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Home My WebLink About0132 ARROWHEAD DRIVE - Health 132 ArrowhPad-Dr* e : Hyanni S:,.. A=270- 155. ---- -- - -- - ------- I i TOWN OF BARNSTABLE LOCATION ,00g Z SEWAGE VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. 7,7 o,c� SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility f 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 w � ado-/s y- Commonwealth of Massachusetts Title 5 Official In+�= specti®r� Form ��. ram; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ~' Property Address ry (% Owner Owner's Name :- information is / /Jn required for every a✓!41 /� �/Tli I'. 7page. City/Townto / / �M [ State Zip Code Date f Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms oZ on the computer, U 4-7g9 use only the tab key to move your M1. Inspector: G 1��T /,S cursor-do not use the return -e. key. . Name of Inspector Z/(/i/r o r� Company Name Company Address D_C_ 6_4� t City/Town l �f State Zip Code 1 " lc � / 79O Telephone tuber 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 Section 15.340 of Title 5 (310 CMR 15.000). The system: Passes ❑ Conditionally Passes Fails❑ as ❑ Needs Further Evaluation by the Local Approving Authority Inspector'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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. V 15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 � a Commonwealth of Massachusetts v .Title 5 ®fficloal Inspect'ion F®r Subsurface Sewage Disposal System Form -Not for 3� VoluntaryAssessments is Property Address Owner Ar l 's information is Owner Name required for every page. City/Town State / ZipCode Date Insp do B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System -sses: 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.doc-rev.6/16- Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address . Owner Owner's Name information is / required for every a 04t r /�/ 01601 page. Cityl I own 091 State Zip Code Date of1ns ection Be 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): ❑ 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 .. t5ins.doc-rev.06 � y .,- Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address -•y� / � Owner Owner's Name ,� information is /,L ' required for every A 0 h �� oa/_Q/ page. City/Town • State ZipCode Date Qf inspafction Bo 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 tatic liquid level in the distribution box above outlet invert due to an overloaded . i ❑ or clogged SAS or cesspool ❑ L Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow t5ins.doc-rev.6116 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I OW L C,�Property A !Iddress V✓ Owner Owner's Name information is required for every Ge7v1 jua`-60/page. CityrFown r— U. Certification (cont.) State Zip Code Date o Inspe tion Yes No ❑ ® Required pumping more than 4 times in the last year IVOT 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. I ❑ 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 I well. ❑ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal 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- 000gpd. ❑ e system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ . ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page,5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name f information is 71 required for every ` q 4415 page. City/Town �d 6 / `? , State Zip Code Dat of Ins ction Co Checklist , Check if the following have been done. You must indicate "yes"or"no" as to each of the following: Yes 6— ❑ mping information was provided by the owner, occupant, or Board of Health ❑ V Were any of the system components pumped out in the previous two weeks? Cl 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 t 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? :<0 Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: �[] Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] Q. System Inf®Irmation Y Residential Flow Conditions: 3 -3 Number of bedrooms (design): Number of bedrooms (actual): ^4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 4 t5ins1c-rev.6N 6. Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 .Y - \.f t d t r t Commonwealth of Massachusetts Title 5 Ufficial Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner - // , information is Owner's Name required for every poll /O� /� . / page. City/Town State Zi Code / p Date Inspe tion ®o System Information • Description: . p� Is4et 9ta7�to�, �O �4,, Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes No Laundry system inspected? ❑ Yes Vo Seasonal use? ❑ Yes No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? • ❑ Yes No Last date of occupancy: ' . �(4ere Date Commerciall/Industrial-Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.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;-fir ., Water meter readings, if available: t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 - Commonwealth of Massachusetts Title 5 'Official Inspection F®r Subsurface'Sewagee Disposal System Form -Not for Voluntary Assessments 0 O G✓��V• �j� Property Address /�i Owner's Name Owner — i information is , required for every 409 /f 1 /WSJ Qa GOI page. City/Town State Zip Code Date o Insp tion D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): 1 • General Information Pumping Records: Source of information: V''P-/ C; 'Was system pumped as part of the inspection? ❑ Yes Leo If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S em: 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(describe): t5ins.doc-rev.6I16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspect'®n Fr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner — Owner's Name / information is 2j required for every poflnsp page. CitylTownState Zi CodeP Dat ction D. System Information (cont.) Approximate age of all components, date in alle (if known)and source of information: �o09- acP Were sewage odors detected when arriving at the site? ❑ Yes [L4-5o`__ Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron 40 PVC ❑ other(explain): Distance from private water supply well or suction line: /o f' feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: �® feet Materia construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins.doc•rev.6/16 _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner/ Owner's Name information is - required for every 14 �/� ®a 6 0 3/Ll page. City/Town (:7, State Zip Code Date ol Inspeolion D. System Ilnformation (cont.) Septic Tank(cant.) 