HomeMy WebLinkAbout0260 NYE ROAD - Health (2) 360 NYE RD., CENTERVILLE
A= 147-030
t _
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 360 Nye Road
Centerville
Owner's Name: Thelma Donahue/Victoria Durno
Owner's Address:
Date of Inspection: 8/23/2006
Name of Inspector: (please print) Patrick T.Sullivan
Company Name: Ready Rooter
Mailing Address: P.O.Box 371
Sandwich,MA 02563
Telephone Number: (508)888-6055
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The System:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
Inspector's Signature: L� �-- Date ' 46
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,1l),000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regiwonal office,,of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable;•and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 360 Nye Road
Centerville
Owner: Thelma Donahue/Victoria Durno
Date of Inspection: 8/23/2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pas 7 section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as app ved by the Board of Health,will pass.
Answer yes,no or not determined (Y,N,ND)in the for the follo ing statements.If"not determined"please
explain.
The septic tank is metal and over 20 years old* or the septi tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank fa' a is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approv d by the Board of Health.
*A metal septic tank will pass inspection if it is structurally so d,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or gh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or unev n distribution box. System will pass inspection if(with
approval of Board of Health):
broken ipe(s)are replaced
obs ction is removed
distr' ution box is leveled or replaced
ND explain:
The system required pumping mor than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the oard of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
r
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 360 Nye Road
Centerville
Owner: Thelma Donahue/Victoria Durno
Date of Inspection: 8/23/2006
C. Further Evaluation is Required by the Board of Health-
Conditions exist which require further evaluation by a Board of Health in order to determine if the system
is failing to protect public health,safety or the environm t.
1. System will pass unless Board of Health d ermines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner w ch will protect public health,safety and the environment:
_Cesspool or privy is within 50 fee of a surface water
Cesspool or privy is within 50 et of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public ater Supplier,if any)determines that the
system is functioning in a manner that protects the public he th,safety and environment:
_The system has a septic tank and soil a/onm(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surfa .
The system has a septic tank and SAS within a Zone I of a public water supply.
_The system has a septic tank and SAS within 50 feet of a private water supply well.
_The system has a septic tank and SAS less than 100 feet but 50 feet or more from a
private water supply well". Method us determine distance
"This system passes if the well water alysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds ' dicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and ni ate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of e analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
I
Property Address: 360 Nye Road
Centerville
Owner: Thelma Donahue/Victoria Durno
Date of Inspection: 8/23/2006
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
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 and overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the 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 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 jpasses 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 foram.]
(Yes/No)The system fails. I have determined that one or more of the above 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 f lity with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the fol wing:
(The following criteria apply to large systems in additi n to the criteria above)
yes no
_the system is within 400 feet of a surfac drinking water supply
the system is within 200 feet of a tri tary to a surface drinking water supply
the system is located in a nitroge sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply' ell
If you have answered"yes"to any que tion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large sy tern has failed.The owner or operator of any large system considered a
significant threat under Section E o failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should ontact the appropriate regional office of the Department. i
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 360 Nye Road
Centerville
Owner: Thelma Donahue/Victoria Durno
Date of Inspection: 8/23/2006
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?
_Z_ Was the facility owner(and occupants if different than owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
_ Existing information.For example,a plan at the Board of Health.
_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 360 Nye Road
Centerville
Owner: Thelma Donahue/Victoria Durno
Date of Inspection: 8/23/2006
FLOW CONDITIONS
RESIDENTIAL
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):
Number of current residents: i
Does residence have a garbage grinder(yes or no):�
Is laundry on a separate sewage system(yes or no):.�p[if yes separate inspection required]
Laundry system inspected(yes or no):=
Seasonal use:(yes or no):&X3 = k Q G,pt:'
Water meter readings,if available(last 2 years usage(gpd)): l`T y„�.•—�{, -,�_ Q ��
Sump Pump(yes or no):
Last date of occupancy:
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203 lzpd
Basis of design flow(seats/persons/sq.R c.):
Grease trap present(yes /pre�ss—en
Industrial waste holding t or no):Non-sanitary waste dische 5 system(yes or no):Water meter readings,if Last date of occupancy/u
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:Was system pumped as part of the inspection(yes or no): �
If yes,volume pumped: gallons--How was quantity pumped determined? 5`0<�, �"�,•� a„� su Gam-,
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information: p
SC�'4`-ate '"�'a..w+�- '��$'tb X' '3 o y c.�.I�� c9�rs� , '0��,,.a...S2. �l�-�Cl� r'c°<rFa•r-�Q� .
