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HomeMy WebLinkAbout0008 HI-ONA HILL ROAD - Health 8 Hi-on-a-Hill " %vd -- �� A=207- o' N SMEAD No.2-153LOR UPC 12534 smaad.eorn • Made in USA wrqf o fWmlml 91p0 Wuw SFI MOPWcam MGM ov 080411:02a p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Berry Owner Owner's Name require 6 o is Centerville MA 02632 11-7-14 required for every page. City/Town State Zip Code Date of Inspection Inspection results:must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Importaling out foam n A. General Information filling out fours f tab ly / ���1t1►uuUpU�p uon the se on ����fti10F/ �' 1. Inspector �' ' s-vim'. key to move your AF cursor-do not James DSears JA M ES . use the return key. Name of Inspector s ; 5 E A R S :ti CapewideEnterprises,LLCo "o ICI Company Name 153 Commercial,Street ��ii� fs'IN Company13111-- Address lea, Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1 $ 11-7-14 ,OEpectors Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection, If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority '*"`This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. IS ns-3113 Title 5OFRcaI I :Subfe suoe SamVe Disposal system-Page 1 of 17 'Nov 081411:02a p.2 <s. Commonwealth of Massachusetts s Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Berry Owner Owner's Name information is required for every Centerville MA 02632 11-7-14 page. Cityrrown State Tip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1500 Gal.Tank D Box and Pit. 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes ,"no" or"not determined'(Y, N, ND)for the following statements. If"not determined," please explain. 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 with a complying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): t5ins-W 3 TWe 6 ONdal kwpectien Fortrt Subsurfate Sewage Disposal System-Page 2 of 17 'Nov 08-1411:02a p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Bens owner Owner's Name information is ry Centerville required foreve MA 02632 11-7-14 page. Cityrrown State Zip Code Date of Inspedion B. Certification (cost.) ❑ Pump Chamber pumpslalarms not operational.System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cunt.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)-are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is fairing 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 is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 1503-3M 3 Title 5 Offidel trrepedion Porrrt Subsurface Sewage D'osposal System•page 3 of 17 i 'Nov 08 1411:03a p.4 Commonwealth of Massachusetts Tit le 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address ,lean Berry Owner Omefs Name information is required for every Centerville MA 02632 11-7-14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 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: ❑ 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. ❑ 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 to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ g 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 e6ssoo is less than 6"below invert or available volume is less than Y2 day flow o0j?- 15ins•3M3 — TrIW 5 ofllael hrepecuon form:SubsurNm Sewage Dispad System•Page 4 of 17 'Nov 08-1411:03a p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Berry Owner Owner's Name information is required for every Centerville MA 02632 11-7-14 page. Crtyfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal conform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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 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 significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.3134. The system owner should contact the appropriate regional office of the Department !Sins•3H 3 Idle 5 Official Inspec5an Form Subsurface Sews ge Dbposal System-Page 5 of 17 'Nov 08 1411:03a p.6 E Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Berry Owner Owner's Name requiredfo Is every Centerville required for eve MA 02632 11-7-14 page. Citylrown state Zip Code Date of Inspedion C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)1310 CMR 15.302(5)j D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins•3113 TWO 5 Dffidat Inspection Forth;SubU rfaaa Sewage Disposal Syelem•Pape 6 of 17 .Nov 08-1411:04a p.7 Commonwealth of Massachusetts!' Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Berry Owner OwnePs Name information is required for every Centerville MA 02632 11-7-14 Page. Cllyrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.Tank D Box and pit. Number of current residents: 0 Does residence have a grinder? garbage Y❑ es No Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 2012-49,000Gals Detail: 2013-74,000Gal's Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per P day(gpd) Basis of design flow(seats/persons/sq.fL,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: f5ins•3l13 MUG 5 Official iispedion Form:Subsurface Sewage Disposal Syst9n•Page 7 of 17 Nov 0814 11:04a p.8 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Berry Owner Owner's Name information is required for v Centerville MA 02632 - - e e 11 7 14 4 every page. Cityrrown state Zip Code Dale of Inspection D. System Information (cons) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: 2008 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ OverRow 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)and a copy of latest inspection of the I!A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): I5ins•3113 Title 5 ONidal Fmpedion Form:Subsurtam Sewage Dispoval Syshsn-Pape 8 0117 'Nov 08"1411:04a p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Berry Owner Owner's Name information is required for every Centerville MA 02632 11-7-14 page. cityrrown state Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components,date installed (if known)and source of information: 1993 Permit *93-222/New D Box 11-7-14. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 30" feet Material of construction: ❑ cast iron ® 40 PVC ®other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): Pipeing is 4"PVC SCH 40. Septic Tank(locate on site plan): Depth below grade: 181.feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain) If tank is metal, list age: Years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 Gal. Precast H-10 Sludge depth: (Sins•3013 Title 5 Ofidal bape:don Form.Subsurface Sewage Disposal System•Page 9 0 17 'Nov 081411:05a p.10 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 8 Hi-0na Hill Road Property Address Jean Berry Owner Owner's Name information is Centerville MA 02632 11-7-14 required for every page. Cftylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29' Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-Tape Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level_Tank and covers at 18'•below grade. Inlet tee, outlet baffle. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene y El 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: I Date t5ins•3113 Title 5 olrrdal ftpectlon Form:Subsurface Sewage Disposal System•Page 10 of 17 Nov 0£i'l411:05a p,11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Bevy Owner owner's Name information is required for every Centerville MA 02632 11-7-14 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass 9 ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Dale Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required)_ Is copy attached? ❑ Yes ❑ No V%u•3f13 Title 5 Of dal Inspection Form:Substuface Sewage Disposal System-page,,al 17 Nov 08'1411:05a p.12 2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Berry Owner owners Name information is Centerville MA 02632 11-7-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D Box is 16"x16"-28"below grade. W/cover at 6". One line out, box is new 11-7-14. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No' Alarms in working order. ❑ Yes ❑ No' Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: LSns-3/13 This 5 Official haspeetion Fomt StAsvface Sewage Disposal System•Page 12 of 17 Nov 0&14 11:06a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s 8 Hi-Ona Hill Road Property Address Jean Berry Owner owners Name information is required for every Centerville MA 02632 11-7-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ® leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is a 1000 Gal-precast pitw/4' stone. Pit at 2'below grade. Pit is under edge of shed. Inspected w/camera,at time of inspection pit was dry. No sign in D Box or line of over loading Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Mine-W13 Tft 5 Official Ins pactian Fam:Sibstuiaee Sewage OEsposel System•page 13 of 17 , Nov 08.1411:06a p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Berry Owner Owners Flame information is required for every Centerville MA 02632 11-7-14 page. cityrrown state Zip Code Date of Inspection D. System Information (corn.