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HomeMy WebLinkAbout0040 THREAD NEEDLE LANE - Health 40 Thread Needle Lane Centerville A=210-083 No. 42101/3 ORA ( o 100 ® o o i o 'PD.o COMMONWEALTH OF MASSACHUSETTS 6- EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED TITLE 5 SEP 3 2002 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS N3A OF BARNSTABLE SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM I HEALTH DEPT. PART A CERTIFICATION r— iAAP Property Address: .(4 d 4vLWZQ. 77 49-a(k PARCEL Owner's Name LOT s Owner's Address: 40 an Date of Inspection: / Name of Inspector: (please print) l Cha �..9m t Company Name: Mailing Address: o; 6'2 S Telephone Number: — ^ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails J Inspector's Signature: Al,(' 0 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11, ,OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: yD Owner: Date of Inspection: Z, Inspection Summary: Check A,B,C,D or E/ALWAYS complete aiid5brf� a;: 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. _ 1_K)IIi, "Comments: .� B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be r aced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of, ealth,will pass. Answer yes,n r not determined(Y,N,ND)in the for the following statements not determined"please explain. The septic tank is me and over 20 years old*or the septic tank(wh er metal or not)is structurally unsound,exhibits substantial in t ation or exfiltration or tank failure is ' inent.System will pass inspection if the existing tank is replaced with a com ing septic tank as approved by Board of Health. 'A metal septic tank will pass inspectioW4 it is structurally sound,- leaking and if a Certificate of Compliance indicating that the tank is less than 20 years d is available. ND explain: Observation of sewage backup or breik water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled even distrib 'on box.System will pass inspection if(with approval of Board of Health): br n pipe(s)are replaced struction is tmoved distribution baoc is hweled orTgA ced ND explain: The system re ed pumping more than 4 times a year due to broken or obstruc pipe(s).The system will pass inspection if(w' approval of the Board of Health): broken are replaced obstruction is removed ND explain: 2 " Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 44b Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board /rderr to dete ine if the system is failing to protect public health, safety or the environment. 1. ystem will pass unless Board of Health determines in accorMR 15.303(1)(b)that the s tem is not functioning in a manner which will protect puby and the environment: _ Ce ool or privy is within 50 feet of a surface water Cessp 1 or privy is within 50 feet of a bordering vegetatedt marsh 2. System will fail unless the rd of Health(and Pub /-IWater Supplier,if any)determines that the system is functioning in a manner t protects the pubbc health,safety and environment: _ The system has a septic tank and s '1 absorpti n system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surfs a wat r supply. The system has a septic tank and SAS a SAS is within a Zone I of a public water supply. _ The system has a septic tank and S and the is within 50 feet of a private water supply well. _ The system has a septic tank an AS and the SAS is ss than 100 feet but 50 feet or more frott5 a private water supply well". Meth used to determine dista e "This system passes if the we water analysis,performed at a D certified laboratory, for coliform bacteria and volatile organic ompounds indicates that the well is fre om pollution from that facility and the presence of ammonia ' ogen and nitrate nitrogen is equal to or les han 5 ppm,provided that no other failure criteria are trigge d.A copy of the analysis must be attached to thi form. 3. Other: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: D Owner: Date of Inspection: 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 r cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to'an overloaded or cesspool cl ed SAS or g / Stat] liquid level in the distribution box above outlet invert due to an overload or clogged SAS or cesspo i Liquid de in cesspool is less than 6"below invert or available volume less than '/z day flow Required p ing more than 4 times in the last year