HomeMy WebLinkAbout0053 WINDLASS LANE - Health (2) 53 Windlass Lane
Centerville
A= 192 074
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UPC-12534 0 ��
No. 2153LOR
HASTINGS.YN
Health Complaints
03-Jun-02
Time: Date: Complaint Number: 3453
Referred To: DAVID STANTON Taken By: LEE MCCONNELL
Complaint Type: ARTICLE XXXIX HAZARDOUS WASTE
Article X Detail:
Business Name:
Number: 53 Street: WINDLASS LANE
Village: CENTERVILLE Assessors Map Parcel: 192074
Complainant's Name: Fire department
Address:
Telephone Number:
.Complaint Description: THERE IS A 55 GALLON DRUM BURRIED
ON THE PROPERTY
Actions Taken/Results: DS VISITED THE SITE. THERE WAS A 55
GALLON DRUM STICKING PART WAY OUT
OF THE GROUND. I SPOKE WITH SOME
NEIGHBORS NEAR BY, AND THEY SAID IT
WAS THERE SINCE THE BUILDERS WERE
BUILDING THE HOUSES A LONG TIME
AGO,AND THEY THOUGHT IT WAS JUST
FILLED WITH CEMENT. ONE PHOTO IS
ATTACHED SHOWING THE DRUM. IT
DOES APPEAR TO BE JUST CEMENT,AND
NOT HAZARDOUS WASTE. THERE WAS
ALSO ANOTHER POST WITH CEMENT
AROUND IT AS SEEN IN THE PHOTO.
Investigation Date: 5/14/2002 Investigation Time: 3:55:00 PM
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COMMONWEALTH OF MASSACHUSETTS '*
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRSy a '
DEPARTMENT OF ENVIRONMENTAL PROTECTION
�'AN
4
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM {
PART A F
CERTIFICATION
Property Address: 53 WINDLASS LANE CENTERVILLE,MA 02632 M192 P074
Owner's Name: TOM O'TOOL �"+':
Owner's Address: 53 WINDLASS LANE M `
Date of Inspection: 12/3/01 RECEIVED " "
ty
Name of Inspector: (please print) JOHN GRACIm �' `
Company Name: SEPTIC INSPECTIONS D�C' ® s ZUU� ,( N
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 t r' M
TOW I OF CiARr�ISTABLE
HEALTH DEPT. s k r
Telephone Number: 508-564-6813 FAX 508-564-7270 a );;
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 4`
} 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: `° F .
t
X Passes
_ Conditionall Passes "
_ Needs Furt valuation by the Local Approving Authority
Fails .
Inspector's Signature: Date: 12/3/01
The system inspector shall submi facopy of this inspection report to the Approving Authority(Board of Health or DEP)withm �4n
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. vi >' ,y.
;Isrx,
Notes and Comments
THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFULL LIFE. RECOMMEND NEW COVER ON PIT-RECOMMEND MOVING TREES
""Phis report only describes conditions at the time of Inspection and under the conditions of use at that thee.`['hts
p Y paz
inspection does not address how the system will perform in the future under the same or different conditions of use. '�tr(
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Page 21 of I I
4
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM cr
PART A
CERTIFICATION (continued) t
Property Address: 53 WINDLASS LANE CENTERVILLE,MA 02632 M192 P074 }
Owner: TOM O'TOOL '
Date of Inspection: 12/3/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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.
k,
Comments: ,ar
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG
THE SYSTEM'S USEFULL LIFE. RECOMMEND NEW COVER ON PIT-RECOMMEND MOVING TREES '
B. System Conditionally Passes:
v�
_ One or more system components as Oescribed in the"Conditional Pass"section need to be replaced or repaired.The system,
t, upon completion of the replacement or repair,as approved by the Board of Health,will pass. `
' Answer yes,no or not determined in the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits �'`' �' '
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced' d " l{
with a complying septic tank as approved by the Board of Health. ,rYf ..
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating gr
f. that the tank is less than 20 years old is available.
' fY
ND explain: n/a �rF�,�
5
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed figr ,ht
or due to a broken settled or uneven distribution box. System will pass inspection if(with approval of Board of
pipe(s) � r.• r� .
