �0 4-c4 � g, � `� ' �� /y- zo L�.,o✓NG vs//TN -� s7tiv� ©.�. 6 ( ll o � _ ^O � fl '� o s.O•�s,wD?'3-Tb.�.� GK. ,�, .hS. o 'fj ,. i'` � - N t�• o / �✓�w ��unt,8/n/G /7 9- �- B•7 ,5-Fx/sr I. roRT 6 oP.C- �� aEP.c � --- _. ��-/2-, - -� Pvc -4 Pvc sue/►+ -!o M TX EL 2D•, scH-40 -�- —� ;, .�•m �L /6, 05 o . F4 /4. 5'5- FL p/►� '�/ 5 2 2 Z o /6.2077 . \ cl G. 0 ; // E/. /6.37 6.03 1- G.33 �9e o-F pond F_r , --.. 7'•�•�t�: f�-20 /YLtx/Ntvi+n GieQu.�io VSG4-r.=A P/e. D F/L E OF � S� Yyi4 G F' sYS TE/1il y;/o ScA[.� � ►� p ,Q Z AbA-rloN or -. 70//- 7Tj.S7- Cc�sv y, jj /3�l�ec�on�s -4,A" (B.oe) I-1OusE'. -rz �./v/v,gr 23.) /999 3 ��. 20 YS//DT / � PE�COLAT/c�V. �7� .Z/sit/N -�•�/G}� ( 3,537 SQ.f T ) .3 BP k. �' /�O Gf{4 f BDR. _ j3 O 6,4 4. O GiCL�. .�L. /c�3.c9 _ !� 1 USA /P.��U!�C�'Y� 3'DO G�4 }'T/C TiAivK �l O /o Y/e A�-3 L®. t Y Saivp G GH/1�fG ����4 (/2)(30+(/2+/2 f36* 36�(0 �'0�= g84S�.F7' 4.rA0i4 6 ; C/4PA6 T'Y 490 AI _ 33 C m.7.4 GAL FT. = 3 38.9 G.4�. /O �I A,cs�ct•1/�/G c.4P,dc/ry 43 sq.f�: /sir • BaTrom of (.c oases 1p� fi O i /. /S O.e.�twiwG �.e��P�tRz� FaR S�ln�iTiti�EY f'u,�aeas. x c�v�.y, /27 P 1 I 2, /T�4Y G�LsTRUGTIC."v T+O MST Tir<_,�- 3"(_3/O GNI /S:GOa�. vD .Cocu. Gu�.aT /Uo vvs�T�R �vGae�n/T.� I� � - An 11. . s rr�e� p/sns 13, ^,eO"5- yv/Thy A�s�tS.�F_D O� we enp GN/PS � O PROP, /�©D G,S•T. � �rvewsT�t.�' Co�w.a-r-o,� NcflA-IARf< . 7'oP or 64e5"r-,Az=r,E zq eq wovp (.0 .f-4 /8: 6 3 (JV! G.Y. P. Apw-,eox. aC 7, LoGUS /-s FLOop Zoti .B .AIVD C (P�l,,c4 into. ZSDO/ 0006P 2�/992 (Arv.)• / E 6. Lmcvss is ovrs/do E of roowne/6ur/c" PoeorocrIc" 0/-rrjb a-r �ss,Esscve5 / IAP 22 7 P vQG�/- �{3 'SN /0 GP) ,er<,vo is ewrs/�.c �wY WG'LLH��ID �9?DT.6CT/Q/V WSTR/eT (WPJ• P,J-, f3K. �l AS / ---,qA 4.4 V E7R F'Y, .4 P B/C'. 114:96 7 PG. to-4 r /6e 2-D/ i'P1.t4N of,l- "D 4 18 c�!vs�TTS_) // D L-✓�Y, vr> D� O 1 Y �5 �i�'�id�� FOR .��JZ�TH D•STi4/!!�Y ' WR f, / ,E.K4rr/,va SST .rArv,,47/ON /8x // _ � /.� 1� '(X. .S TEsT (y{uGE Hbt� -4 oc o,,, ou / - .?© P,aT t� x.8 23, /99 9 v h �E 45'7 aw, /s � � /�v�E-.aR. Yam• / � `�� �`.L,�Y/lT/ON P`;L � /ekArLO 18 �g� 8 �iQoPDSD PrF o P, P OP. -A j .6 G Z0481 4 \ , /2 X,36 A AC. t ' VOAA"A4 PRO Y.="D ,} fad DONP.LD ��\' E36A�D ©F /-/��4Z/-/ MONCEVtcz v,( Ma.20487 O / /0 s-0.00 i PR OROSFp _5; /4"I'rAA Y SYS r,=I" U{-'G14,>A b.=' U .�6,5 9 18'` 3'0 0 0 0 - ., .,BM.•p-� �. // RED L 14 Y POA IP �ash AP _ R v , t 9 g q Fo/e �4�PL ol4v� Go>a �� Rip L i�.Y Pcwo /�o�a BONA J-P W A40/vcE v/c z , _ L I ZA I-34 Tf f D. TiE'UST.c",E FOR THE "� 13�NCHi�IA/�'K G/y/� 'iycs//�/EER -'TAN4�Y ,4M/L y 7/e UST %/UwA'2 5" /9 9 9 ST. A/L/1/G zo p 414 Y POND RoA-P - �� /uoT�'S'� 40 PDi1lh WESTpE/VN/S�Mi4 SGAG.E �3/�oT6G e260/