NOT due to cloggE: or obstructed pipe(s).Number of times pump Any portion of the AS,cesspool or privy is below high ground 3tteer elevation. Any portion of cessp I or privy is within 100 feet of a surface7ter supply or tributary to a surface water supply. Any portion of a cesspool privy is within a Zone 1 of a blic well. Any portion of a cesspool or ivy is within 50 feet of a ivate water supply well. Any portion of a cesspool or pr is less than 100 fe ut greater than 50 feet from a private water supply well with no acceptable w er quality anal y s. [This system passes if the well water analysis, performed at a DEP certified labo tory, for oliform bacteria and volatile organic compounds indicates that the well is free from p lutio from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal ,dr less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis be attached to this form.] (Yes/No)The system fails. I have dete ined that a or more of the above failure criteria exist as described in 310 CMR 15.303,t erefore the syst fails.The system owner should contact the Board of Health to determine what wil a necessary to corre the failure. E. Large Systems: To be considered a large syste the system must serve a facility wit a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"y s"or"no"to each of the following: (The following criteria a ly to large systems in addition to the criteria above) yes no — the syste is within 400 feet of a surface drinking water supply the s tem is within 200 feet of a tributary to a surface drinking water supply t system is located in a nitrogen sensitive area(Interim Wellhead Protection Area— WPA)or a mapped one II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or swered "yes"in Section D above the large system has failed. The owner or operator of any large system considere a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 R 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST c-- Property Address: U-. Owner: Date of Inspection: Check if the following have been done. You must indicate`yes"or"no"as to each of the following: Ye 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? (l _ 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? i/ _ Were all system components,excluding the SAS, located on site? V _ 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: Yes no �_ 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(3)(b)] 5 Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: , Owner: Date of Inspection: ( d FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Ll Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): L/qQ Number of current residents: Does residence have a garbage grinder(yes or Is laundry on a separate sewage system(yes o n6:__ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: es or (Y © _ Water meter readings. if available(last 2 years usage(gpd)): aQ Q UOQ Sump pump�or(:_ a G — l pp i' Last date of occupancy: COMM ERCIA NDUSTRIAL Type of establishment. Design flow(based on 310 5.203): d Basis of design flow(seats/persons/s c.): Grease trap present(yes or no):_ Industrial waste holding tank prese yes or no):— Non-sanitary waste discharge o the Title 5 system (yes or Water meter readings, i ailable: Last date of occu y/use: OTHER escribe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of th8 inspection( o o): If yes, volume pumped: 10W gallons-- How was quantity pumped determined? •Q�& Reason for pumping: _ ,anw Q�,Qa TYPE OF SYSTEM IZ-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) Tight tank _Attach a copy of the DEP approval —Other(describe): Approximate aye of all�components to installed 'f known)and source of i60, mation: Were sewage odors detected when arriving at the site(yes o no . 