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 1eT6.3113 role s Oftel me pee6on Farrtc Subsurface Sewage Dispoael System•Page 14 or 17 Nov 08=1411:06a p.15 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments B Hi-Ona Hill Road Property Address Owner Jean Benny Owners Name Informa8on is rewired for every Centerville MA 02632 11-7-14 page. Cityltown State Zip Code Date of Inspection D. System Information (cons.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ot =S ' REAR e _ 1 �EeK- i i o t5ins•3113 Tile 5 Of&cial Insperson Form Stbsrrrace Sewage Dlepoaal System•Page 15 or 17 Nov 08 1411:07a p.16 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Berry Owner Owner's Name information is required for every Centerville MA 02632 11-7-14 page. Cityfrown state Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Nq Estimated depth qhigh ground water: 12' feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked,date of design plan reviewed: 8-30-85 Date Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: T.H.on Design Plan 8-30-85 no G.W. at 12'. Bottom of Pit at 8' below Grade. Bottom of pit at 4'above T.H. Depth abutting property drop's off 20'+. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 151ns-3113 Title 5 OIIk3al Inspection Fomr.Subsuafeae Sewage Disposal System-Page leaf 17 Nov 08-1411:07a p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 8 Hi-Ona Hill Road Property Address Jean Berry Owner Owner's Name Informrequired is Centerville MA 02632 11-7-14 tion required for every page. Citylfown State Zip Code Date of Inspedion E. Report Completeness Checklist ® Inspection Summary:A, 0. C, D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 TiUsSOMdatl on Fom[SubsWace SewageOisPosa System-Page17 o117 -No. % FeeV THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS y application for Misp.oeal 4pstem (Construction permit Application for a Permit to Construct( ) Repair K) Upgrade( ) Abandon( ) ❑Complete System X Individual Components Location Address or Lot No. B 14 i 01VA—O(GL R 0 Owner's Name,Address and Tel.No. 0 5j rtwta-C �v to + :Zew isazkl Assessor's Map/Parcel a OS Fr H i —(Mx4..0(Li-RA CA5Q72_9W!(•cb Installer's Name,Address,and Tel.No. 509—4 7-1 $$Z1 Designer's Name,Address,and Tel.No. CA Ocw co C GuTc-32M5;cS LL-c- 15 %_r - PEA Type of Building: Dwelling No.of Bedrooms Lot Size (R + sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) RL'PC�4-C� �•—$OX Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si d Date ( 5-eZC71 Application Approved by Date t I Application Disapproved by Date for the following reasons Permit No. L4 — Date Issued t C/ y Fee C/(/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplication for Disposal 6pstem Construction permit Application for a Permit to Construct( ) Repair K) Upgrade( ) Abandon( ) ❑Complete System 9 Individual Components Location Address or Lot No. g N 1 .01VA_Cd f L(.R!) Owner's Name,Address and Tel No. Assessor's Map/Parcel aa7 08 C-c J l` I? Hi_6AJ A_T (L?_"6kkj�lC.t Installer's Name,Address,and Tel.No. $02-477 -$$Z1 Designer's Name,Address,and Tel.No. CR hiw 1D c- GumSR t5e5 LL-c. N/� Type of Building: Dwelling No.of Bedrooms Lot Size (a 3 + sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil t. Nature of Repairs or Alterations(Answer when applicable) PICIPLACr__ 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 Certificate of Compliance has been issued by this Board of Health. y, . t Si d xx Date Application Approved by Date �- - Application Disapproved by Date for the following reasons f Permit No. /L — L14 Date Issued °" --------------------------------------------------------------- ---------------------------------------------------------------------- �, THE COMMONWEALTH OF MASSACHUSETTS '•_1 BARNSTABLE,MASSACHUSETTS Certificate of Compliance ,THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(x) Upgraded( ) Abandoned( )by to 6--Lt3049 CG J'(fWQ2lSZ LI-C-. at �:� i --owA-14I LL (Zn has been constructed in accordance, with the provisions of Title 5 and the for Disposal System Construction Permit N,5--)0/'J 7= dated Installer