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HomeMy WebLinkAbout0004 THREE PONDS DRIVE - Health 4 THREE PONDS DR., CENTERVILLE A = 193 181 IIII UPC 12534 ' No.2 3_R '�r HASTINGS,MN TOWN OF BARNSTABLE p� UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS NAME ADDRESS' �iE- VILLAGE LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE: OR CHEMICAL eqe ,,e (Give same information for any additional tanks on reverse side of card) DATE OF PURCHASE OF EACH: 1. AOX ` , 2. 3. 4. DATE OF FIRE DEPARTMENT PERMIT: /�i©✓ d/� TESTING CERTIFICATION SUBMITTED: PASSED DID NOT PASS • /73 FEB 2 199 (� TROY WILLIAMS g SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 385-1300 19 Hummel Drive South Dennis, MA 02660 Lx ' = COMMONWEALTH OF MASSACHUSETTS . - - EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION Property Address: C--4ce.,'1/,Name of Owner fi—r✓.v.c r} G t/t r 4'i r. l 1.28/9 y Address of Owner .��y i� S Date of Inspection: 31S yI W l,c Tr. Name of Inspector:(Please Print) Troy Williams C'_.'rL✓v /k� . 1 am a DEP approved system inspector pursuant to Section 15.340 of Tide 5(310 CMR 15.000) Company Name: Troy Wiiiiarric Se tic inspections Maaing Address: 19 Hummel:Drive So. Dennis MA 02660 Telephone Number: (508) 385-1300 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails ! Inspector's Signature` J/�17 Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS Although system meets i`ie minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system, piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. ' E'v 1 SeCj 9 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (contirx ) Property Address.owner: 4 Three Ponds Drive, Centerville,MA Date of Inspection: Francis Guertin January 28, 1999 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: IV14 One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, air, as a Y m, upon completion of the replacement or repair, approved by the Board of Health, will pass. Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination In all instances. If "not determined",explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or ezfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 obstruction is removed -v ; sed 9/2/98 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Nor,"Address: 4 Three Ponds Drive, Centerville, MA Owner: . Francis Guertin Date of kupection: January 28, 1999 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A111/9 Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and.the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS'Is less than 100 feet but 50 feetor more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 PeRe3 f I I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 4 Three Ponds Drive, Centerville,MA Property Address: Francis Guertin Owner: January 28, 1999 Date of Inspection: D. SYSTEM FAILS: A(/19 You must indicate either "Yes" or "No" to each of the following: 1 have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due-to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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 60 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E_ LARGE SYSTEM FAILS: ,All You must indicate either "Yes" or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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 If of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. P.p., 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 4 Three Ponds Drive, Centerville,MA Owner: Francis Guertin Dace of Inspection: January 28, 1999 Check if the following have been done: You must indicate either 'Yes' or 'No" as to each of the following: Yes No Pumping information was provided by the owner, occupant, or Board of Health. _ None of the system co p p `Sen or-m Y components have been um ed•forat least two weeks and-the system has been•receiving•normal flCow �(rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. N1/9 As built plans have been obtained and examined. Note if they are not available with N/A. JL/ _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout. V/ _ All system components, excluding the Soil Absorption System, have been located on the site. �L _ The septic tank manholes.were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. / The size and location of the Soil Absorption System on the site has been determined based on: Y _ Existing information. For example, Plan at B.O.H. _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) / (15.302(3)(b)) _ The facility owner(and occupants,if diNerent from owner) were.provided with information on tha.propermaintenarsce of SubSurface Disposal Systems. revised 9/2/98 eeRr 5ol II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: owner: 4 Three Ponds Drive, Centerville,MA Date of Inspection: Francis Guertin January 28, 1999 RESIDENTIAL: FLOW CONDITIONS Design flow: g.p.d./bedr om. Number of bedrooms (design): Number of bedrooms(actual): pc Total DESIGN flow (-3 Number of current residents: Q Garbage grinder(yes or no): /Va Laundry(separate system) (yes or no):/Vo; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use(yes or no): ,VD Water meter readings,if available(last two year's usage(gpd): �� = IV S UUO 9 a�/. 9'7 _ �Q d U O 4 j(o sn-5 Sump Pump (yes or no): /VO Last date of occupancy:_ �,r c Ct p / V COMMERCIALJINDUSTRIAL: N/4 Type of establishment: Design flow:_ qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)— Non-sanitary waste discharged to the Title 5 system:(yes or no)— Water meter readings,if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information:_)?t' `/2114 oe-G d-4d p�Cf g'p �7.t✓ r H7 D hr.. �7 o is„-L O c✓r,t✓" System pumped as part of inspection: (yes or no) /V0 If yes, volume pumped: gallons 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) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed 4if known) and source of information: 4, G6 n van Sewage odors detected when arriving at the site: (yes or no) /vo reviSed Page 6ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(contirxsed) Property Address: Owner: 4 Three Ponds Drive, Centerville,MA Date of Inspection: Francis Guertin BUILDING SEWER: January 28, 1999 (Locate on site plan) Depth below grade: 1 Material of construction:_cast iron Y/40 PVC_other(explain) Distance from private water supply well or suction line A11iF7 Diameter y„•� Comments:(condition of joints, venting, evidence of leakage,yetc.) 72•P L $ Tts✓..r� �(L ca I� �+ 7/ 1+'1 s d 7C c H S rJ t 4 r7 0 h s SEPTIC TANK: (locate on site plan) Depth below grade:-0'' �+w) T S c ✓ �' ^P +• 6 �. Material of construction: ✓concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age Js.age confirmed by Certificate of Compliance_(Yes/No) Dimensions:_ Sludge depth:_ / Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: ^16/JL Distance from top of scum to top of outlet tee or baffle: /Vo 3 c vvti Distance from bottom of scum to bottom of outlet tee or baffle:iV,- -S c How dimensions were determined: n—a10z— , Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structuraHntegrity, evidence of leakage,etc.) Pv ++L.s �� r /� `o r ` .�_ ,�v o✓ ��f hit f{ �' mil^ w oy k v-S uv�tv /fo CA7e SJ'Yv 7'V v-w a is t c✓ /--"r stti f 0.S �o w Gf✓c14xrI�t �-"� '�' n y r�r✓J ✓t (/e—c_c•, GREASE TRAP (locate on site plan) Depth below grade:_ 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: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 had 7of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: 4 Three Ponds Drive, Centerville, MA Date of Inspection: Francis Guertin January28, 1999 TIGHT OR HOLDING TANK:I`/1(Tank must be pumped prior to, or 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/day Alarm present Alarm level: Alarm in working order:Yes No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: !�✓ / Comments: (note-if level and distribution is equal,evidence.of solids carryover,evidence of leakage into or out of box; etc.) PUMP CHAMBER:LvI/y (locate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) revised 9/2/98 page 8ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(corn inuedl Property Address.owner: 4 Three Ponds Drive, Centerville, MA Date of Irupection Francis Guertin January 28, 1999 SOIL ABSORPTION SYSTEM(SAS):iV (locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods) If not located,explain: Type: leaching pits, number: Oti.