6 Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: C4 O � Owner Date of Inspection: Q TIG or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below gra e. — Material of construction: concrete metal fiberglass po ylene other(explain): Dimensions: Capacity.: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in wo g order(yes or no): Date of last pumping: Comments(condition o arm and float switches,etc.): DISTRIBUTION BOX: ✓(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 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.): , G ju PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(ye�sno�� Comments(note condition odition of pumps an -ap ances,etc.): 8 Page 7 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 44D� - ✓�- Owner: Date of Inspection: BUILDING SE locate on site plan) Depth below grade: Materials of construction:_cast iron 40 P other(explain): Distance from private water supply we uction line: Comments(on condition of jo' ,venting,evidence of leakage,etc. . SEPTIC TANK:_(locate on site plan) Depth below grade:" . i � b � `' Material of construction: concre a_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10a0 C)� Sludge depth: 1' Distance from top of sludge to bottom of outlet tee or baffle: ao Scum thickness: 10 Distance from top of scum to top of outlet tee or baffle: O Distance from bottom of scum to bottow of outlet tee or baffle: 1? How were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as relieed to outlet invert,evidence of.leakage, etc/..�1): } GREASE TRAP:_(locate on site plan) Depth below _ Material of contc : concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or ba Distance from bottom of scum to bottom o tlet tee or ba Date of last pumping: Comments(on pumping reco ndations, inlet and outlet tee or baffle dition,structural integrity,liquid levels as related to outlet inve idence of leakage,etc.): 7 Page 9 of 1 1 i OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection: 21 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why:_ Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: t/leaching trenches,number, length: 1, 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.): cc 0 CESSPOOLS: (cesspool*must be pumped as part of inspection)(locate on site plan) Number an figuration: Depth—top of liq inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydrau ' ure, level of ponding,condition of vegetation,etc.): PRIVY: (locate on site pl Materials of constructio Dimensions: Depth of solids: m Coments(no condition of soil,signs of hydraulic failure, level of ponding,condition of vegetate etc.): 9 Page 10 of 11 O OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: q0 Owner: Date of Inspection:' 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. 1d,tr�-Q- 3 60' 10 Page 1 1 of 11 w OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 96 Owner: Date of Inspection: (� SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater �e�feet y Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: '✓Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach docu entation)_ �L Accessed USGS database-explain: „L You must describe how you established the high ground water elevation: am 11 No.-! W-•-,t ...... ......... ... _� THE COMMONWEALTH OF MASSACHUSETTS 7/ BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinii for Diripagal Work.. TouBtriirt"inn ramit Application is hereby made for a Permit to Construct ( ✓) or Repair ( ) an Individual Sewage Disposal System at: L� Ito% =,cation-Add r" C or Lot No. ......................_..:�=•-`'� G I --------------------------------- ... �_.�✓��✓ C-� � dress ae... . 'Y. ----------------------•--------...--- D. 3o�C_ 7..._.;�3Pe'-!o11P®�c�'T....... Installer Address UType of Building l Size Lot___Z�./ __.._...._Sq. feet �.t Dwelling—No. of Bedrooms____________ ___________________________L—Expansion Attic ( ) Garbage Grinder Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures ------------------------------------- RP ---------------------------------..._...---•-------•-•--•-•--------•-•--•------•---•-•-------- W Design Flow.................../Ze.................gallons per4A+sea per day. Total daily flow......................----6�. _ ..........gallons. WSeptic Tank—Liquid capacity/0_._.galIons I engtli________________ Width----- Diameter----.----------- DepthC�.`�................ x Disposal Trench-- No. _�................. Width.....`?............ .total Length.-._-3.y--------- Total leaching area----- l__7__..sq. ft. 3 Seepage Pit No------------------... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (V-T- Dosing tank ( ) Percolation Test Results Performed by.. 9_.> � � ......��..................... Date.......1�47_._ �^....•.._.. ,.a Test Pit No. 1......_..... minutes per inch Depth of Test Pit...I2Y......... Depth to ground water........................ 44 Test Pit No. 2.-4,2-..._minutes per inch Depth of Test Pit...1e'V-------- Depth to ground water........................ 