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HomeMy WebLinkAbout0131 STONEY CLIFF ROAD - Health 131 STONEY CLIFF RD. CENTERVILLE A = 190 013 037 I llll UPC 12534 No.2®1533LOR 'bsrco � HASTMOS•MN r Commonwealth of Massachusetts 0 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is required for Centerville MA 02632 May 6, 2009 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. Important: A. General Information When filling out forms the computer, r,use 1. Inspector: only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. Company Name r� PO Box 371 -17 Jan Sebastian Dr. Company Address Sandwich MA 02563 rerun City/Town State Zip Code 508-888-2805 S112843 Telephone Number License Number B. Certification certify that I have personally inspected the sewage disposal system at this address and that thy.;' information reported below is true, accurate and complete as of the time of the Inspection:—The inspection was performed based on my training and experience in the proper function and rr�aintenan.ce of on site sewage disposal systems. I am a DEP approved system inspector pursuant-to Section 15.340 of Title 5(310 CMR 15.000).The system: �= ® Passes ❑ Conditionally Passes ❑ ails nz , co ❑ Needs Further Evaluation by the Local Approving Authority C) uo. f��• May 12, 2009 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. L b 5do q 131 stoneycliff•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 1 { Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is Centerville MA 02632 May 6 2009 required for Y 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: ® 1 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 completio 'of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in e ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 ars old*or the septic tank (whether metal or not) is structurally unsound, exhibits subs ntial infiltration or exfiltration or tank failure is imminent. System will pass inspection if th xisting tank is replaced with a complying septic tank as approved by the Board of Heal-I. *A metal septic tank will p,@(ss�inspection if it is structurally sound; not leaking and if a Certificate of Compliance indicating✓that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settlled'or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed f 131 stoneycliff•03/08 jr" Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ..'" 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is y Centerville MA 02632 May 6 2009 required for , every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or re ldced ND Explain: ❑ The system require pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass spection if(with approval of the Board of Health): ❑ brokef!i pipes) are replaced ❑ a�struction is removed ND Explain: 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 envir,nment. 1. System will pass unless Board of Health determini/es/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: F: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board o,.f 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 t6nk and soil absorption system (SAS) and the SAS is within 100 feet of a surface wafer 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 aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. 131 stoneycli f•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is y required for Centerville MA 02632 May 6+ 2009 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is)4ess 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 an/ofa�mmonia erformed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no othe ailure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: a� D) System Failure Criteria Applicable to All Systems: You must indicate "Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow ❑ ® 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. 131stoneycliff•03/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 4 Commonwealth of Massachusetts H - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is Y required for Centerville MA 02632 May 6, 2009 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or" "to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 40 eet of a surface drinking water supply ❑ ❑ the system is within 00 feet of a tributary to a surface drinking water supply ❑ ❑ the system is loc ed in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) a mapped Zone II of a public water supply well If you have answered "yes" to any uestion in Section E the system is considered a significant threat, or answered "yes" in Section D ove the large system has failed. The owner or operator of any large system considered a significan hreat under Section E or failed under Section D shall upgrade the system in accordance with 31 CMR 15.304. The system owner should contact the appropriate regional office of the Depart ent. 131 stoneycliff•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is Centerville MA 02632 May 6, 2009 required for y every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system 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)] 131 stoneycliff-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is Centerville MA 02632 May 6 2009 required for y every page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD Number of current residents: 4 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 years usage (gpd)): 2007=230 GPD 2008= 136 GPD Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): aiions 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 TitlX5ystem? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: % Date Other(describe): 131 sloneycliff-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is required for Centerville MA 02632 May 6, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: Ready Rooter records: Last pumped Aug 11, 2008 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): Approximate age of all components, date installed (if known) and source of information: System installed Oct. 18, 2000. As-built and engineered plans on file with Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No 131 stoneycliff•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is Centerville MA 02632 May 6, 2009 required for y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 28"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 20"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: 11 X 5 X 5.5 1500 Gallons Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 36" Scum thickness 1" at outlet Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure and dip tube. 131 stoneycliff•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is Centerville MA 02632 May 6, 2009 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Next maintenance pump due Aug. 2010. Inlet and outlet PVC tees in place. Liquid level at outlet invert. Risers bring covers within 6"of grade. Grease Trap (locate on site plan): Depth below grade: feet i Material of construction: ❑ concrete El metal Zbess ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from topdof�'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 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 inspectio (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fib-- lass Elpolyethylene Elother(explain): 131 stoneycliff-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 