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HomeMy WebLinkAbout0346 WHITE OAK TRAIL - Health 3q(.0 No. 42101/3 ORA ESSELTE 10% (* O 0 0 0 ' \ COMMONWEALTH OF MASSACHUSETTS ExECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS . DEPARTMENT OF ENVIRONMENTAL PROTECTIO.Ni - nF; ;;FACI.c n kjr, 30 Sri 9: 59 1� 7v i Sit 0�44 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 346 White Oak Trail Centerville Owner's Name: Jim O' Bannon Owner's Address: Date of Inspection: Name of Inspector:(please print) W' 11 jam _ •Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P 0 Box 1089 Centerville, MA Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT I certify that 1 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 o[Title 5(310 CMR 15.000). The system: v Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 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 seat to the system owner and copies sent to the buyer,if applicable,and the approxing 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 r Page 2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Address: 346 White Oak Trail Centerville Owner: Jim O'Bannon Date of inspection: 7-6 6 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. =aVe ses: t 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 Condition lly Passes: One or more syst m components as described in the"Conditional Pass"section need to be replaced or repaired.The system,up completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not Bete ined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is m tal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substanti 1 infiltration or exfiltration or tank failure is imminent_System will pass inspection if the existing tank is replaced wi a complying septic tank as approved by the Board of Health. •A metal septic tank will p s inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is I ss than 20 years old is available. ND explain: Observation of s age backup or break out or high static water level in the distribution box due to-broken or obstructed pipe(s)or du to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of ealth): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstn-tied pipe-(s).The system will pass inspection if ith approval of the Board of Health): broken pipe(s)are replaced obstruction is rtmoved ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 346 White Oak Trail Centerville Owner: Jim O' Bannon J Date of Inspection: G C Further Evaluation is Required by the Board of Health: j-f�jli�onditions exist which require further evaluation by the Board of Health in order to determine if the system i protect public health,safety or the environment. I. Sys in will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the Sys( is not functioning in a manner which will protect public health,safety and the environment: esspool or privy is within 50 feet of a surface water sspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. Systeff will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is fi nctioning in a manner that protects the public health,safety and environment: _ e system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surfac water supply or tributary to a surface water supply. e system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. he 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 pr vate 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 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,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Ot er: 3 Page 4 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 346 White Oak Trail Centerville Owner: Jim O Bannon Date of Inspection: c3 D. Syst Failure Criteria applicable to all systems: You must' dicate"Yes"or"no"to each of the following for all inspections: Yes No ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or Llogged`SAS or cesspool _ �tatic liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or iesspool iquid depth in cesspool is less than 6"below invert or.available volume is less than%day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number f times pumped y portion of the SAS,cesspool or privy is below high ground water elevation. y 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 Kater supply well with no acceptable water quality analysis.