04 .....---••••----------------•----•-••---•... .. ................ ...... ...... 0 Description of Soil.......C&AAz`. ...-=•.............//�2'.-------------------------=---------------------•-----------------------.............--- W V ------ -................................... •---------------------------------------- ----------------- ..------------ .._..-------------------- •----------------------- •--------- ...-•----------------- W VNature 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 TITLE S of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. G Signed .............~ .�.. .°....1/�r!L........ L -� ............. .................................:...... Dace Application Approved B ........................................................................... ....� ' s ....�.. ... PP PP y ............... �ce Application Disapproved for the following reasons: .................................................................................... . . ................... . ............... ............................................................................................. ......................................... . ..................................................... ........................................ Dace PermitNo. ......T5.- ---------------- ------------- --- Issued .................................................................... Dare .,-«.w.•y-'�,,••.tyrd��v...-,--'...�-,..� -v-.-.+v+r+-va,.+,�,�., _...�,.��....- ya..rwti,,.....�f,. .....--�.i-.-- �.. ..,.,.,., •yv .., a..w-�..,.... ...,..-�..+rr.,,.-�..,....r,,._ _ -.. .. a�-a.� S3 T No..L.,L-. Fxs... t6..<�.......... r t THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for D4,ipw3al Worlii C omitrttrtiou rrrutit Application is hereby made for a Permit to Constn>ct ( ✓) or Repair ( ) an Individual Sewage Disposal System at: Location- \ddm or Lot No. Pcl .s. �✓�,�j-wo/�/l-•---------•---- % �✓/�✓Gca�'.1a�� ,9n? -tiny ..: M/�,�J ,(� Oo•ner Address I J_. ...................................... a, t/...... _�.fl�c?�-I.(�(.J/ Installer Address { Type of Building Size Lot.__ ©_.�...........Sq. feet �.. Dwelling— No. of Bedrooms................•----___-___________--_-.._Expansion Attic ( ) Garbage Grinder ( )/tJ4 aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------- - • ••---...---------------- -------=-----•-------------------------•-•---•---..._......•. wDesign Flow...................���_____.._.........gallons perFger-san 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..--- 9.�...sq. ft. 3 Seepage Pit No______________-__.._ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (✓S Dosing tank ( ) _ 1 aPercolation Test Results Performed by. ...'�......��2�' .................................. Date.......?�fA t �7 L' Test Pit No. 1......_Z- minutes per inch Depth of Test Pit___ ...... Depth to ground water........................ Lz. Test Pit No. 2.L..z...._minutes per inch Depth of Test Pit.../yt......... Depth to ground water........................ CAI' Description of Soil....... AA 4` __.. r/7'/'9 ..�._...-���ZA�L- x U .........--•--•---•••••--•-•-••-••--•---------------------••--••-----••••--------•--•--••-.......•---•--•----•--••---•---•••-----------•-------------••--••--------------......._.......--•-••--•--...... w 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 TITLE 5 of the State Environmental Code —The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. ok&Signed ..............- ........1�u1.�.._... �e ......... .... .................................:.... Dare Application Approved By ..---------` .... ..t < a,�,=<, .............. e...-..`�. Application Disapproved for the following reasons: . ..................................................................• . ........................... . ... .............. ........................................................................................ ..................................................... ......... .. . . p Dace PermitNo. ......./... ..-....L1...................... Issued ................................ . . . . ................... Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (NILlEr#iftrate of CTlomplian e THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( x ) or Repaired ( ) by ... „'LI .44-------------------------------------- ------------ .............................................................................................. -- atf�....... t .. ....