Were sewage odors detected when arriving at the site(yes or no): iv c�
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 360 Nye Road
Centerville
Owner: Thelma Donahue/Victoria Durno
Date of Inspection: 8/23/2006
BUILDING SEWER(locate on site plan)
Depth below grade: Q a'
Materials of construction:_cast iron //40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade: jy„
Material of construction:concrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions:
Sludge depth: 3 "
Distance from the top of sludge to bottom of outlet tee or baffle: 3 t�'
Scum thickness: '1
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: i C."
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition structural integrity,liquid levels
as related to outlet invert,evidence of leak a ge,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top/ions,
r baffle:
Distance from bottom of scum toet tee or baffle:
Date of last pumping:
Comments(on pumping recommt and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidenetc.):
i
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 360 Nye Road
Centerville
Owner: Thelma Donahue/Victoria Durno
Date of Inspection: 8/23/2006
TIGHT or HOLDING TANK: (tank must be pump at time of inspection)(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal erglass_polyethylene_other(explain):
Dimensions:
Capacity: /switches,
Design Flow:
Alarm present(yes or no):
Alarm level: Alarm in s or no):
Date of last pumping:
Comments(condition of alarm anetc.):
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: C "
Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chambe ,condition of pumps and appurtenances,etc.):
f
Page 9 of 11
OFFICIAL —
INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 360 Nye Road
Centerville
Owner: Thelma Donahue/Victoria Durno
Date of Inspection: 8/23/2006
SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
leaching chambers,number:
—Zleaching galleries,number: 1 b�g�, c �'T.� -_,��, _ ors �..�j 6(� IS P ,
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.):
� W�e, l.mz.r.� � ��`T c5ac�.Ac��G`� +�nv.+� m►-a�t►:� '�T�� �(r ®c��r'
'ta� 5'��w v+a`.�. M-P (Mi C.,►\1,
\w\�L1J"�a ./L�J t•YVvre. t/'E:ate—v'`��4a Vim. C ��✓— 44-6,
CESSPOOLS: (cesspool must be pumped as part o 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 or o):
Comments(note condition of soil,si 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 hydr ulic failure, level of ponding,condition of vegetation,etc.):
i
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 360 Nye Road
Centerville
Owner: Thelma Donahue/Victoria Durno
Date of Inspection: 8/23/2006
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.
! I l s r
�` � - `CD
Aq = 33 '
357
0
Gt - 33 `
3
6
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 360 Nye Road
Centerville
Owner: Thelma Donahue/Victoria Durno
Date of Inspection: 8/23/2006
SITE EXAM
Slope
Surface water
Check cellar f
Shallow wells
Estimated depth to ground water > u 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 feet of SAS)
Checked with the local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
'Cctr•rbS�CA.�.T��,.s'A. Geav��
You must describe how you established the high ground water elevation::
✓�/� A' PtMh aw—J2_ c A ).erCY r
TOWN.OF BARNSTABLE
I P-gATION SEWAGE # - p
I AGE ASSESSOR'S MAP& LOT 1�7-- �
'INSTALLER'S NAME&PHONE NO.' rC� stp
.'SEPTIC TANK CAPACITY
-LEACHING FACILITY: (type) L1 Zdil?b Ili (size)_�12-t� .
NO:OF BEDROOMS
,BOULDER OR OWNER
PERMTTD:a►TE: X COMPLIANCE DATE: Z(c5-51 Q
`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
`': `ot site or within 200 feet of leaching facility): Feet
I tlge..of Wetland and Leaching Facility(If any wetlands exist
;within 300 feet of leaching facility) Feet
Furnished by
i
• i I
No. Fee '
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Mi$tJ0 r *pgtem Cow6truction Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.3GO N 1 G VbAko
Owner's Name,Address and Tel.No.
Assessor's Map/Parcel f-y l ^� D��61ve L_�V ti i V_,
Installer's Name,Address,,and Tell..No. S Designer's Name,Address and Tel.No.