(This system passes if(lie well water analysis, performed at a DEP certified laboratory.,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, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma (Yes/No)The system fails. I have determined that one or more ofthe 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. arge Systems: To b considered a large system the system must serve a faci!ity with a design now of 10,000 gpd to 15,000 gpd- You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to die criteria above) 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 sm-face drinking water supply _ — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—1WPA)or a mapped Zone 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 answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significantlthreat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.T e 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 Property Address: 346 W-hite Oak Trail Centervillp Owner: Jim n'BAnnnn / Date of Inspection: �1-�--f�� 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 i/ 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? l/ 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) v _ 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? 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)13 10 CMR 15302(3)(b)J 5 Page 6 of i l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 346 White Oak Trail Centerville Owner: Jim O'Bann n Date of inspection: 6 FLOW CONDITIONS RESIDENTIAI. Number of bedrooms(design):. 3 Number of bedrooms(actual): . DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):. Number of current residents: Does residence have a garba grmder(yes or no): �' Is laundry on a separate sewage system.(yes or no): ,/mod lif yes separate inspection required) Laundry system inspected(yes or no).X0 Seasonal use:(yes or no):� eq Water meter readings,if av t/labie(last 2 years usage(gpd)): 2004 — 47, 000 Sump pump(yes or no): A— 2003 — 41 , 000 Last date of occupancy: 1f cs COMMERCIA USTRIAL Type of establis ent: Design flow(b d on 310 CMR 15.203): gpd Basis of desi flow(seats/persons/sgft,etc.): Grease trap p esent(yes or no): Industrial w ste holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):_ Water ter readings,if available: Last da a of occupancy/use: OT ER(describe): GENERAL INFORMATION Pumping Records C Source of information: ;F- Was system pumped as part of the inspection(yes or n ): If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM _Septic tank,distribution box,soil absorption system _Single cesspool Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: Id IC Y � Were sewage odors detected when arriving at the site(yes or no): 6 I'agc 7 of I I OFFICIAL INSPECTION F01A4—NOT FOIL VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 346 White Oak Trail Centerville Owner: Jim 0 Bannon Date of Inspection: ?-6 BUILDING SE VER(locate on site plan) DcpUl below adc: Materials of onstruction:_cast iron _40 PVC_other(explaut): Distance G n private water supply well or suction line: Comments on condition of juutts,venting,evidence of leakage,etc.): SEPTIC TANK:`(locate on site plan) Depth below grade: ), Material of construction. 1/coiurctc metal fibcrglass_,olyedlyiene _otllcr(explain) _ If tank is metal list age:_ Is age conftrnted•by a Certificate of Compliance(yes or no):_(attach a copy of ccrtiftca(c) t v Dimensions: Sludge depth: 3—�/ ' ,t Distance from top of sludge to bottom of outlet Ice or baffle: IA Scurn(Itickness: 4-1 j I Distance from top of scut, to top of outlet Ice or baffle: t Distance from bottom of scum to bouont of outlet tee or baffle: )Z.', I low were dimensions determined: ©7j*n. 'rr ..,./� Comments(on pumping reconullendations,inlet and outlet tee or baffle conditicn,structwal integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): GREASE T 1':knmctloll: (locate on site plan) Depth belo _ Material of _concrete metal fibcrglass polyethylene _other (explain): — Dimcnsionst Scurn Ihic css: Distance 111 top of scunn 10 top of outlet tee or baffle:_ Distance otn bottom of scum to bottom of outlet tee or baffle: Date of I t pumping: Conunen s(on pumping reconu,endations,inlet and outlet ice or ba(lle condition,structural integrity, liquid Icvcls as relate to outlet invert,evidence of leakage,etc.): 7 'age 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 346 White Oak Trail Centerville Owner: Jim O'Bannon Date or Inspection: TIGHT or HOLDINGLTAN : (twik must be pumped at time of inspection)(locate on site plan) Depth below grade:Material of constructioe_metal_fiberglass_polyethylene otha(explain): Dimensions: Capacity: Rallons Design Flow/(yc gallons/day Alarm preseor no):Alarm levelAlann in vvo►king order(yes or no):Date of last g: Comments( on of alarm and float switches,etc.): DISTIUBUTION BOX: (tf present must be opcncd)(locale on site plan) Depth of liquid level above outlet invert: d Conunents(note if box is level and distribution to outicls equal,any evidence of solids carryover,any evidence of leakage into or out of box,ctc.): PUMP CIIAMBLR: /of c on site plan) Pumps in working ordeo):— Alamrs in working ordno): — Conunerrts(note coed" mp chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 346 White Oak Trail Centerville Owner: Jim 0 Bannon Date of Inspection: T j-1-0 .� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type y - aching pits,number:_ leaching chambers,number: - 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.): 3 CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and con figuration: Depth—top of quid to inlet invert: Depth of solid layer: Depth of scu layer: Dimensions of cesspool: Materials Cconstruction: Indicatio of groundwater inflow(yes or no): Comm" is(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIV/ts(note ocate on site plan) Materstruction: Dime Depth Comm condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 e OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 346 White Oak Trail Centerville Owner: Jim O' Bann n 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. ?L VJ ✓� I `35, Y 1 y �i 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 346 White Oak Trail Centerville Owner. Jim Ur-Bannon r Date.of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells ' ,yZ, Estimated depth to ground water 0 feet 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 fe t of SAS) ,/Checked with local Board of Health-explain: t,.—,s i� Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You muAdescr�ibe how you established the high groundwater elevation: J ,y .d ;0-S :P-_b ® Z, 1 sr l J/a' tjCf Q 1?6k 11 790 - 63eq � 361 dx as �yx CeP� SO� - 737 �/ 60 Is ��•� !� r 7 7c3 °F o�' � �B No. 1�47 Fee 5 0 . 0 0 THE COMMO EALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - OWN OF BARNSTABLE., MASSACHUSETTS 01ppfication for Mis ppaal *pgtem Construction Permit Application for a Permit to Construct( )Repair(x)5 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 346 White Oak Trail Owner's Name,Address and Tel.No. 781 —3 5 6—0 4 0 0 Assessor'sMap/Parcel Centerville A Som Virk 42 Holbrook Ave ;-,? Braintree, MA 02184 Installer's Name,Address,and Tel.No. 7 5.-8 77 6 Designer's Name,Address and Tel.No. Wm E Robinson Sr Septic Service PO Box 1089 , Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(n9 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 sand Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting of D-Box, 3 stonepacked maximizers . _. _ZZ_1X � 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 E vironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss d by thi oar f Health. 9 Signed Date ` Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued No. Fi/'�� Fee -. THE COMMO EALTH iOF MASSACHUSETTS Entered in computer: Yes e _-PUBLIC HEALTH DIVISION - OWN OF BARNSTABLE., MASSACHUSETTS 01pprication for ;Digpogal 6pgtem Congtruction Permit Application for a Permit to Construct(: )Repair(x4 Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 346 White Qak Trail Owner's Name,Address and Tel.No. 7 81 -3 5 6-0 4 0 0 Assessor'sMap/Parcel Centerville, A Som- Virk 42 Holbrook Ave r9 Braintree, A 02184. Installer's Name,Address,and Tel.No. 7 5_8 7 7 6 Designer's Name,Address and Tel.No. I Wm E RobinsonsSr Septic Service PO Box 1089, Centerville, MA 02632 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. _- Garbage G nder(ng Other Type of Building No.of P ons 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. .�Y Description of Soil sand ' sr Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching consisting ofg�_ D-Box. 3 stonepacked maximizers. ���"� ►,� 10, Date last inspected: Agreement: * The(under igned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordanee4ith the provisions of Title 5 of the E vironmental Code and not to place the system in operation until a Certifi- cate of Compliance has been iss­d by this oar f Health. �✓ Signed Date Application Approved by Date sT A 4:9, Application Disapproved for the following reasons Permit No. " Date Issued ————————————————————————————— - f r .THE COMMONWEALTH OF MASSACHUSETTS Virk f _13ARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (x )Upgraded( ) Abandoned( )by at 346 White Oak Trail, Centerville has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer W E Robinsons Sr Septic Sry Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No. ,� Fee $5 0.0 0 THE COMMONWEALTH OF MASSACHUSETTS "l PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Virk Migpooal *pgtem Congtructton Permit Permission is hereby granted to Construct( )Repair( x)Upgrade( )Abandon( ) System located at 346 White Oak Trail Centerville, MA 02632 Installer: W E Robinson Sr Septic Service aAd 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 it. ` Date: -� -'' Approved r t NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. rY CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, William E. Robinson, Sr. ,hereby certify that the application for disposal works construction permit signed by me dated A concerning the property located at 346 White Oak White Oak Trail Centerville, NU, meets all of the following criteria: * There are no wetlands within 100 feet of the proposed leaching facility. * There are no private wells within 150 feet of the proposed septic system. * There is no increase in flow and/or change in use proposed. * There are no variances requested or needed. * If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete the following: A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) B)Observed Groundwater Table Evaluation(according to Health Division well map) SIGNED: d DATE LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998 (Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted). 