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Home My WebLink About0023 WOODVALE LANE - Health 23 WOODVALE RD. CENTERVILLE A = 190 176 riir 2J�gFGVCIEDCom UPC 12534 0 � No. 2-11553LOR HASTINGS, MN Commonwealth of Massachusetts w Y Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Ow ner ON ner's Name ll information is �eo 1 4 required for every page, 5 Town State Zip Code Dati-of Inii3ection 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. tnng out f:When A. General Information (� �,52 filling out forms �• on the computer, use only the tab 1. Inspector: key to move your � cursor-do not 0 � use the return Name of Inspector key�`'� / V f Company Name f// /c�-� � 0 !�� // Company Address GS 4+ G y ()�p Cityrrown ✓ State Zip Code (J� a)90 -77�0 O Telephone N er License Number B. Certification 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 SectionI15.340 of Title 5 (31 MR 15.000). The system: rc Passes ❑ Conditionally Passes ❑ Fails a73 ❑ Need Further Evaluation by the Local Approving Authority f -7 r-r+ Inspector Signature Date i The sys em 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 conditionsof use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5Official Vfln, surface sewage Disposal system•Page 1 of 17 l5iro•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �1100dU-- /-, /— a� Property Address 2 ✓1 G Ow ner Oar ner's Name information is (::�"�Vi Ile Od-6.'� required for every page. (Ay/Town State Zip Code Date of 4ns p6ction B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System P ses: 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) 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•3/13 TWe 50fnclal ImpecUonForm Subsurface Sewage Disposal System-Page 2of 17 Commonwealth of Massachusetts lugTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Cw ner Ov ner's Name information is required for every page. T7Tow n l� State Zip Code Date of fnsp6ction B. Certification (cont) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumpslalerms 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): ❑ The system required pumping more thany 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 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 mannerwhich 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 5res W13 Title50ffldal iris pecti on Form Subsurf ace Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System FormlI- Not for Voluntary/ Assessments rYo �J ('/00G' llA I� G— C, ✓tom Property Address ner Ov ner's Name information / "� OoZ 6 information is 7 2.. CPS ✓l/! -� required for every Slate Zip Code Date of n pecti n page. City/Town 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 ❑ 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 ❑ �j Liquid depth in cesspool is less than 6" below invert or available volume is less than'/z day flow t5ins•3113 Tide 50flicial Inspection F orm Suosurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address N.G Ow ner Owner's Name /i A Information is C4? ,�VV1 /7 6),-6 required for every State Zip Code Date of ns p6ction page. Citylrown B. Certification (cont.) Yes No � ElRequired pumping more than 4 times in the last year NOT due to clogged or Er 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. ❑ L� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ E '� 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 coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S 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- 10,000g pd. ❑ The system fgjj.% 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 11 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. Title5omcial InspecticnFaar SUDSUIWe SewagoDiaposal System•Page 50f17 l5lns-3l13 Commonwealth of Massachusetts Title 5 Official Inspection Form n Subsurface Sewage Disposal System Form - Not for Voluntary Assessments / Property Address r/1 G Ow ner ON ner's Name information is C2� ✓y!`� �4 required for every page. Cilyrrown Stale Zip Code Date oyinspAction C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following; Yes NNo,/' ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ E Were any of the system components pumped out in the previous two weeks? ❑ as 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) LJ ❑ Was the facility or dwelling inspected for signs of sewage back up? Ld ❑ Was the site inspected for signs of break out? 'r ❑ Were all system components, excluding the SAS, located on site? Q� / ❑ 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: lJ Q 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(5)] D. System Information Residential Flow Conditions; 2 Number of bedrooms (design); Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 5rts 3l13 Tide 5 Wiciei Im pecdon F orm Subeurtace$ewage Dispose)Symem•Page 6of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ✓tGl�l Cw ner Ow ner's Narne6 /^ information is -- � required for every page. CitylTown State Zip Code Date of Insp, ctio D. System Information Description: 0 Number of current residents: /� Does residence have a garbage grinder? ❑ Yes 0 No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes S" No information in this report.) Laundry system inspected? ❑ Yes B'No Seasonaluse? ❑ Yes 2 No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes' No Last date of occupancy: p Y: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM R 15.203): Gallons per day(gpd) Basis of design flow (seats/personslsq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No I Water meter readings, if available: 151ro-3113 Title 501Aciel Inspection F orm Subsurface SewageDlsposel System-Page 7of 17 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System //Form -Not for Voluntary Assessments "� �� C.