10 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is Centerville MA 02632 May 6 2009 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gfieons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition lalarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, two outlets, equal flow. No sign of high water staining over outlet inverts. No solids carryover present. Riser brings cover within 6"of grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No r fr< 131 sloneycliff-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is Centerville MA 02632 May 6 2009 required for Y every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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: Type: ❑ leaching pits number: ® leaching chambers number: 2-500 gal ea w/4'of stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS located and inspected with camera. No sign of past hydraulic failure. Clean stone visible through sidewall of chamber. Liquid level 2"from base, high water staing 8" from base of SAS. Hand probing over and around SAS found clean dry sandy soil with stone. No sign of present or past ponding. 131stoneycliff•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is required for Centerville MA 02632 May 6, 2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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 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 h raulic failure, level of ponding, condition of vegetation, etc.): I 131stoneycliff-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 13 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 131 Stoney Cliff Road Property Address Dianne Cameron Owner Owner's Name information is required for Centerville MA 02632 May 6, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. ' I i I , i 1 I I 1 j Q 3 3Gt C.3 O O � -3 - 131stoneycliff•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 14 TOWN OF BARNSTABLE LOCATION 3 ( c�.nc�1 C ; �c�(. SEWAGE# (Do- 6 Q 3 VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY <D c) CX , LEACHING FACILITY:(type) Q � .rkcS$size) SdJcra �/ y NO.OF BEDROOMS S\ OWNER PERMIT DATE: COMPLIANCE DATE: /O//• O Separation Distance Between the: e Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist , within 300 feet of leaching facility) Feet FURNISHED BY i A 3 6 ' 0 01 L- 3 3 0, < �. i 3 TOWN OF BARNSTABLEe � LOCATION /�� ,�7o�rL�/ ��r i�l� SEWAGE # DD 23 VILLAGE ASSESSOR'S MAP & LOT/Q0 0 INSTALLER'S NAME&PHONE NO. Y77�o3y1 SEPTIC TANK CAPACITY /SD4 ,,rr LEACHING FACILITY: (type) �04 6,at/, A-e/t//,: �s(size) NO. OF BEDROOMS 3 BUILDER OR OWNER 2 1A641�/9 PERMITDATE: /0-/7-l9 COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching faci 'ty) Feet Furnished by . • �� - '�. � • 'r�) �� � ��_. .. � ,d,� . ' �� '� j ��� I ,. � ., . .,. , Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for �Dioponl *pztem Construction 30ermit Application for a Permit to Construct(j,,)rRepair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. �` C' ,�'�� Owner's Name,Address and Tel.No. ✓f f' 1- (mod:j 3 Assessor's Map/Parcel 9e 03 g Installer's Name,Address,and Tel.No. 4j�.,;J a:741'57 Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil 5•�,a2c' �a Nature of Repairs or Alterations(Answer when applicable) :r&5n4 & /fit® 6.,,1 .57 7,_ _ 00 `!A/3� C�/L' &S Et.//r,6 7/ /5Xeee wIv Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been i su0 by this oard o Health. Signed ,e- - Date /0 - ff? Application Approved by Date /Q— Application Disapproved for the following reasons Permit No. Z47y"6 2 3 Date Issued I TOWN OF BARNSTABLE LOCATION _/3l ,�To`!��/ �/�"mil SEWAGE # 00 G 23 VILLAGE_ C�G�f�'�►/i/� ASSESSOR'S MAP & LOT-/40 r�l3 INSTALLER'S NAME&PHONE NO. `177w3y9 ': SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ize) NO. OF BEDROOMS_ 3 J BIMDER OR OWNER PERMITDATE: /D-/T-00 COMPLIANCE DATE: . 10 -/8—00 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of:leaching fa 'ty)--`... Feet _,..: Furntshed I - d U s \r. Fee t / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: !� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLEs MASSACHUSETTS 01ppYication for Migoal 6petem Construction Permit Application for a Permit to Construct((,,Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. ?J� S'r C' ! Owner's Name,Address and Tel.No. 53 Assessor's Map/Parcel G EHT�%1/�//!= D✓ Installer's Name,Address,and Tel.No. 41,9 og+y Designer's Name,Ad ress and Tel.No. ✓osz!idh D, /3.veo-0s Type of Building: Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures 4 Design Flow 't gallons per day.,�Calculated daily flow gallons. Plan Date ,Number of sheets " Revision Date Title = -� Size of Septic Tank 1 Type of S.A.S. Description of Soil .Nature of Repairs or Alterations(Answer when applicable) Z 5ro !Wa 6AZ Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this oard o Health. Signed 11 Date /D— 00 Application Approved by Date Application Disapproved for the.following reasons Permit No. Z 3 Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( l—),Repaired( )Upgraded( ) Abandoned( )by _4)4 43 ors-»»c'4 at 111 Snoeo.—, has been constructed in accordance with the pro/visions of Title and the for Disposal System Construction Permit No. 7� -G dated / 0'—/7— Z-Oyz? Installer _9&► 2nlS Designer The issuance of this p t�gsh .Ln t be construed as a guarantee that the sys5)1;functio a deli hedj�Date N C� Inspector /1 0 (/ .I Y ----------------------------- .i 9 ----- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEs MASSACHUSE S Miopo$al *pztem Con0truction Permit Permission is hereby granted to Construct( 4Repair )Upgrade( )Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to ' comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this t. /) o Date: /o ' / 7 Approved by �� t i l/6r99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETC$ . YD APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION HIVE rWITHOUT DESIGNED PLANS) hereby certify that the application for disposal worts construction permit signed by me dated /D— /?-—Od concerning the property located at r �0 -�K///�-reets all of the Following cniena: Ir the failed ssem is conne^ed to a residential dwelling only. There are no commercial or business uses associated with the dwelling. 4--T'n-e soil is classined as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. 4/ 1 iere are no wetlands within 100 Fer;of the proposed septic system 6--There are no private wells within l:0 fert of the proposed septic s✓stern (/ There is no increase in Clow and/or change in use proposed 4---There are ao variances requested or rterded_ i ne bottom of the proposed leaching facility will not be located less than dve feet above the maamum adjusted-oundwater table elevation. (Adjust the goundwater table .sing the Frimp(cr method when applicable] • If the S.A.S. will be located with'_fo fee;of any vegetated wetlands, the batzom of the proposed leac ring facility will net be located less than foureen(14) fee;above he macimum adiused .—oundwater table e!evauon, Please complete the rollowing: �) Top of Ground Surace =iz/auon(using GiS iruorrrtauon) `/9 8) G.W. Elcvaaon _the :NLA2C ;]-h G.W. ,-adjustment D F.FERENCE aE 15VEEN a,and 3 ? (Sketch proposed plan of system on backl. a::,c--ich ioidL- ,�� 0 T 2 -Smo �w/, Or y u/r�15 o �� � � ,