O Nqe::rli;;e WY CL XA_
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 30 gallons per day. Calculated daily flow L gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 5% 6--/ Type of S.A.& 14 C, k. Ccc
Description of Soil S.4--o
Nature of Repairs or Alteratio (Answer when applicable) C-�/ U
l ✓� L vcr
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 Cod and not to place the system in operation until a Certifi-
cate of Compliance has bee o
Signed Date t
Application Approved by Date J/f-
Application Disapproved for the following reasons
Permit No. F' o Date Issued J f i
No. Fee J i
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
,
Rpprication for Mioo Y *raem Construction Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No.?—��O y b� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 4
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
_�,o a 1ti X_
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 c) gallons per day. Calculated daily flow 3 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank `<rn S t Type of S.A.S.
Description of Soil /� F_ 0 <'.4L1
Nature of Repairs or Alterations(Answer when applicable) _tit,�TY� U Qc—
a ✓rr /,�i ��i �l T—�_�[a�✓I L-r ru r�0i
r
Date last inspected:
i
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 Cod and not to place the system in operation until a Certifi-
cate of Compliance has been is Fiis-$o
Signed Date
Application Approved by Date � �� rf
Application Disapproved for the following reasons
Permit No.g.Y �-3o L/
Date-Issued`"-
THE COMMONWEALTH OF MASSACHUSETTS —
BARNSTABLE, MASSACHUSETTS
(certificate of.Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(K)
Abandoned( )by c ►4 DIP— S t=O-T f c-
at GO N'40 &A-f) e'EA-1 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. — a dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the syste wj function as designed.
Date _ � � ' Inspector \
- ! O ---- ----------------------------—`—
No.
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
'igpogal *pgtem Congtruction permit
Permission is hereby granted to Construct( )Repair( >-4 Upgrade( )Abandon( )
System located at
e /lam'
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:
/Construction must be completed within three years of the date of this e it. 4
Date: ?a/�'c�/ �� Approved by �-
lot" l
• y• II
t
• m is To Be Used For the Repair Of Failed
NOTICE. This For a
Septle Systems Only.
ON OF SKETCH
AND-APPLICATION FOR A
CER1r11gCATI ITHOUT I ,�
POSAL WORKS CONSTRUCTION PERMIT(W
DiS ENGINEERED PLANS)
! i
!
• lie dion for disposal works
I �b� hereby certify that the epp ;
c"ceming the ,
me dated
�stniction permit signed by a
meets in of the
ptopefty looted at
falloa►ie6 criteria:
leMb loe�ted within 100 fhet of the proposed leeching fbefl�►
✓• ' �1�1'e we 110 wet i
Ib p��
Hells with%1 6 ft ott-of the proposed n$le system
Vi. 111Ce eR �
/Th"Is no hseseese in row an"dheer hi use proposed , l k,
I ,
/ needed
v "M We no Val
t of
lesdtMg fucOlty rri11 be located
with%250 het of etty wetlands.
the bottom of the ,
fthe PbP will be located less then fourteen(14)feet above the sstaxisnum adjusted `
pip ned leeching facility 1 to 4
table 0100toss. I
iNt tse eemplete the Momflis
DivisionG.LS,snap)
}
A)1bp of Oreuod g (aceotd ft to me 8ngineerins
e000rdbg to HeeN11 Division well map)
0) Table glevetton( �t
DATE$
. : slaNED;
„
LICLN�ED SEMC SYSTEM
INSTALLER fN'l HE TOWN OR BARNSTABLE NUMBER
Airs N'fM tte.e..e InNatt.►oe.a....ewslA�d otee dt.�. ; .
d1b plan ahonid be submhtedl.
i �-- :.
v
2-W e �O TOWN OFBARNSTABL,E
LOl AfION !l�</� SEWAGE# '7tr 3�F{
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size) V W v,,
NO.OF BEDROOMS Q`'^�' "'� y
OWNER ��yv�,a
PERMIT DATE: S t fi= COMPLIANCE DATE: T1 <!)
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the 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
FURNISHEDBY
Ic JA A q_ 33 "
F0o0
I 3 r
1'i• ••+.\J7° `.1 by
2 v �WN OF BARNSTABLE
LUC,,U71ON Al SEWAGE # - t
VILLAGE ASSESSOR'S MAP & LOT LZ --l -0
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ®-cab -t� a�•�--.