✓O 0 C I/'o �e �- /tip Property Address J Cw ner Owner's Name /J information is � ✓!/�<l C /�/¢ o')_ 6 3� 8 required for every --- page. CitylTown State Zip Code Date of I spection D. System Information (cont.) Last date of occupancy/use: Date Other (describe below): General Information Pumping Records: Source of information: /V 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 Sysle-m: 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) 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 (descri be): •P 17 t5ins y13 TiVe501fcidlrupecUcnFamSubsuAaceSewegeDisposalSystem age Commonwealth of Massachusetts N Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / ON ner Owner's Name / 1414 information is 6eV, required f or every page. C iFfrow n State Zip Code Date o Ins ectio D. System Information (cost,) Approximate of all components, date installed (if known) and source of information Were sewage odors detected when arriving at the site? ❑ Yes Building Sewer (locate on site plan): J/ Depth below grade: feet / �o Matedai of construction: r� ❑ 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.): Septic Tank(locate on site plan): Depth below grade: feet Material g onstruction: concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Jr _ Dimensions: Sludge depth: - Tibe 5 Official Ins pecbon F orm SubsLeace Sewage Disposal System.Page goW t5ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 W/o 0 Cj�-G 4L 2- ,v- Property Address Ow nerrn- ON ner's Name CC Information is ��VVIrequired for every State Zip Code Date of Inspe tion page. City/Town D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 1�p 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 leakage, etc.): vl ✓7 i✓l ✓Ip4 4'g2C4c'J k G '7yC�l l✓I O o G _ � I (Oki J/410✓t Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ 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 pumping: Date t5ins 3113 Title Sofficial Impaction Form Sumulace Sewage Disposal System-Page 10of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C� 3 U0 t) ��A le Z_"r' Property Address vi c G, Ow ner ON ner's Name information is ( p� �G/` �// 0j6_a T g required for every l i-C --.--1— page. Cityfrown State Zip Code Date of Insp ction 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): 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 l5ins•3113 Title 50ffidat InspecticnForm Subsurface SewageDlsposaf System•Page 11 of 17 Commonwealth of Massachusetts x Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address / ' GG Cw ner Cw ner's Name J information Is C--e��!mi 2 l / / 6 required f or every page. Cityffown State Zip Code Dateof Insp ctlon 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,): S-0 1 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: t5ns 3113 Title 5Off ei InspootlonForm$ubsulaCe Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address G ner ON ner's Name Information Information isX- required for every page, City/7own State Zip Code Date of Ins ctio D. System Information (cont) Type: )) ,Soo �`► �l�✓1 (� G vh��ys ��> ❑ 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.): X2 c4at4 /I C_ 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 t5ns 313 Tide 501BciallnupecticnForm Subsurf ace Sewage Disposal System-Page 13of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / � (✓ / Cw ner 0,Y ner's Name information is G P� ✓(/l �//� Gab 5oL _ Ll a required for every page City rrown State Zip Code Date of Inspectio D. System Information (cont,) 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.): t5ins 3113 Title501(tciel Inspection Form Subsurface Sewage Disposal System Page 14 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r7 c:?: - ? i(/o 0�1' G � Z_ Property Address / tti G Ow ner ON ner's Name information is 'eV7 V'V///,e required for every State Zip Code Date of nap ction page. City rrown D. System Information (cant.) Sketch Of Sewa e.