Loading...
HomeMy WebLinkAbout0367 OAK STREET (CENT./W.BARN) - Health 368 OAKATREET. , CENTERVILLE 194-042 a UPC 12534 No.2._ 1_R HASTINGS,MN Commonwealth of Massachusetts ., Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments k 368 Oak Street, Property Address Toby Leary Owner Owner's Name information is Centerville required for every MA_ 02632 4-30-13 _ page. Cityrown State Zip Code Date of Inspection i 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. Important:When filling out forms A. General Information ,,u�unn�uuu on the computer, DF_i .90hil//�. use only the tab 1. 'Inspector: JAMES key to move your cursor-do not ,!Ames D_Sears t0J\ U -�- use the return =o: QED C key. Name of Inspector CApewideEnterprises,LLC ICI Company Name SPE `�0 153 Commercial St_ ''��►ru,n,,,,n,m``" Company Address — r�.< Mashpee MA 02649 Cityll-own State Zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification 7 f I certify that I have personally inspected the sewage disposal system at this add'raess and that theme information reported below is true, accurate and complete as of the time of theJI,spection:The inspection was performed based on my training and experience in the proper function{and maintenah, of o� site sewage disposal systems_ I am a DEP approved system inspector pursuant to Section.,15.340 of Title 5(310 GM 15.000). The system: - t;Zz y ` ® Passes ❑ Conditionally Passes ❑ Fails ry ❑ Needs Further.Evaluation by the Local Approving Authority 5-1-13 ,.I spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be 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 j---, the same or different conditions of use. � 5/o 15ins-3/13 Title 5 Office!F s n :Subsurface Sewage Disposal System-Page 1 of 17 May 03 13 10:47p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 368 Oak Street Property Address Toby Leary Owner Owner's Name information is required for every Centerville MA 02632 4-30-13 page. City/Town State Zip Code bate of Inspection B. Certification (cunt.) 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 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) isstructurally unsound, exhibits substantial infiltration or exfiitration 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 y Compliance indicating that the tank is less than 20 years old is available. . ❑ Y ❑ N ❑ ND(Explain below): t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 May 03 13 10:47p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form =1 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 368 Oak Street Property Address Toby Leary _ Owner Owner's Name requinform r on is Centerville MA 02632 4-30-13 requiredd for every page_ Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ 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): i . i - ❑ 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): ❑ A. 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 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 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 p P Y 9 9 s t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 May 03 13 10:47p p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 368 Oak Street Property Address Toby Leary Owner owner's Name information is required for every Centerville MA 02632 4-30-13 page. Cityrrown 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 usedto determine distance: *k This system passes if the well water analysis, per-formed 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 0 ® 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. i is less than 6"below invert or available volume is less than Y2 day flow 4 &k11,,A,,c t5ins•3113 Tme 5 Orfidal Inspection Farm:Subsurface Sewage DisFosal System•Page 4 01 17 May 03 13 10:48p p.5 Commonwealth of Massachusetts - Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 368 Oak Street Property Address Toby Leary Owner Owner's Name information is required for every Centerville MA 02632 4-30-13 page. CityTown 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, cesspooi.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 I 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 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 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 El ❑ 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 15.304.The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Official Inspection Fonrr.Subsurface Sewage Oisposat System-Page 5 of 17 May 03 13 10:48p p.6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary,Assessments 368 Oak Street Property Address Toby Leary Owner Owner's Name information is required for every Centerville MA 02632 4-30-13 page. Citylrown State Zip Code Date of InspeCion 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 NIA) ® ❑ ' 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- El ® 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(5)] 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 I t5irs-3/73 Tile 5 ORdal Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 May 03 13 10:48p p.7 Commonwealth of Massachusetts ~ = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 368 Oak Street Property Address Toby Leary Owner owners Name information is Centerville d for every MA 02632 4-30-13 require page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. tank old pit and Infiltrator I . Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ 'Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2011-160,000G Detail: i , 2012-125,000 Gal s Sump pump? e ❑ Yes ® No Last date of occupancy: Present Date Commercialllndustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seatslpersons/sq.ft., etc.): Grease trap present? El 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: 15ins•3113 Title 5 Official Inspection Form:Sul siutace Sewage Disposal Syslem-Page 7 or 17 May 03 13 10:49p p.8 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 368 Oak Street Property Address Toby Leary Owner Owners Name ��— information is required for every Centerville MA 02632 4-30-13 page. Cityrrown State Zip Code Date of Inspection. D. System Information (cont.). i Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA 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:a ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool El Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative 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): t5ins•3113 Title 5 Official inspection Form:Subsurface Sawa a Disposal system•P age 9 of 17 May 03 13 10:49p p.9 Commonwealth of Massachusetts W Title 5 Official Inspection Form �! Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 368 Oak Street Property Address Toby Leary Owner Owner's Name information is required for every Centerville MA 02632 4-30-13 page. City/town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank and pit 1977 Permit#77-2991 Newer,Leaching 1997 Permit#97-357 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): ` 39" Depth below grade: 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 to old pit PVC SCH 20. Pipeing to newer leaching 4° PVC SCH 40 Septic Tank(locate on site plan); Depth below grade: 291? feet Material of construction: ® concrete - ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: year Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gat. Percast Sludge depth: 4" I5ins•3113 Title 5 Official Inspection Form:Subsurface Se.vage Disposal System-Pegs 9 of 17 May 03 13 10:49p p.10 Commonwealth of Massachusetts €i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r 368 Oak Street Property Address Toby Leary Owner Owner's Name information is required for every Centerville MA 02632 4-30-13 page- Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cunt.) Distance from top of sludge to bottom of outlet tee or baffle 26" , Scum thickness N 3,.-- _ 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 15" 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 at 29" below grade w/center cover at 4", Old type inlet baffle. Out let baffle to pit. Out let PVC sweep to newer leaching. No sign of leakage or over loading. Note: Maint. pump after inspection. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle . Date of last um in : p p g Date t5ins•3113 Ttle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 May 03 13 10:50p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 368 Oak Street Property Address Toby Leary Owner Owner's Name information is required for every Centerville MA 02632 4-30-13 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 ❑ polyethylene ❑other(explain): .A Dimensions: -- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes • ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•311 3 Tftle 5 Official Inspection Form-Subsurface Sewage Disposal System•Page 11 of 17 May 03 13 10:50p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments 368 Oak Street Property Address Toby_Leary Owner Owner's Name information is required for every Centerville MA 02632 4-30-13 page. Cilyfrown 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 -- 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.): 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 pu`mps 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: t5ins•3113 Title 5 Official Inspedion fomc Subsurface Sewage Disposal System-Page V of 17 May 03 13 10:50p p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form *QvvSubsurface Sewage Disposal System Form-Not for Voluntary Assessments ti 368 Oak Street Property Address Toby Leary Owner Owner's Name information is required for every Centerville MA 02632 4-30-13 page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Type: ® leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries 'number: ❑ leaching trenches number, length: ❑ leaching fields number,dimensions-- El overflow cesspool number: ❑ innovative/alternative system Typetname of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,, etc.): Leaching.is one old 1000 Gal Precast pit w/2' water. Newer leaching is four Infiltrator High Cap w/4' stone_ Camera out to leaching. Leaching is wet. No sign of over loading, solid carry over or holding water. 