C+4P�"k)lD� �[-�L� -157g U-J Designer LA �#bedrooms Approved design flow f f gpd / / f f° The issuance of this permit shall no becoaaistru`d as a guarantee that the system will funotion de signed VAT", �Date Inspector ` I�/ --f/,' / /I 1 1" ___________________________________ ------------------------------------- �1 No. — Feev THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS -isposal 6pstem CConstrnctiol 'Vermit Permission is hereby granted to Construct( ) Repair()<) Upgrade( ) Abandon( ) System located at and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction m us e gt�i}p within three years of the date of this pe it. Date , �1 Approved by Z® r � 7 � • TOWN OF BARNSTABLE LOCA770N �� SEWAGE # VILLAGE �E2vi (� ASSESSOR'S MAP & LOT ad • D 67 INSTALLER'S NAME PHONE NO,-�/9 6, N 14SEPTIC TANK CAPACITY LEACHING FACILITY:(type)//ZFe-�1S7 1 / (size)/b0 b NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER R v BUILDER - G &y DATE PERMIT ISSUED: ? DATE COMPLIANCE ISSUED: � �- 9 VARIANCE GRANTED: Yes No �"'�f \ti 4 vdim (So2IS T �' LC"pe1� THE COMMONWEALTH OF MASSACHUSETTS BOAR® PF HEALTH . .!tiJ.. 40 OF...... ..i� ............................. Apphration for Disposal Works Tomitrnrtinn runfit Application is hereby made for a Permit to Construct y `' or R air - jIt i Se a e sail Sys em at: y }'� ✓/°� lam!V✓ . ....., -/ice--- - � .._...:. - ion-Address or t No ................................................... -- �, �J - y� C..................... owner Address G. h. T .._._ �i f a — ---------- ------- = w-••----•--=s•----.....--•--------••---------................---------------- Installer Address d Type of Build n Size Lot_.. .`........Sq. fe t U ,., Dwelling—No. of Bedrooms............................................Expansion Attic ()CV Garbage Grinder 1 .S pa., Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ) 04 Other xtures .._.. W Design Flow....t7�.__..__ � _Q_.____.gallons per person per day. Total daily flow...... '.rZ_5.....................gallons. WSeptic Tank—Liquid capacity_A allons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width.................... Total Length............ _.._._ Total leaching area...__. ..___.._ sq..ft. 4.Seepage Pit No--------/......... Diameter.....1- _..... Depth below inlet.... Total leaching area.._ :�_ _....sq. ft. Z Other Distribution box Dosing tank ( ) Percolation Test Res s Performed by-----.1� , 1. . Date- 6............` 5/. Test Pit No. 1 .=._minutes per inch Depth of Test Pit..J' ------- Depth to ground water.4?U 1e ...1;7- Test Pit No. 2................minutes per inch Depth of Test Pit....V..e........... Depth to ground water........................ f----•----- - --- -------------------------•--• ...... --------- D cription of Soil j ��� ..G"---------------------- �----•--•--------. .. x 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia9ce has b ed _ Signed ,------`----- '.......... ........................ .- ...............V....................... y 7 � Application Approved B pp pp y ------- -------- ------- . .. .....------....---...---.........................---...---.......----... ---- Application Disapproved for the following reasons: .............................................. .... ........ .. ... .... .. . ... .. .............................. .........................I - Dare Permit No --- --- - .1...... .... .......... ......... No......................... �"�, � FE119 ../..................._ THE COMMONWEALTH OF MASSACHUSETTS BOAR® ,F HEA�gL�TH E'-- -..OF...... ...4 �.J,�r�r.f._?�..................................... Application for Uiip.anal Workii Tnntitrnrtion Frrutit Application is hereby made for a Permit to Construct (,. ) or Repair ( ) an Individual Sewage Disposal Sys em at �� - .. .............••••-••--- aYton-Address � t o. ----•-..... d-- s------------------------------------------- Owner .A - W Installer Address f l f Q Type of Building Size Lot. 7.c__ - -•-•Sq. feet Dwelling�' o. of Bedrooms...........................................Expansion Attic (14,10 Garbage Grinder (1. 04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria � ) - 04 Other..fixtures_ - ..................................................................................... - -- ---------•----•-•--------•---••-------•-- W Design Flow....b.,--__-..: �r:s;___.gallons per person per day. Total daily flow------- .....................gallons. WSeptic Tank—Liquid capacity_ �.64allons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width....................