� leaching chambers, number:_ leaching galleries,number:_ leaching trenches,number,length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (n to condition of soil, igns of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) 11 1 v✓. r7 , Sw. -k Le mot, Jh.l �r __n�w ✓'0. J/2ck J A- 4Je_r�. ✓a..A CESSPOOLS: (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(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_N/1 (locate on site plan) Materials of construction: Depth of solids: Dimensions: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 9/21/98 G ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM WFORMATION(continued) Property Address: Owner: 4 Three Ponds Drive, Centerville,MA Date of Inspection: Francis Guertin January 28, 1999 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) UOL 31 �. I �Kc,K 36 , /Ur6�r I . 37,E revised 9/2/98 Page 10 of I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: owner: 4 Three Ponds Drive, Centerville,MA Date of kispection: Francis Guertin January 28, 1999 NRCS Report name A111-9 Soil Type_ Typical depth to groundwater USGS Date website visited s�yv a S--? 5/7• (� ' Observation Wells checked zpn�r �- 3•y Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 1.5fFeet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site 1Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators,installers VUsed USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) c.h ctu t-i.c- Uf y c !ow t70 ,n, a �tc by (�J ')� h o b�!c�}cr �► n d . , �-z,1 cf* p Yl t 3 . S o c,r, f c, h (n . c, L. rp J�.,J w o.-F C.✓ revised 9/2/98 Page llorll eo-or -1999 09:1`5AN CENT OST FIREDEPT 5087902385 P.02 Make application to local Fire Departmerrt Fire Department retains original application and issues duprtiiCate as Permit. r� APPLICATION and PERMIT Fee: 10.00 r for,storaq@4tank remcval and transportation to approved tank disposal yard in accordance with the provisions of`IM.G.L.`ahapter 1A8. Section 38A, 527 CMR 9.00, application is hereby mane by: 0 00 Francis Guertia -Tank Ownef Name(pi�z print) X C21 agrrahve ap er pem n Address ►W 4 Three Ponds Drive, Centerville, MA s,reer COY srsre ziy c•i . . + ar Advanced Environmental Advanced Environmental Company Name Co. or Individual PMtf P.O. Box 472, S.P'gennis,. MA Address Address Pant nnr Signature(if applying`cr=ermit) Signature(if applying:cr:e►mit) g Z7 IFCI Ceri;r"ec Other [ IFCI Certified = _? # Other T . Tank Location 4 Three Ponds Drive, Centerville, MA Stage AddM3Y Tank Capacity(gallcrs i .nnn Substance Last Storer ff 2 Fue ll.,Oi 1 Tank Dimensions(dia,:e;r x length) Remarks: IV YL Firm transporting waste Advanced Environmental State Lic.# MV5083856100 Hazardous waste mar?- ` Approved tank dispcsai•hard J.G. Grant Tank yard# 03501 Type of inert gas Tank yard address Peadville, MA + . . City or Town Centerville 01920 FDIO# Permit# Date of issue February 5, 1999 Date of expiration February 19, 1999 Dig sate approval nurrba!7 19990601269 Dig Safe Toll �Tel. Number-800-322-4844 Signature/Title of OtSc r panting permit After removal(s)send =?-290R signed by Local Fire Dept.to UST Regulatory Compliance Jnit.One Ashburton Place, Room 1310, Boston, MA.. TOTAL P.02 p� a No.. ._..�....... Fx$...J®..:'........ THE COMMONWEALTH OF MASSACHUS BOARD OF H Id�l"ll��� IV 0 dUIlO� .3 378t/1SN8V8 .......... �' ._.....-..-_....oF.?A v�9. ........-i B ....Ql--dde.-o1...Jo3rans ppv Applirtation for Uhipvii al Works Tnnitrnrtaun Vamit Application is hereby made for a Permit to Construct (/) or Repair ( } an Individual Sewage Disposal System at- ...... _ ocation-Address or Lot No. ...- - ...................------------------ ---- ....... ----------- •....... --••--. .._. :...