-.L. �.�tie...._............ ......... .. . -- .......• has been installed in accordance with the provisions of TITLE 5 Cof The State Environmental Code as described in the application for Disposal Works Construction Permit No. _.... _.L/................... dated ------..._............................._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE...... .... ... ......... Inspector .. - -----............................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH qq _ TOWN OF BARNSTABLE No....J...�- --•�•--- FEE....10�.......... Biapofitt1 Vorhp�,,Tongtrudiatt "nutit Permission is hereby granted.....................:. -�.�.____�1. _ A '.o---_-•------•---- to Construct (k ) or—Repair ( ) an Individual Sewage Disposal System (^n _,, J Street qa, as shown on the application for Disposal Works Construction Permit No.l --_,{y�.___ Dated.......... ................................ -------------------•------------ -?....................................................... q v Board of Health DATE..................I =/.-. _........ FORM 3850B HOBBS 6 WARREN.INC..PUBLISHERS ®-p C1_07 6) TOWN OF BARNSTABLE LOCATION �� N�� � �' LE LA SEWAGE # LY3-4 VILLAGE ['E�277E?-V !L LE ASSESSOR'S MAP & LOT Z INSTALLER'S NAME & PHONE NO. M.•C_ M SEPTIC TANK-CAPACITY 1000 G/9-L ., LEACHING FACILITY:(type) (size) ' NO. .OF BEDROOMS _PRIVATE WELL OR PUBLIC WATER PORQC BUILDER OR OWNER DATE PERMIT ISSUED: ' Z 0 ' 63 DATE COMp`UA'N_ �ES`II VARIANCE GR2T`�m Yes d' -- ` ,. � :� /� I c `� `�/' l�� t `� bG��� � 1���---• _ .. �� � e • �\ ' � U ` � � .. 7 �� � �. � � .. (� `� S SESSo2 MAP 210 R cEL: 8 4 a 3 "�sT Hot. . 1.a s � N dTE� Cut? eWT EoK i K -r �-D- I NGri t�lEE2 DIJAP. KELt Est' I. 1/Et?"t`ICAI_ t Tot F(SSuN � Ft?oert QUAD s grjI Lit N(, SEfi t3AG+c5 u. v 2. MuN(C I PAL t•JttT ELL fS /�YRI L..ABt.:� . 3a 5 16 Ia b,a.T 1 t 1�-q2� , � 3. S GH E>✓V LE 40 - 4" Pvc. 1>t Pa= To SE USED , v, - PeJZC, iZAT'F- `'2 1��w/1�, 'T:H P-O V 6 H - OOT S EPr'1 c. SYSTTEM, �4E- fL,00D Fa G -1 . ALL. Pmu+ST UNITS To c,oW:F- M hl ITt I Gi2E,Qr MA¢a}t .r-H- -J-•H- 2 A At S H TQ=� LOfiD t t.l SPEC t l UST i o►.15, �c�r�s�'ZS 47•R -t;5 5, P1 PE P ITC- Flu } = 1'�t p PER 1=ooT V(\ICES 5 ��ev E�cv OTHEV-1-41SE NOTED. 16P Tc�P �,` 6. P1 F-ST 2. oP P1 PE OUT OT- D- BOX TO BE L�f-=vCL. 4f SvstolL-1444- 4f SuBSot 44 b 7. THE 5EPTIc- SYSTEM 5 t4oT- - i3F..z�-t DEs I U►.a Erg LocATtot->: Mfg' t AYE s L krttz5 TO Ac coM M ODATE 7t4 usE DF A G A28AGVE G1ZI►J e, D� OF 8. ALL_ GoNST2�JGTtoN CETAJL-S AP-F- To ZE IKI C0AfZSE GOfiRSE C-oWFO)z-MAWS WITH THE STATE Or- MASS . SANT' SAtiID 'F�2VI?�NME1JTf1L c.o>� �TITL.� v� , 1-5-z 3�.`j GQ,AV�I_ `t. 60t-.1TC-AGToV- To VEP-tr-Y L�ATtot-t. of Apt, UTii_iTES CoAt?SE P2t o2 TO cow ST 2v c-T i b+4. WN;T� I`t4' 35.5 lo. DISTR413L1'T ot-J Fox To >~E "ATEtZ `jESTECa TD P=NSv '- qa� SAKE >.EVE�►aEss Aran EQ�e�L. �ww . 4I � - I74. 3.4 11. ALL 5 kle-C 1_If1E5 ANCI SES'TI C- SYSTEM CoMFr->NCNTS Atz2F- Tz5 t3E A M1 u i M vM btSTAWCC Or- Id V-00 Au- j Na GP,.a��aowATEr- �ricou�r�.e-E� W ate-- t.-1 rl 4E:5. AZ` --- SEPTIC, SYSTEM MSI&N 4 3 0 _ 43 '--. rL0 38SS �. 'FLOW EST t MPoTE BEDPk70 r-tS AT 110 GAL/ra4Y/t3� `f 4� 6t AL/DhY �k . � 5E PTtI c- T^t,t K: 4 ` p5 \� -f 4o <5^t / Y x 1.5 Ds►.Y'S G7Al-. �C,�)orn , . ! 115E 1000 6-tfILLO+,4 SEr-Tlc. -TAh4K LEACH 1 Nil G- AZ EA USE S 1►JFtL1-P.Ar0E-5 W 1j-1+ 2 err- St DE AAA <SAL:/DAY l3oTToM ReEA. 39-117 = 231; Sf C1.0 = 238 GALEi `t' / k TOTAL- U`ip�C.ITY = 4`14- (AL-/bAY / f IN 1 `.-� �-r- '�"�---� �/ JE PT I C- I o N 4 47.,57� 3 bISTW LUj ►01.1 t t►,IES Z" F iSTO+ lE A0� -roeap FavW�ar►da EHr�e�wv T++><ouc7-r+ ToP 2 of 311"-IYz' TM N' L� `�. `1 pM /� WASFI�D SToh1 E / let 5i AB 4 / / Ems. E�. Z 3,q' Z Cb � pe. --•-_.,_, � _-i ��`— `� -5 E17Ti G TAN K (H ) t TEE '5 t�E S � fi F t L T EAZ01'S ��.' 3' I•z S t�EE P� x x I N LET - Cup, 10" Cbowl 'j W t TR 2' OP sPDWE (3,t-'h -7'- 1.Z,5') OUTLt-T: 4�;'upl I`T" N al - Zo) r gENCHMAf2.K AT Pk NAit_ ELEV. = 4s.o LOCATION' LoT 19 TH 2F.cr,> N Et<PLZ Lao uE _ GEt'tre-PYIL-L-E MA Key PR.EPAP. 0 FOZ: Pt=�.l ltiIENT WDtZ.T t-t-- Pl=.oPo k Ct5I Y 5cAL�E : DATE '• iZ-Z3-Q 1G E t �'RJDf'oSEC' SPGT Et..l=v : 43 , j,' •: . V / .n s THOMAS J. Me-LEU-AW P.E. JoHR Z.MHAREST, J2,PL.S DEMARES'r-Mc.LCLLAN ErVc5,INEERIN6 t7M # Z- w5 3