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 May 03 13 10:51 p p.14 Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 368 Oak Street Property Address Toby Leary Owner Owners Name information is required for every Centerville MA 02632 4-30-13 page. CityrFown State Zip Code Date of Inspection 'D. System Information (cant.) 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.): r . o i t5ins•3113 Title 5 Ofidal Inspectim Form:Subsurface Sewage Disposal System-Page 14 of 17 ti�1ay 03 13 10:54p p.1 �U Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 368 Oak Street Property Address Toby Leary Owner Owner's Name required on is Centerville MA 02632 4-30-13 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 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 /3fe r 5/0 a • a n . t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 May 03 13 10:55p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 368 Oak Street Property Address Toby Leary Owner Owners Name information is required for every Centerville MA 02632 4-30-13 page. Cityfrown State Zip Code Date of Inspection D. System Information (cons) Site Exam: ❑ Check Slope ❑ Surface water ❑ Checkicellar Shallow wells jV 6 Estimated depth tolFigh 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: 6-1.5-77 Date 1 i 0 i 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. Depth,noted on construction permit # 77-299 6-15-77 No G W at 12'+ Before filing this Inspection Report, pleas e see Report Completeness Checklist on next page. t5ins-3113 Title 5 DRciat lnspeaion Foan:Subsurface Sewage Disposal System-Page 16 of 17 May 03 13 10:55p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments w 368 Oak Street Property Address Toby Leary Owner Owner's Name information is required for every Centerville MA 02632 4-30-13 page. Cityrrown state` Zip Code Date of Inspection E. Report Completeness Checklist _ ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System failure Criteria Applicable to All Systems) completed ® Systerh Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or.attached in separate file i t f_ M f 15ins•3113 Tide 5 Official 1^spsction Farm:SubSuAaae Sewage Disposal System•Pa@e'7 of 17 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[pprication for Migpogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair(Vloul'�pgrade( )Abandon( ) D Complete System El Individual Components Location Address or Lot No.3 W C AY.46%— Owner's Name,Address and Tel.No. Assessor'sMap/Parcel194 0 Inst s N e,Address,and Tel.No. Designer's Name,Address and Tel.No. .�� �vW 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 '3W gallons per day. Calculated daily flow C��� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Z)(SC\ I W j2 Type of S.A.S. 4-1ISn s3 AZ Wx' Description of Soil p Nature of Repairs or Alterations(Answer when applicable) l 6/ 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 d not to place the system in operation until a Certifi- cate of Compliance has been issued is B Signed Date Application Approved by Date Application Disapproved for theYollowini reasons Permit No. Date Issued ti J No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Tipprication for Mizpozar *pgtem Construction Permit Application,for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 0 T J � Owner's Name,,'Address and Tel.No. W ` �4 _ i Assessor's Map/Parcel I 1 fl /7 L.lc,? Instate s�s `mo d Tel. Designer's Name,Address and Tel.No. Y Lam/_7' 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 33y # >'�' 4gallons.,p r day. Calculated daily flow Jy� gallons. Plan Date i N tuber of sheets Revision Date � N Title Size of Septic Tank_ / Type of S.A.S. � p2,T!:A7 ` Description of Soil "" V Nature of Repairs or Alte ations(Answer when pplicable) -�(/�-s l !4 f / t,� (A pe f% , �1/ Date last inspected: Agreement: n The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordanc with the provisions of Title 5 of th Environmental Code nd not to place the system in operation until a Certifi- cate of Compliance has bee f ea Signed , Date �~�� � Application Approved by Date .3 —/,5-" 7 Application Disapproved for the ,ollowing reasons Permit No. 3 Date Issued ——————————————————————————————————————— _ THE COMMONWEALTH,/OF'MASSACHUSETTS t, - r BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CEtOn-si 'S vw a isp_osal System Constructed( )Repaired ( ) Upgraded Abandoned b ll ,I o �- s-r at lN- vMS� E? .