-pisposal System: Provide a view of the sewage disposal system, including ties to nhan!dsEketch manent reference landmarks or benchmarks, Locate all wells within 100 feet. Locate ater supply enters the building. Check one of the boxes below: in the area below [I drawing attached separately i 1 14 c lip' \1s Q RJ�r Title 501fidal ins pectionForm Subsurface Sewage0isposal system•Page 15 U 17 t5lns-3113 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ner O+J ner's Name Inf /"'�l a / Information is e✓� Vvl /P, doZ 6�� C required for every -- page. City/Town State Zip Code Date of spec ion D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells / 1"k Estimated depth to high ground water: 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: I)a►e ❑ 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: 4'1-c�'C41 Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3I13 Title50fflcial Inspacton F orm:Subsurface Sewage Deposal System Pape 16 of 17 Commonwealth of Massachusetts up Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not/for Voluntary Assessments �j Property Address / Orr ner Ox ner's Name information is CpN�✓v/ required for every page. Cityrrown State Zip Code Date of Inspe tion E. Report Completeness Checklist 0""Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed U Sy,stem Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Tibe5Officiat Ins pecGcnForm Subsul ace S"eDlsposal System-Page 17d 17 No. ��" Fee___L_" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIppfication for 30igaal bpgtem Congtruction Vertu Application for a Permit to Construct( . )Repair( grade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 3 (,JQo- (/q 2 aC Owner's N Address and Tel.No. Assessor's Map/Parcel C.� f �r A 4 yn C rof 77�- 11�33 Installer's Name,Adds&ajj TdANCO Designer's Name,Address and Tel.No. 350 Main Street W. Yarmouth- MA 02673 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow 3 3d, gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /5"d o Type of S.A.S. SQo 1!A t. Sir,J�l�s Description of Soil Nature of Repairs or Alterations(Answer when applicable) 1►'IS e ( t So p a � 4— 1 • bx - f C e S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of H lth. Signed Date CP •/�7 •o 0 Application Approved by Date Application Disapproved for the following reasons Permit No.z4ry 6 6 Date Issued � ` No. Fee` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �- Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Z(ppfication for Zi5pozai *pgtem Con!gtruction Permit Application for a Permit to Construct( )Repair( ✓ UUpgrade( )Abandon( ) 0 Complete System ❑Individual Components '. Location Address or Lot No. 07 3 L J0 ✓A I c:' Owner's�e Tel.No. -y �4 � ?P c ) �YOC� Assessor's Map/Parcel t 90 (/ !O.1- a 923 Installer's Name,Address,p►4'eWCANCO Designer's Name,Address and Tel.No. 350 Main Street.^6,' /U/Fi W. Yarmouin,�'MA 02673 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( Other Fixtures Design Flow gallons per day. Calculated daily flow 3 3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank S ° o Type of S.A.S. So 0 5'14 Description of Soil' Sa L.�x Nature of Repairs or Alterations(Answer when applicable) = S ('° ! So o 5 4 v Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boaz H-calth. 15 Signed ` ( ��^^ Date o Application Approved by i Dated Application Disapproved for the following reasons Permit No.7-O&W 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( ) 4 i Ab dq d( )by at e. ��/O �/�tZ 7ZET. t t E'c, 'ZtrL�y has brn construct /i cc�ce with the provisions of Title 5 and the for Disposal System Construction Permit No. ((�o dated 6. Installer Designer The isspanpe° this pg i hal`1 notenstrued.as a guarantee that the s t yAill functio' as esig�n d Date / •'ft--� Inspec3r- � ZU -------------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS _f 7� PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Oiipooal 6potem Conotruction Permit Permission is hereby gr tad to Con tract( Rep7( �4 ra ( )Aban n System located at -' t5�G' ��` e �, eo,? P ' /`'`� 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:Constructip/hust a leted within three years of the date of t Date: � Approved by ' TOWN OF BARNSTABLE LOCATION SEWAGE #07ow`966 VILLAGE6en Te--<VI Ile. ASSESSOR'S MAP & LOT eygQ *,7 INSTALLER'S NAME 6z PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY cy LEACHING FACILITY:(ty o � 51.E 9.4/. GWmAeeS (size)075-X/,3 )ea , NO.OF BEDROOMS - PRIVATE WELL OR PUBLIC WATER BUILDER O ��OWNE DATE PERMIT ISSUED: 4�4 �91- DATE COMPLIANCE ISSUED: �" 5, w VARIANCE GRANTED: Yes No qL►y ' �` ®' aj �Y Nf�d 1/6199 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, J '\ .., , hereby certify that the application for disposal works construction permit signed by me dated (e • l 07 ,o-z) concerning the property located at 0 3 61)" IAA-L 02d meets all of the following criteria: The failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system There is no increase in flow and/or change in use proposed /• There are no variances requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] �• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) ®, B) G.W. Elevation a l 6 +the MAX.High G.W. Adjustment.0c C) DIFFERENCE BETWEEN A and B SIGNED : CA a_ _ - _ _ DATE: Cr - /F • 6 0 [Sketch proposed plan of system on back]. q:health folder:cent J............................................................................. .............. TOWN OF BARNSTABLE LOCATION /�.CJ6'QVf I� R� SEWAGE #076t�'-'`�6� VILLAGE6el 7foe Vr 1 ASSESSOR'S MAP & LOT,/ �* INSTALLER'S NAME Cz PHONE NO. A & B CANCO 775=6264 SEPTIC TANK CAPACITY /d le:-214110;1 LEACHING FACILITY:(ty _/ x> �'�/. C /g�+ �'S �size)o��x�✓� X a NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER O OWNER, E� le ��, DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: '"' w VARIANCE GRANTED: Yes No �h h h