LEACHING FACILITY: (type) 61 tgO (size)
NO.OF BEDROOMS
BUILDER OR OWNER LPG r._K[�.0
PERMTTDATE: — <-COMPLIANCE DATE: a((1-
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
r
1
r
o
No. 3...............s� Fim$..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..?LG. .........................OF.... s' � .a '�v------ ....----------•----•-----•--...-•----
Appliration for Dispaiial Works Tontitrurtion ranfit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
System at:
....: d ._ .....t�✓ .�..! - -------------------------•----------. !v� r-v� - -----...--- --------•---------•-----------------------•...
^�� �7 Location•Address or Lot.No.
�{/f�fd�.C� 'Sc:.et%L Q�%Ar. _ ft� ?. ._.... ®" 4 _._._._.__._ / �1Jd .i . ..............'
....... _..... ..... ........ .......... ........ .__..
Owne Address
Installer Address
d Type of Building Size Lot..et*6.�...........Sq. feet
U Dwelling—No. of Bedrooms....7.;1.. .....................Expansion Attic (ev4e Garbage Grinder (✓&e,)
P4 Other—Type of Building /i o9 kCc-h No. of persons__..._.43................. Showers ,4? — Cafeteria ,V�
04 Other fixtures ............................... ..
W Design Flow.............................11 ........gallons per person per day. Total daily flow................. ............gallons.
WSeptic Tank—Liquid capacity`a ...gallons Length________________ Width................ Diameter---------------- Depth................
x Disposal Trench—No. .................... Width_..-____•._-______-- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (v) DosmCtank ( )
~' Percolation Test Results Performed by.... ................................ Date......-r _:. ...........
Test Pit No. 1-----!4-------minutes per inch Depth of Test Pit______ �........ Depth to ground water.._!lt.d. ......
G4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
----------•-•--•---•-------••-•----•--•--•---•......•-------•-------------------------••....................................................................
0 Description of Soil......®_'o? !4474! -----`5`' ................................................... ......................................
6 -------------------- d_;Z7 ----�'6e ' 'f?9,V------ ---_--..------------------......................................
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 iIT,i� 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b9c<Issued by the board of health.
ne
�--A
..............
Application Approved By.._... --�-- - v
--------------------
Date
Application Disapproved fort e following reasons:................................................... ---•----------•-•-•--------•---------------•-------•-•••----
.......................................------------...-----..-----------------•......_..------.....-------••-.--•-•---------------------.............................................................
Date
PermitNo.......................................................... Issued-.......................................................
Date
N01�'- ... Fss.................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF
Appliratiun for 11ispoii al Works Toustrurtiun amit
Application is hereby made for a Permit to Construct (I-) or Repair ( ) an Individual Sewage-Disposal
System at:
.................................... ..C......_r__T__e.__ v_�___G__.-.__-r..._....._...---....-•-----------------•--.....--•---------
Location-Address r Lot No.
.....2)?'.4,i�_._._.+ ��Or1s. ?n 'c E'.v - �• -•---
r� --•......... ........•--•-.----
ess
------.Add..._.._.
Installer Address d Type of Building Size Lot___ '._�..el........Sq. feet
U g— _.....Expansion Attic (10VO Garbage Grinder
U Dwelling No. of Bedrooms.....��,__'f'- '±"_____________
a`•4 Other—Type of Building tftffii r< No. of persons 8............... Showers
g --•--•-----•------------ P - (� — Cafeteria (
Other fixtures . ---------•-•--..
W Design Flow................................ ..__..gallons per person per day. Total daily flow._..__....____...__` _ _._.__._.._..gallons.
WSeptic Tank—Liquid capacity.4�.gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box Dosing 4pk ( )
a Percolation Test Results Performed by............................................................................................................. ..._.......... Date...._._�.�"�_ _...._....
�7 /� ti, o C-.v
a Test Pit No. 1................minutes per inch Depth of Test Pit______-..•_---_____• Depth to ground water.._---_____-_-_____-__.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a _-•----------------------------•--------•------.....--•-----•-••-----......••••-•........._....--••-•.........................................................
Description of Soil........!.-� eoopo" v r
. . ........ r a :.. . .. ••-•-V .....•--••-.....•--••-. ••-•-•••.... . ... . ...................... .. ......... ............................................................
.............••-----.....--••_....-•---.._....-
- .----. --_ ---•-------•-•----•-------•---•----•----------•-----------••••••--...••••-•-•-_....
V 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 Sanitary Code—The undersigned further agrees not to place the .ystem in
operation until a Certificate of Compliance has b issued by the board�ealth. f
~ Yj
ied.._! _..�.�..__. e„E.