Health): ;n
_ broken pipe(s)are replaced
P
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
1�,
. �N4
_broken pipe(s)are replaced 5"r '
_obstruction is removed
tFY
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ND explain: n/a 4
E
Page 3 of 11
t '
OFFICIAL INSPECTION FORM-NOT FOR"VOLUNTARY ASSESSMENTS 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART Ask
CERTIFICATION(continued)
Property Address: 53 WINDLASS LANE CENTERVILLE,MA 02632 M192 P074 � ��
Owner: TOM O'TOOL # `
Date of Inspection: 12/3/01 4 `
iY
C. Further Evaluation is Required by the Board of Health: E w
sy ^ hf:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system,As
not functioning in a manner which will protect public health,safety and the environment: 4 ,
_ Cesspool or privy is within'5.0 feet of a surface water = 4
_ Cesspool or privy is within'S0,feet of a bordering vegetated wetland or a salt marsh `
i, xl
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment: ? rm
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
a
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
! _ The system has a septic tank,and SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well". Method used toidetermine distance n/a
"This system passes if the well'water analysis,performed at a DEP certified laboratory,for coliform bacteria and r
volatile organic compoundg,indicates that the well is free from pollution from that facility and the presence of ammonia v �� t.
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy 1& IV
of the analysis must be attached to'this form. � ��`.
a:
3. Other:
n/a
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Page 4 of I 1
t-' ��«:
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t—AS4,
PART AMA..
CERTIFICATION(continued)
Property Address: 53 WINDLASS LANE CENTERVILLE,MA 02632 M192 P074
Owner: TOM O'TOOL
Date of Inspection: 12/3/01
D. System Failure Criteria applicable to all systems: ' Ii+
You must indicate"yes"or"no"to each of the following for alLinspections: c,
Yes No �� �
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ,
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool; ry
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow r
X Required pumping more than 4 times in the last year ND due to clogged or obstructed pipe(s).Number of times x :�
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is.less than 100 feet but greater than 50 feet from a private water supply well with!"',
no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP '� `
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free, r 1
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or "4 a'
less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be ..
attached to this form.j R:
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 31.0Ll
t CMR 15.303,therefore the system fails-The system owner should contact the Board of Health to determine what will be
necessary to correct the failure. ;
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. ;,)k
3 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)
yes no
_ X the system is within 400 feet of a surface drinking water supply s
IV,
X the system is within 200 feet of a tributary to a surface drinking water supply =f41
_ X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
t
` 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 Iflige system has failed.The owner or operator of any large system considered a significant threat fit,
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner.. �a",
should contact the appropriate regidnal office of the Department.
Page 5 of 11
fq-
OFFICIAL INSPECTION FORM-NOT FORYOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B ,ry,y,:..
CHECKLIST
Property Address: 53 WINDLASS LANE CENTERVILLE,MA 02632 M192 P074
Owner: TOM O'TOOL
Date of Inspection: 12/3/01 '., 31
,
Check if the following have been done.You must indicate"yes"or no as to each of the following.
Yes No t b
X Pumping information was.provided by the owner,occupant,or Board of Health s ��t
1i 1x
X Were any of the system components pumped out in the previous two weeks? 4'"
X _ Has the system received normal flows in the previous two week period'?
_ X Have large volumes of water,been introduced to the system recently or as part of this inspection?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) t,
P `
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS,located on site'?
K
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the a a,p;
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? c r
X _ 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
X _ Existing information. For example,'a plan at the Board of Health. v
A Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is z
unacceptable)[310 CMR 15.302(3)(b)]
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Page 6 of 11
r
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C ;*F
SYSTEM INFORMATION t `
Property Address: 53 WINDLASS LANE CENTERVILLE,MA 02632 M192 P074 P h
Owner: TOM O'TOOL }
Date of Inspection: 12/3/01
FLOW CONDITIONS J.
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4 "x
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: n/a
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] ;'
Laundry system inspected(yes or no): NO .9k; "
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a •:3 ,
1�
COMMERCIAL/INDUSTRIAL tib '
Type of establishment: n/a 'A �
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO ,
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a ,
OTHER(describe): n/a t+`
GENERAL INFORMATION
JV
Pumping Records
Source of information: n/a �
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons-- How was quantity pumped determined?n/a . y .