- ' Owner Address /Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms......F.W..Q........................Expansion Attic WC) Garbage Grinder (Alr pa., Other—Type of Building 601..M h:-------.- No. of persons.--.sue------------------- Showers (C ) — Cafeteria ( ) A4 Other fixtures ...................................................... W Design Flow. ................ ---s��s-.-gallons per person per day. Total daily flow--.....a.>�0....................•.•..gallons. W ... Septic Tank�Liquid capacityt _gallons Length----3__.._... Width------PF- --. Diameter---------------- Depth................ x Disposal Trench—No- ------ Width_-V ------- Total Length.:---s_._... Total leaching area.__-_.sq. ft. Seepage Pit No..--_---_/--------- Diameter_....... ._.._. Depth below inlet..--- .... . Total leaching area.�d,l_...sq. ft. Z Other Distribution box (�j. Dosing tank ( ) °i '7M Percolation Test Results Performed by----A1 ...a�o! s -------------- Date---. ---------------------- Test Pit No. 1----------------minutes per inch Depth of Test Pit--.-.--------------- Depth to ground water----------------..---... Test Pit No. 2................minutes per inch Depth of Test Pit--.----------------. Depth to ground water....................---. .-..----• ------- ---------------•-----.----- --------•----...•------------------------•-------•--------------------------------------------------- O Description of Soil......-a ................IAft ►1---V-ah sa L----------••------•-•-•----------------••-•--••-••--•-•-••---•-----•-.----- V ------------ •--------- ......� ........ ............. ....... -------------------------------------------------------------•--•-•-•--------------- W --•--•-----•-----------------•----•-•••••-•---•--•-----------•-••--•----•--••-----•••-•-•--•-•---•------•--•---------•------....-----•-•-----••----------------------•-•-•--------••-•----------•------- UNature 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'TTL , y g g p - y of the State Sanitary Code— The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has been ' ed�by the and f ealth. Si e --------- ----- '... D e Application Approved By....... ------ -------•-• --•.-- =. '2 �-----....... .............. Date Application Disapproved for the following reasons---------------------------------------------------------------------------------------------------------------.. -----------------------------•---•--------------•-•---------------------------•---------------------•-•-•..---------------------------------------------------------------------------------------------- Date Permit No............. Issued - -•.� �... ---------------------- Date No. .._...1.:... FEs. .... •� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ...................OF......<7?9VV,.9 Y.......Z9,po..) -f 40ration for Dhipoiiai Works Tomitrnrtinn Vrrmit Application is hereby made for a Permit to Construct (v ) or Repair ( )Kan Individual Sewage Disposal System at: ri dgy:::----7 . ...__�. !. Z!Z,:.-•`f7- el --•-- --•--------------•-•------....._........ Location-Address / or Lot No. �i Owner Address � Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms..rTLC�0_________________••-__-___Expansion Attic (•U�) Garbage Grinder (AI43 pa, Other—Type of Building ---------- No. of persons.........5P.............. Showers (o?) — Cafeteria ( ) Otherfixtures ---------------;:-------._...--•---•------------•-------------------------------------- -----___..---•---------------------•---•-----.._._.......---• W Design Flow..................- -J SE.gallons per person per;lay. Total daily flow__-_-__. _._ ................. Ions WSeptic Tank r Liquid capacitv Q'4?�gallons_ - J�ength....'�.______. 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 (Lr,�` Dosing tank ( ) aPercolation Test Results Performed by.... ................................. Date_._.�-.aQ7:_7i............... Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ k, Test Pit No. 2................minutes per inch Depth of Test Pit___............