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------!---------- Diameter...._ .ff:___.___ Depth below inlet_.. ......... Total leaching area.....%P_ ....sq. ft. Z Other Distribution box (ice Dosing tank ( ) _ '-' Percolation Test Results Performed by._....1,� ` 1` .. _ ��1( __ `_ ._____ Date_.. -'.�._' ..r----, aTest Pit No. 1 4.__n...minutes per inch Depth of Test Pit...f P ... Depth to ground water F-:t—(.'r �° ( , Test Pit No. 2................minutes per inch Depth of Test Pit....P........... Depth to ground water...t........................ Description of Soil %* .-• ••••--•••--••--•--------•••••••••-••......------•--••----•••--•-- x -----------------------------------------------------------------------------------------•-----••---•••--••••---------------•------••••••-•-------•••••••••-•-••••-•••-•----------.........•-----..... U Nature of Repairs or Alterations—Answer when applicable...__...............................................•.._......................._._.___...__._... ----------------------------------------------------------------------•-------------•-••---------------•----•-----------------------•--•---------------•---------------------•--•------••-••••-------••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. gSi tied ------------- --------------------------------------------------------------------------- ----------- 1----------'--------.. Or � � �_.. � to �/ ) Application Approved BY ..... .. ....._....- .......//11' ("-:-,I(��C !/� a -------------------------------- -------------------------- ------ .... ---------�-- .�_. Date Application Disapproved for the following reasons: .................................................................................. ..... .. ............. .. . .... .... ...... ......... .................. .........................................................:---... --. .............---....------............. ---------------- f - e /. � Date. Permit No. ------q---_--------• ;�--t.7:'..--�-------- Issued ----------------�..%... -.. :<...... .....- e THE COMMONWEALTH OF MASSACHUSETTS BOARDaOF HEALTH pFM, 4- , - Cer#tf rate of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( ) by ----- --- ---- - 2 ........ 11 . �c y......... .................... ............. ... ... . ,� nsta er f® .................................................................... --- .. ..--- -- has been installed in accordance with the provisions of TITLE� f�The Stare Environmental Code as described in the application for Disposal Works Construction Permit No. ........,� ....... .�t,�.% '^dated ...................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................... .. 3.©........ 3......................................... Inspector .......... --��.........------------------------------------.------------- ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD/,OF HEALTH ....../......�. ............ O F... .......................... / No.... `' FEE........................ I giiip.aiial WorhD Tnngtrnrtiott Vanfit Permission is hereby granted............................................................................ ..------------------------...... ••-•••••--............... ..._.. to Construct( or le air ( ) an Individual Sevt age DIs osal S �l em r E . atNo-------- ----------=---- �.�=�_ � :'.....!`�.a_ ���E-� ��,.�';- .....................t-, / ....... ....................................... treet as shown on the application for Disposal'Works Construction Permit No.f-.�_'.::ZDated.......................................... Board of Health DATE------------------••-=- ......---r.......I- FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ` r ',..i . .: .., . ! 7W 2 L - - 7 9 � 6?_ y S vb; Cac.cr(� zed �J z,s - G19 ;6� �ti 6 _i LAI PETEk a ! Wt�1Eti59 o .__!.. _ .. rNo. RAM N 0 29733 T NAL" TES!' o , 4- ? C-4? 70 lot 1,7 M qy „ i �'�'t�.lG •• G� , G'.E.2T/F/E.O PG DT F�L:4N �f { ebb — 1�1 ► rF � -� Zc>' yQT.E14, t .dGQ:v .�6, 45//c� - r-L - duo / E�Eo.v 7,A14 ,• ox%v aF l��t.. - .2.E6isr�.er�.�.�vo-sli.2tiEya,Cs c- ' �' .. tTl�lt�vt„e,V /•s iYo7--13.4SE0 o�v,4,v iiY.ST,e-. ' !%iLJEiYT.S!/,2,/Ey,,4ir/o. T,siE O�FS� A SAC:j SC>45 { i S a �y J. r Sod r.. I 17) �1 1b tF16Z 'oN ,b NVAMns b313do� N -l0 fill g i