� has been constructed in a cor4ance with the provisis ofTi�the,5vand for�i�sp�os . ystem Construction Permit No. 7 dated / Installer jcocX t2i� Designer The issuance of this ermit shall not be construed as a guarantee that the syst .rp 'll fu tion as d s'gned Date Inspector r -------------------------------------�--- No. 7 7-3 6-7 Fee V C� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi.5po.5ar *p.5tem Con5trurtton permit Permission is hereby granted to Construct( )Re Pgrade( )Abandon( ) System located at �1a S�` VV, �vY�-Sl 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 completedwithin three years of the date of this permit. Date: `f 5 -9 / Approved by N, , ' � t 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 PERMIT (WITHOUT DESIGNED PLANS)- I, e hereby certify that the application for disposal works construction permit signed by me dated 7 1 S-9 7 , concerning the property located at meets all of the r following criteria: • There are no wetlands within 300 feet of the proposed septic system • 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: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. GV Od ., � � S r TOWN OF BARNSTABLE LOCATION �G SEWAGE ,yy� ASSESSOR'S MAP &LOT VILLAGE —& INSTALLER'S NAME&PHONE NO.. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) w (size) NO.OF BEDROO S BUILDER OR PERMIT DATE: �'" 7 COMPLIANCE DATE: Separation Distance Between the: Felt Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Private Water.Supply Well and Leaching Facility (If any wells exist :"Feet- on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by ,i i. . 3i _ TOWN OF BARNSTABLE y'LOCATION �o ���Z SW SEWAGE # / ��-3 0'`V?T LLAGGE ASSESSOR'S MAP& LOT ?7 +v INSTALLER'S NAME&PHONE NO. .r SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS_.- BUILDER OR WNE O VI.PERMITDATE: "P�" C q 9 COMPLIANCE DATE: 7 -/ 7 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 ` ��� � � �: t, � �;: �� � ��- � f�3 �� ��� �4 3 � � �;� ,��� __ . r , 7 70;No..-- ............ Fim 0............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 0_0.,j .... _.............OF.......... .................................. -for Ubipoiial Marks Tomitrurtiou Prrutit h eb ' ade for a Permit to Construct or Repair an ladividual SewaorF, posal Application is ve y System at: ------S1.1F------ ddre ------------- .................. ------------- ............ ...btva .. .................................. ......... ........... ..................... ............................ ................ 0. ...VA4LAF....................................... Owner Address SON Li ............W,94,WE... ... .... ........ ....... ......../?............................... .................................... Installer Address Typ,e of Building Size Lot__-?J,,,_6Q__j------Sq. feet ,;,,:Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder (Ae- P4 'bthe,—Type of Building No. of persons............................ Showers Cafeteria a Other fixtures ............................................................................................................................................... Design -Flow......SCE-------: _________________gallons per person per day. Total daily flow.............C:3ad-----_--------------gallons. 9 Septic,"',,T-,�fik'Liquid capacity/4M_0_gallons Length.... Width_V__Cp------- Diameter..........___.. Depth................ Disposal Trench—No. .................... Width-_--_--___--__--_.-- Total Length----___-_---____---- Total leaching area--------------------sq. f t. Seepage Pit:No...... Diter../ _JW ame V9,)..Y. Depth belQwelnl ... Total leaching area..................sq. f t. Z Other Distiibution box Dosing tank Percolation Test Results Performed by A-0-F"--- Date... ��'Z ......................... .. 3_ ---- ---7-------- Test Pit No. I----------------minutes per inch Depth of Test Pit-.-_......._..___... Depth to ground water........................ f� Test Pit No. 2................minutes per inch epth of Test Pit.._...._............ Depth to ground water-_._..-.-__-.--.-------- a . I-------- ---------- . ............................. ------4-7, --- - --- -- . ....... __V - _�� ------ Description of Soil..0-- - ----- -- ---- -------------- ------ ..... ... .... U --------------------X--- ... ..... --- ------0116V.. -------------------------------------------------------------- -------------------- --------- ---------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------- ................................................ Agreement: I The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary 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. Signed-- ....... ................ ....... .....................------ ..... ..!3k. ------ Date ........... D ....... ..!!,? Applicatio'n Approved By.... 0--op 1. .. ....... Date Application Disapproved for the following reasons:....................................................................................... .......................... .......................................................................