_._.. Depth to ground water....................... R; :. DDescription of Soil................................................................ r ----------------------------------------------------•---••------------ x 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 L, 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i edtby the bb"ard,pof health. fSi e n --•-- :. ..................................... .._...._.. .......... Application. Approved BY ------- ------------••••- f.. ,Z V f -N F. Date t.M .. Application Disapproved for the following reasons:---•---------------•------••-----•------•------•--•-•.......................................................... ........................................-•••••--••------•--•-••---------•-•--••......-----•-••---....._..---•--------------.---•••••---•-•-•----------••...---••--------••----••-------•---•--•......-- „' Date PermitNo.-•,-•--•==............................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT V../ / ?.........O F............ .......:....................................................... Tnrtif iratr of Tomplianrr 6, THI IS.TO CRTI That the Individual Sewage Disposal System constructed ( ) or Repaired ) bY------- ----.--- l,Tl'L= G... .... ...........f...........---- .................... ......xi��--.._ .. --I tallerat ---e-4.4w".4le '� has been installed in accordance with the provisions of T 5 of The State Sanitary Co e-asI�esc in the application for Disposal Works Construction Permit N .. ..`.`9...................... dated_....___)` " + �.._e___._.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. __. Inspector_____________________ DATE...... - THE COMMONWEALTH OF-MASSACHUSETTS BOARD O HEAL .... �.OF................. ........................ .. '`Y.......................... D • --" No....-•---•---._�_..... FEE........................ 'Disposal nrkg � ' .a ati on amit Permission i hereby granted ••........._ � t ............................. ................ to Construe or �2epair ) Ivldual �c ge is ,ystem at No. ti/-� r�a!1.�4p �► ��7G . . y ......................................................t �C ---- Street as shown on the application for Disposal Works Construction Pe mik' N(..-.__ ated _ ........... Boaarrd off Hea-• lf__. d - ----th--..___�. ............................... � DATE-----':.:-)............................................................. ... FORM 1255 HOBBS & WARREN, INC., PUBLISHERS —C� t >t`,1 �ts,-T _,�•__ �j y \ I WVE.LT ��-1. 4-!�l Tidi>-�( FLvw 110 4 3 % SSU G•RD. `� 2 � 3S�ogele O 1F�T"1 G T La+�l W- = 330 r (S D % - 4-9 S 6.P.D. USte- t c>oCD GAL. 1SsxvAvl 1SN�d �',► �a a-. _PIT - uSc-- (oC>O <40. nS S� I, 14o POW It-M. / r Nv- -',U;GwALI- AREA = tso s. A113 dd 0i 1 �pX 32zgq `tor&& IGoo SF 2.s = �6 jWroad BV7-rOAA ZOEE � ST-. Go sue. A t .o So TOTAL. 4'L5 'oT41_ L/S1Lam( r-LDV-/ = 3306.P.D. OL�.�!� PEr�GUt_pT1U�1 C2l�Tl= I I�.1 2M1u 021�SS. ` • +TN. 32± - io. fir'• i t �� � 'J 90 1 Z. T1`ST 9'ZZ/ 78 F(ea-JA. Tor two ti 8ci �.. 7zc9ss �aiin 1►J�'1-Z. J? G711. 4rppB D1ST IW G,at.. 11 S „� -Box 11.4- SEPTIC (C :. 'v. 1000 bg tiwv. IWV• 1) 2G GAL. '10 -lu.� Lsw N A 4 PST SA,,1*-> WAfNRD STOWE-- LeZ. I.O� 1 .o• � I i�� CGQTtF=1CD PLC)-r PL L a C A T I OI-A CENZ 5L./I L.cZ �o VAT I GUIt-ctE=�{ T►-,,N,7" T1-1G rovlJbATtDhI SNa�W Pi- 4t,1 Ri�1-��EUGE V4C.1Z t::nI Cc:.tilr'l_�l5 W ITI•A TIa` SIDE LP-A eT �p Aug SErk�nc►� t:cC�I�CM� ITS of TF+t� -To w LJ at'= �3AR tJST`r�+� r~cs �4O'� 611¢T �4Sb' 85A�J VA'it� �� BQATLIZ. GY. 4JY'C 1�G. tZC61S rlai7l D i�.►JG SU�vEYu�'.S '(-1-11� C�I_h►--1 I�.; I-�UT L'Ate,C'C� Ul a /Sa.J GSTEf��/1l_l.i= U Rr�AS i� IWrIC'.J.'✓�C��J �iU�-`/t=�' 1��i' �:t=L � T�i i11GWL]D T'A.PPt_IC --1 Ait c J E= k_n Y t_ (IlUPP 3i.e_ _ FU--� L T ' r TOWN OF BARNSTABLE A LOCATION SEWAGE # S a VILLAGE ��. �-a✓ ✓r I L,S- ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ��' (size) NO.OF BEDROOMS BUILDER OR OWNER u Q✓-{� �-, PERMITDATE: COMPLIANCE DATE: 79 o r ,?a Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by. h,� L LOCATION o _ EWAG PERMIT NO. 19 b VILLAGE I N S T A LLER'S NAME i ADDRESS ma`s e UILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � . � J� /Q f6ii �� 0 f �� r