Application Approved B _ ' ~ a�
PP PP Y = ------------------------------------------•••-•••-••-•............-•-•-
Date
Application Disapproved for th following reasons----------------•---------------------------------------------------------------------------------------......---
••-••-•-•......_....-•-••-....-•-•--•••-••••••••••--•--•••••••---•-••••••••••-•--•-••-•-•-
Date
PermitNo......................................................... Issued-.......................................................
Date
i
THE COMMONWEALTH OF MASSACHUSETTS
r'�
BOARD OF HEALTH
C �!/<v.
':TCJtU..........................O F.............................................�
........................................
ClErrifirtt#r of Tuntrlianrr
T IS TO-CE TIFY, That the Individual Sewa, Tiqd�tem constructed ( or Repaired ( )
b
Installer
at-• •-•-•-••• . A_
• • /S1,
-
has been installed in accori
th the provisions of TI �5o,-The State Sanitary d cribed in the
application for Disposal Wstruction Permit No.__...__3__________............
......... dated_..-._.. ._-_.___..............................
THE ISSUANCE,OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.,
DATE .....1-• ?y
•-1----... Inspector-------------2
{--------------------------------------------••••--•------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............OF...---- .B�`?.✓ t. Gr3a /O
No._.......'............. FEE........................
iu � unr1hrutit
Permission is reb granted....... '/----
to Construc ( or Repair ) an Indi0� a ewage Disposal System
atNo... Y .. ............. --••---......----------._.._._---•--------.._...----------------------
Street li,.+"
as shown on the application for sposal �t orks Construction Permit No.._._ ..____._ Dated___..fff...._____JJX"......................
•..................•••-••-= .-•---
�, � Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
'51 W t.E F A M t LY - B E O Ro oM �-- o T
ND GARBAGE 6iZjND6i2. � •
otstLY Ft.oW s Ito Y. 3 = 33oG:P�?
I SEPTIC, TANK =. 330XI50% --1495G.P. Q �OO.Ov 97 8
uSE 100o GAt.. q9.3 r� �98�0
ot5Po5A1 Pt'r u4E woo GAL. �{+'
5 t VG.WAL1 5 40 1,lt;� 0
15o 5.F 'X �•5 a 37 G.>?�o d .
Ioo9� 0
BOTTOM AREA f . j�o SiF. v. Prr
So S.F x I• o A ��o G.p oq_. . L,o T Z 3 61 r
-TdTA1-. c>EstGN *4Z5
-To-rA%- IAA t t-l( FL.ov,! = 330(.PD. 98 n°'2 ay. GAt— I
j PE2COLATtON RA?Ej t''iN 2M�N ot`.�E=55 ° ' TA6N'
Ce
OF
C RICHARD ALAN ' IV98-or8.
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BARTER
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TEST ?-ISIS To`p 9`7`1a�.Z..
FL- 18.9 INv.
1000 INv. - q8.z
DIST �N�• GAL. 98.0
SGPTIC. ,
2 t000 �N� BaX 97,E TANK I
LEAcu
SP14t, P►T INv.. INV. i
WI'rtl 97,L 97.4
WAS4SD
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8 o No• 5*CP.LE SCALE �Ia>,�t*" V_ 1/31143.
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FOUND P`-P`N_ R6FGR-St4GE i
NE.gmo►,i LoMPu(5 WITN-THS SIDELINE L.o "r Z '
AuD 56TQAGK R.6Q�t2>rMEN'f� oF'!µE- '
'TOWN 40T p1^N '�, 2Bt p6, "► Z
t_OGp►TED WlT 11J THE GLoo PLA
DAT� I` 1-s
A;LA Sn "z SAxTGV-i NYC- INC.
R.EG I ST faQ6� t.AN D S u�Y�aYo>�S
Tuts PL&IQ 115 PIO*T BASED Glci AN os-rc-e.vILLEr • MASS•
'INSTRuMEN�' ;u2vEY �TNE•oFi-'SETS Suc�t,� i
�' NoT I3G- V>C•nTd UCTC:.G'-MI►�C L���- ti.111[.�� APPl.1GA►�T' �/`Y 1 D S/*(�RO
LOCATION`S SEWAGE PERMIT NO.
VILLAGE
I N S T A LLER'S NAME A ADDRESS
e U I L D E R OR OWNER
DATE PERMIT ISSUED 2
DATE COMPLIANCE ISSUED
va-
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