1g� V I I A fv � 4115 v l 1 AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION.S 1/C+ c.c.s , 'ri° Q /rZ SEWAGE t€ VILLAGE ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. 170 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) G ✓'� (size) NO.OF BEDROOMS J BUILDER OR OWNER 1�✓ 1� PERMTTDATE• "7-' 1 Y COMPLIANCE DATE:151--/<'- 9 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 leachingyJracility) �/ Feet Furnished by U� j t i ? � t http://issgl2/intranet/propdata/prebuilt.aspx?mappar=192245&seq=1 9/26/2014 TOWN OF BARNSTABLE LOCATION 3 4/ t�, Tip Q� !iZ SEWAGE9'9— VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. 1?a 1 -LF'72' SEPTIC TANK CAPACITY /E ' LEACHING FACMITY: (type) 3`'WZZ6 and i' (size) // i • ' ' NO.OF BEDROOMS 3 BUILDER OR OWNER PERMTTDATE: 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 feet of leachingfacility)--,-? Feet Furnished by L' "' J y �A t� � ` 4 � � . C ! j< � �" �---�• 1t 1 5 y� i� ) I t / I\ � /�, r' i�. 1 L C A T ION F A GE PERMIT NO. M;1 AG INS LL R'S NAME i ADDRESS • U i DER OR DATt PERMIT ISSUED DATE COM►LIANCE ISSUED /�'S �' �-, _. -f r`t! ,�� � � �. � �} - � �� r � = L - . a 1 r ' r- No................ _...... YmB............................. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HE-A TH .... Appliration for DhiposFal Works Tonstrnrtiun Prrutit Application is hereby made for a Permit to Construct K) or Repair ( ) an Individual Sewage Disposal system t .......... .. �----..... . - ----- --- •- o �+---•-Lo n-Address •� d Owner s wZW //� /�/' Installer Address ,v Type of Building Size Lot. -�'. `.._._..Sq.��f�ee� Dwelling—No. of Bedrooms.........L �.....-•••••......----•••....Expansion Attic Garbage Grinder Other—Type e of Building a - yp g ............................'No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ------------------------------------•-••----•-- •--............----•- Design Flow.............. ...... _ e� ....:.....gallons per person day. Total daily flow �D ........................gallons. W WSeptic Tank—Liquid'capacityORPgallons Length .=S!....... Width.... ........ Diameter................ Depth...&..`...._.. Disposal Trench—�..................... Width�....�............. Total Length............y._......Total leaching area............ ......sq. ft. Seepage Pit No....... ............ Diameter.._..- ............ Depth below inlet.... ............ Total leaching area.-.._--.-_--._..._sq. ft. Z Other Distribution box (®) Dosin tank '6 '-' Percolation Test Results Performed bye4W-�,...t.0V.. _..11' _.... Date.... r------------------- Test Pit No. 1........ ...minutes per inch Depth of Test Pit......6......... Depth to ground water 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Ra' Description of�Soil..... --------- -r�r'rti° f`-- ��ar - `� 0- - ! r ---.....-••••-•. x _1' ........�1. .At_ c_t1��.Z... V ............ .............................•-----•-•••-------••••-•-••-•----•-•----•--•••------...--•-...--•--....---••-•--•-•......------•••......•••••. ........................................................... 0 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 TITI.- 5 of the State Sanitary Code The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b kn issued by tl�e• of health. S new(...... .': " ® ated�� Application Approved BY......- --- --- -----•----- - - -• - ��-,��---•---•--•----.......... ......A --�-;� ------•----..:..-- Application Disapproved for the following reasons:............................. —. •-••--•----•-•............................................Date-----•-------- ............. ------------------------------- •---------------- .------------- --------------- •-----------------------------------------------•------------------------------- Date PermitNo......................................................... Issued_.Y/ -- - ---•-•--- -•------- Date wo THE COMMONWEALTH OF MASSACHUSETTS 1 BOARD OF HEA TH ..... -W.. -------------OF......kC/,G Y)h .S ._.._..../ ._................... Applirtttiun for Diipuittl Works Tonstrurtiun Errant Application is hereby made for a Permit to Construct K) or Repair ( ) an Individual Sewage Disposal Sys t �f7 > � Oak /vf67 Ole v///C .............................................. --............