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool s =
_Overflow cesspool
_Privy
RIVV x
_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): n/a `k
Approximate age of all components,date installed(if known)and source of information:
NEW D BOX AND LEACH FIELI)PUT IN 6.10.97
h:
Were sewage odors detected when arriving at the site(yes or no): NO ��
Page 7 of 11 ..'.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM
'! PART C n,
SYSTEM INFORMATION(continued)
Property Address: 53 WINDLASS LANE CENTERVILLE,MA 02632 M192 P074
Owner: TOM O TOOL
Date of Inspection: 12/3/01 Nw;
BUILDING SEWER(locate on site plan)
Depth below grade: 14"
� P
Materials of construction:_cast iron X40 PVC_other(explain): n/a ?� ,
Distance from private water supply well or suction line: n/ac
Comments(on condition of joints,venting,evidence of leakage,etc.):
x � r
n/a a �t
SEPTIC TANK: (locate on site plan)
Depth below grade: -6" '
Material of construction:_concrete' metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7,,;',W,4'z10"" � t
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: n/ate
Scum thickness: 2" �i:
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: PLANS #
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND. RECOMMEND PUMPING NOW $ ...
EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.RECOMMEND NEW COVER ON TANK a
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a '
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a $
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a � '.
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related npp
1
to outlet invert,evidence of leakage,'etc:)': tad
"Sit
n/a
k
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n 7,t
i
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Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C a"
SYSTEM INFORMATION(continued)
Property Address: 53 WINDLASS LANE CENTERVILLE,MA 02632 M192 P074
Owner: TOM O'TOOL
Date of Inspection: 12/3/01
TIGHT or HOLDING TANK:, (tank must be pumped at time of inspection)(locate on site plan) <
1
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a3 fi.
i Dimensions: n/a ,:
( Capacity: n/a gallons t
d Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO �
Date of last pumping: n/a (}
Comments(condition of alarm and float switches,etc.): µ
n/a " A;�;
DISTRIBUTION BOX:X(if present must be opened)(locate on site plan) ,"� ,•
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE s r
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. :
BOX IS STRUCTURALLY SOUND.RECOMMEND MOVING TREES NEAR D-BOX TO PREVENT ROOT
DAMAGE. }
PUMP CHAMBER:_(locate on site plan) `
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a .
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Page 9 of 11 ':
t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C '
SYSTEM INFORMATION(continued) i
Property Address: 53 WINDLASS LANE CENTERVILLE,MA 02632 M192 P074
Owner: TOM O'TOOL tt"
Date of Inspection: 12/3/01
SOIL ABSORPTION SYSTEM(SAS): _ (locate on site plan,excavation not required) ;, fys
r �r.
If SAS not located explain why: tt
p h`
n/a ''
r
Type
n/a leaching pits, number: 0
n/a leaching chambers, number: nla f.
n/a leaching galleries, number: n/a nrr
n/a leaching trenches, number, length: n/a }'
4 leaching fields, number: 4 CULTEC 330 n/a overflow cesspool, number: n/a
n/a innovative/alternative system r
c
,Type/name of technology. n/a .'
z �-z
Comments(note condition of soil,signsof hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
` THERE ARE4 CULTEC 330 AND THEY APPEAR TO BE FUNCTIONING NORMALLY. DID NOT EXPOSE
THERE WAS NO INSPECTION COVER TO GRADE.CULTECS ARE IN 1.5FEET OF STONE,PROBE SHOWS "y
THEM TO BE DRY.THERE IS AN OLDER 1000 GALLON PIT.BOTTOM OF FIELD AT 61 .
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) '�b• .
Number and configuration: n/a � "
Depth—top of liquid to inlet invert: n/a � ''
Depth of solids layer: n/am=
Depth of scum layer: n/a
9
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): Y;
n/a
PRIVY: (locate on site plan) ;
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs'of hydraulic failure, level of ponding,condition of vegetation,etc.):
r
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Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FORVOLUNTARY ASSESSMENTS
SEWAGE DISPOSAL SYSTEM
SUBSURFACES M INSPECTION FORM,
PART C
SYSTEM INFORMATION(continued)
K1 y
Property Address: 53 WINDLASS LANE CENTERVILLE,MA 02632 M192 P074 �" y`
Owner: TOM O'TOOL #` }
Date of Inspection: 12/3/01
a :
w: X.
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. sT; a
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Page*1lo II § \ :
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS l \ ^
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C < \/
SYSTEM INFORMATION¢A(n1A3 \ <\�
Property AddR■: 5 WINDLASS LANE CENTERV LLR MA0 62M19 P074
Owner: TOM OIOOL
Date«lmpc,lom 123/01 \ '
SITE EXAM . \ \
_Sloe d
Surface water >\.