•................................................................................................................................ Date PermitNo......................................................... Issued......................................... .............. Date 1, --------------------------- 7 N ............ Fes$. .. f � r(, THE COMMONWEALTH h?F MASSACHUSETTS BOARD OF HEALTH Appliotion -for Di ' anal Works C onotrurtion Vrrnrit Application is h ebbs ade for a Permit to Construct ( ) or Repair ( ) an :1qdjyidual Swag posalSystem at:......_?1.... ----•-. -----•. ...................••- ...... � o ic, .s ..------ ..-- Location-Address ar Lot No. Owner _ Address a ----....v... 1-----.....1�T.I.d-- --------------•--------•--------- -------••--••-•--- WALn/vj_'...... =........... ................................. ,Installer Address UType of Building Size Lot.. 3i__`JJ..._.Sq. feet DwellingNo. of Bedroom— ___________--------Expansion;•Attic ( ) Garbage Grinder aOther—Type of Building p S.- .- �L°r��`/.�+tr.. No. of ersolls____________________________ hoovers ( ) — Cafeteria ( ) dOther�;fistures •--------- a W "Design Flow-------_- O' -_______ ________ ___.-gallons per person per day. Total duly flow.._.._. c�....._.._....... ...gallons. . 1:4 Septic Tank L Liquid capacity �v__ allons Len�thS--&-____. Width_. 1 t q 1` 8" a .. Diameter Depth. -------- - x /bisposal Trench—No_____________ _______ Widtth-------------------- Total Length-------------------- Total leaching area....................sq. ft. Seepage Pit No_______________I-__ Diameter..--!- Depth bel awi(inlet ____ ._ Total leaching area:--_---_-.-.-___-sq. ft. z Other Distribution box ( ) Dosing tank ( ) a ~.Percolation Test Results Performed by... . .__. ____________________________________ Date--_-____----_._-_--__--.._-_-_--._----- Test Pit No. 1----------------minutes per inch Depth of Test Pit._....____-__-______ Depth to ground water........................ (14 Test Pit No. 2----------------minutes per inch epth of Test Pit.................... Depth to ground water...-------------------_ Jot ---- O Description of.Soil___ `. " i �_.�__ k � *" �` _ . W U Nature of Repairs or Alterations—Answer when applicable--------------------------------------------------------------------...........------------------ ------------------------------------ Agreement The undersigned agrees to install,the aforedescribed Individua' I'Sewage Disposal System in accordance with the provisions of Article \I of the State Sanitary. Code= The undersigned further agrees not`to place the system in operation until a Certificate of Compliance has bee issued by the board of�health , A. .Signed _ ............................................. -------• -----7._ ........ Date Application Approved BY F .. �'=�'---- � '`.a ' ; -y Date Application Disapproved for the following reasons:. ;:. Date PermitNo................................................ -------• Issued------------------------------------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF AAEALTH Qwrtif iratr Of (.9outpliaurr THIS IS TOkl"_770 RTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by ..-.... = ._.. ----•--------r-------- Ku ` `"' Installe� "'� at........ k x ' has been installed in accordance with-the provisions of A"c) --� of'i'he State Sanitary C Te as described in the application for Disposal Works Construction Permit No.- __- - _ . --__- ' --------• dated .. ,� .7....---_.. THE ISSUANCE OF THIS CERTIFICATE. SHALL NOT BE CONSTRUE© AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION.,SATISFACTORY. - 7 � DATE-------- .._� 3 Inspector------------------- r THE COMMONWEALTH QFMASSACHUSETTS a; BOARD OF; HEALTH " �. ........e3 ...... OF....... � + G- i No. ...... - FEE_, ............ DitiVatitti Norkp QLawitrurtion rantlit Permission is hereby granted----- blff tf--•-- 7-C)------ ----- -------- - ---- -•------___________-------- to Cons c al: V(L�'"�or Repair (�an I divr Sewa e rsposal SysTM/ at � r--- i------------------------------------------- Street as shown on the application for Disposal Works'Construction Permit, No......... -_z .°Date _..,n ' ' - =---- r / /7_. ,� Board of Health DATE t , . , , .FORM 125.5 HOBBSL{& ,A.RREN. INC..aPUBLJSHERS- 1r °� u ..• .N" - - ' . - --------------- LOCUTION : lot 5EW&C.4E PERMIT UO. VILLAGE J-oII�ISTQLLERS/ IJ�,tJIE�� ADDRESS 117 SrI BUILDER 5 1.1 &ME ADDRESS ANTE PERM T ISSUED 77 — — — DATE COMPLI &&ACE ISSUED : �r ��� 77 J f 1 IN. Cr\ y � � y f I l /J D �6�ric re Ap - i! _ A � r G, C6VZTIFIELD PLoT P•L.A1" LbCATI O" C6RTlFY T"A-r TAF— ��N�,�-�-�o�J 5�10�►-► �-A� Q�Fc2c�.1G� 4-IEQEafl� CCAAPLYS . WlTN Tt-1E 'SiLzEL1►.�E_ `S �c a� �� ��.i P,_�.�.t o c= t-Atia AWLD SETUACk IZEQUi2E.Mck4TS b;= THE "ToWU Gam : 1 j�fLTt TJ �isG \ ems tr`� � r DATE81�YTEZZ gzEGIStLRED. LA►.tp SU�vcYorZS r1-�IS DLAN IS ►-1OT E!, SE'� OSTEi�V,LIL- o II�CaSS, 1 7 SvevcY t T�a� o�cSrs �,f�ow,w /�PPtt CAST -� KbT eEl Usco ro oeTE2Mi�4& -LOT L.IWE-S