••-•...--•--•----...... ...._.. Lo 9-Address / or Lot No. - / ,---------•-----•-----.-----•-•------•---------• ........ '.... .. .. [ Owner �f f1�S.Q Address - S M jL ...................-- . ------... f !.. ................... Installer Address Type of Building Size Lot.�6..................Sq. fee U Dwelling—No. of Bedrooms---...... ......... -- .Expansion Attic 4'�4 Garbage Grinder { Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fix re W Design Flow.......:....................................gallons per perso pe_day. Total daily, flow......... ` .........._____.... ions. . �� ` 1 f WSeptic Tank—Liquid capaclty/.._._....gallons Length................. Width.._d......._ Diameter................ Depth ....... x Disposal Trench—%..................... Widt� ------------- Total Length.._........:... Total leaching area....................sq. ft. Seepage Pit No..................:.. Diameter........._..._:..::_ Deptl below inlet-----.--.......:.... Total leaching area.----._.-- ......sq. ft. Z Other Distribution box (� ) Dosi tank (/� a�r j .r- . /A/ c a d 7 G a Percolation Test Results Performed by ------------------ --------- f-------__ Date.__.___._..._....... .__._./........ ,.a Test Pit No. I........ ...minutes per inch Depth of Test Pit--_.__-l?-.......... Depth to ground water-.._.Y...Q,.w. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a � ®G � a. . -- ---•------•-. � � ��------------------- •--------•--------- D Descri ti oil 0.-_a 'k L "� r_ __i_____ -- . Qa ................ --------- ....... ... ... ... Kqvft ------------ ---------------------------------- MI ....------•......--•---•----------------•-----••...------•---------•----------•--........,......_.:•-------...--•--------•----•------•••--------•-•------------------••-------•-----•----------••-----•- U Nature of Repairs or Alterations—Answer when applicable............................................................................................... }--- r Agreemenf The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT LE 5 of the State Sanitar Code—The undersigned further agrees not to place the system in operation until a Certifigat6llNot Compliance has b en issued by t of health. S n .�•• f >r Date A lication Approve B �:'. PP PP Y....... . . ..: • .................••... l� jjO Ad..,.... Date Application Disapproved for.the following reasons: -----------------------------•---------------••-------------•--•----•--•---••---•••••-•--.....� -•-•-•---------------•----•-••-•---••----•--------------------•--•--•---•-•--•------•---•------------•---••----•••..........-------•---------------------------•-------•••-----••-•----•-•-•--•---....._ *' Date PermitNo......................................................... Issued.......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD . F HEALT ..... .`7 ..'.........OF........ dxK�:" '.....�.............. (�rrtifirtttr of f�unt�rlittnrle I�S I CERTIFY That the Individual Sewage Disposal System constructed eT or Repaired ( ) by.. `.. ---J,� --- /at-- ---- ------•-----v . •... .has been installed in accordance with the provisions of5 of The State Sanitary- ode as described in the application for Disposal Works Construction Permit No `'-7,j....__...... dated__...�(0,�_�..—... ............... THE ISSUANCE OF THIS CERTIFICATE.SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------- . ----------------------=- •b•.._�':..._ � ._....---- Inspector.......:. ------------------------------------------------------•---------.......: THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OE- HEALTH 7� l ..� 1...............OF.......... ...................................................... 0......................... RE }Q±............... Bifivustt urk Iuntrnrtiun rrutit Permission is herebyranted-~---. .!.... T'* '.tTn---------------------------------------•-•. gto Cons ucPol Repair an Individuals al Sstai .. tre t � as shown on the application for Disposal Works Construction P rpit N :._•: __..___ ._ Dated.. .yf1-.�.: Q! +J� .x....... ✓ , /r � --......r:--------••-•-----.-_ •--••••.' Board of Health DATE. . - FORM 1255 HOBBS & WARREN, INC., PUBLISHERS y � �'.c ,xea �" ,;`? L, '. 'C �,� .3 .� oN7-rE vc: �-� o�•/ /� �nv�Yc- 6Q L3�rsu d `F' c` V J� Q.,- LAO /e ti .Lot 6 J `o ,h �,.' "o e i e .� s 7� o� r ! �a'�> �� 1/vdac� � L 1Y1y1Y��, y D�'j j . (7 ��...J�, �"r� � .J��,•fL`�'Tr '!._1° L ! 77 C' Y r/ l Y r.".5 Srk 0 ;�7 F 4 ;,7c/ of 0 � 1 cs PLAMOF LAND f A, U F •. th ���� OWNED BY VIAA k q 14- ',� / FRANK rn fRAN1( `a»c/cc 'J'd d^✓/c2�(�" ci CONERY u � CONERY �^ NK CONERY 5 TR ST. �8•D qa GS73 C' . ��NO. sx3s`o HYANNIS, MASS. OM REGISIVRM"004K=n n Lana CUMVVIOR 10HA SCALE t 1N -ZOi*t. -