_Check m|| ra \ .'
Shallow wells
« .
\ ƒ»
Etimalddepth to ground water !q+feet }\/
Please indicate c)g|metho susedtodetermine the high ground wire elevation:
. d) \
NO Obtained from system Agp plans on record- Rchecked,date o design @| na reviewed: Ra \&\
YE Observed site(abutting property/observation hole within 150 feet oSAS)
NO . Checked with local Board o HaA4k@gm Ra
NO Checked with local 2avato % +Balge-(attach dcumm! !am@ \ /\
NO Accessed USGS database-explain: @a
You must describe how yualm§+e the high ground water elevation: < y
GROUNDWATER DETERMINED ON SITE NO WATER&IlO .80TTOM OF FIELD AT6
�
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Fee
THE COMMONWEALTH O MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Application for 30igpoga1 *pgtem Construction 3permit
Application for a Permit to Construct( )Repair(k)Upgrade( )Abandon( ) El Complete System 1:1 Individual Components
Location Address or Lot No. �43 ('j i n c0 1 tgss RH C Owner's Name,Address and Tel No.
CC. — AVN%14Y, ►a o`Too1c.
Assessor's Map/Parcel 2
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
0,0(tc)0 i. v4hpUs f l{,� r� l@ l t 0
Type of Building:
Dwr ellin No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 9 eo P67- h e K �To FX is% S.%s9,1fr !r
ILI>%19/ y-Cv/ree- 330 C11RMLAS .5o inynnC- d., /`
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu y this oard f I
Signed Date _ ��gf
Application Approved b Date y 147 g
Application Disapproved for the following reasons
Permit No. Date Issued
.,,n... stf_
No. /�� � 6.5 ° - f Fee '►.7 �7,l
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
�. 01ppfication for Mi!5pooaf *pgtem Con.5truction Permit
Application;for a Permit to Construct( )Repair(tom)Upgrade( )Abandon( ) O Complete System O Individual Components
Location Address or Lot No. S 3 W i/t o ►qs5 Rr.1 F Owner's Name,Address and Tel No.
Assessor's Map/Parcel
Q .:
Installer's Name,Address,and Tel.No. F' Designer's Name,Address and Tel.No.
G0R.00 N% Us
r _
Type of Building:
Dw� No.of Bedrooms y Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
r'
Design Flow gallons per day. Calculated daily flow gallons.
s
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) D-0 /S,T J o X 7o Fx rs% S.T1/ r
Yi) /9// -Cvc 330 ChAr11 E�2S r2/,y SIanc
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1 Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been is y this oard aI al 6
Signed Date
Application Approved b t Date
Application Disapproved for the following reasons
�ry °
Permit No. " Date Islued 11�^t
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(/ )Upgraded
Abandoned.� )by G o 2 N,-,'3 t r v S
at ' / 11 2/00 1 .rt +has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.4�24_,-747%dated 09�"AO ;-;`j�-_2 77.
Installer Designer
The issuance of this perm/it shall not be clstrued as a guarantee that the system will function as designed.
Date --7 Inspector
--------------------•----------------
No. ' Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mis�pogar *p.5tem Congtruction Permit
Permission is hereby granted to Construct( )Re air( )Upgrade( )Abandon( ) /
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date oof�thji' rmit.
Date: J Approve yci<b —_' � / ,
NOTICE: This Form is to be used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PEIZMIT (WITHOUT DESIGNED PLANS)
1, hereby certify that the application for disposal works
construction permit signed by me dated 7�,Ne I 01 1 q c('7 , concerning the
property located at S3 L✓il?,ol� 6--147 meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
�v • There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed. ,
SIGNED: DATE: O ��
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 3Z _
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
jxert
r4wc�j
TOWN OF BARNSTABLE
LOICATION K SEWAGE # 7 sa
VELLAGE 0E/ 1/Z o/�� ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO._GO 20 o n ,Y.p��-5-6 y0
SEPTIC TANK CAPACITY /Oa 0 G.91
LEACHING FACILITY: (type) viTee C�A �s (size) ® X
NO.OF BEDROOMS
BUILDER OR OWNER 7;720�l,4 S Tp�
PERMTTDATE:_�cr�yF /U / �) COMPLIANCE DATE: 97
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
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