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 7j Distance from bottom of scum to bottom of outlet tee or baffle I / How were dimensions determined? " le cle6-«e Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 7. ; . t5ins.doc•rev.6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 N Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 101,lAAee_ Owner information is Owner's Name / required for every q 4i 0) (0O/ ?/ / page. City/Town State ZipCode J Date Insp ctio D. System Information (cont.) s Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass 9 El polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day — — Alarm present: ❑ Yes ❑ No Alarm level: 'Alarm in working order: ❑ Yes ❑ No 1 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 i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address 1 Owner Owner's Name information is _ /� �o required for every �/ 7/ page. City/Town State Zip Code Date Insp ction D. System Wormation (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.): dyIe(/�� M SL-9/ el 4 s 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: Y•r„' ,t5ins.doc•rev.6/16+^ Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page-12 of 17 1 Commonwealth of Massachusetts Title 5 'Official Inspection For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Owner Owner's Name information is required for every �✓d✓d/ / /�l � 3 / page. City/Town 91 / St—ate' Zip Code Date of nspe tion D. System Information (cont.) ` Type "00 ��ll®h �j �/ � ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ :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.): C/1-0 J49 Ke cz bA j _ro// ® a, • _ �-eG l�1 �b0a� � S� L9 / Vo 66G(A`!L ' 44-10 1140- 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 f �. Indication of groundwater inflow ❑ Yes ❑`No , t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 commonwealth of Massachusetts Title 5 "fflclal Inspectl®n For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments rroper[y Hatlress Owner � '' Owner's Name information is �� / 3 required for every oo�� /,�} page. City/Town =L State ,Zip Code Date Insp ction 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.): 4.4 1 ` 15ins.doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 t Comrnonvvlaalth of Massachusetts `title 5 OfficoalInspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Name information is - required for every Cal yftyJsf 6(2I page. City/Town /� State c ZipCode Date f In pection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two per ent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where pu water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately 0 /3'oo Sep4<C- UL A / d / 46 Ly A� f s� .+:. •fi4 l5ms.doc re 6/16 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17 . t, t q Commonwealth of Massachusetts Title 5 OfficlW Inspection For Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M � - —ell ®W V(�� G Property Address Owner Owner's Name A information is required for every ,( oc page. Cityfrown State ZipCode Date of y Spec tj n D. System n$orma$aon (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar • ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: i ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ;❑ Observed site (abutting property/observation hole within 150 feet of SAS) _� Checked with loc I Board of Health -explain: 101-7 s -t- %E-s� l�s ❑ Checked with local excavators, installers -(attach documentation) ❑ Accessed USGS database-explain: You must dbe how � yoft�eabljshed the high ground waterelevation: 6.1 roc,ah /0C c/e 07_"" le Ile-ell lG� 1462L W Before_filing this Inspection Report, please see Report Completeness Checklist on next page. t5in's.doc-rev.6/16 1 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 , "" Commonwealth of Massachusetts Title 5 ^fflclal Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary ^Assessments M ll • ! / V�V V'�4� •V Property Address f f Owner Owner's Name information is o� 6 IZn/ectio/�irequired for every G1 e/lf/d 0 page. City/Town State Zip Code Date of E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed Sy em Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc•rev.6/16 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 17 of 17: No. � 1— 3 -7 i Fee dU THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zlpph.Cation for Mis�p0!5. al *ps�tem ConOtrurtion Permit Application for a Permit to Construct O Repair O Upgrade O Abandon O Complete System ❑Individual Components Location Address or Lot No.-" Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder ( ) Other Type of Building QFeY No.of Persons Showers(' ) Cafeteria( ) Other Fixtures Design Flow(min.required) p gpd Design flow provided �y gpd Plan Date '— r�� Number of sheets / Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Signed Date Application Approved by Date r!/9 Application Disapproved by: Date for the following reasons Permit No. U d"l, a2 Date Issued ( o— -.— — —————————— ——————————————————— a _.ram 4 w i I i „r R � a rT F' i > .} i � ° - 3.ti j,� ... r,.. k S• � t v Fee C)0 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yew/ PUBLLC,�Fi�Ee4LTH DIVISION TOV1iIV OF'DARN' TABLE, MASSACHUSETTS AppItcation for Mi9;po9;a1 *p5tem con'�truction permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) Xcomplete System ❑Individual Components Locatian Address or Lot No..-" Owner's Name,Address,and Tel..No. Assessor's Map/Parcel ,� - J 3 3�Ol�oGv�//,�D O/2 • X/y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 0, Type of Building: Dwelling No.of Bedrooms 3 Lot.Size sq. ft. Garbage Grinder ( ) Other Type of Building 0��-� No.of Persons Showers( ) Cafeteria( ) Other Fixtures _. Design Flow(min.required) - � gpd Design flow provided - �O gpd w Plan Date -" r Number of sheets / I Revision Date ` Title Size of Septic Tank Type of S.A.S. € Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system ins accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of- ----•' Compliance has been issued by this Board of Health. i Signed Date O r Application Approved by G1i.• Date Application Disapproved by: U Date for the following reasons Permit No. 3o)-7 Date Issued f v-S d�► r - =-; -_ ..:� - ----------_————————————————— F THE COMMONWEALTH OF MAS ACHU T WN - -� BARNSTABLE, MASSACHUSETTS Certificate of Comphauce THIS IS TO CERTIFY,that the On-siie-Sewage Disposal System Constructed X) Repaired ( ) Upgraded ( ) Abandoned( )by ,W Z :e�0�� at J 3 a- 46FOrakV •9 4iT has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ACV-9-3? -7 dated /0 Installer �/ � Z-�OZy/ Designer�� .� /j��`P�', X #bedrooms .5. Approved design flow 3 gpd The issuance of this permit shall n t be construed as a guarantee that the system wiltf1 u c i�on�as design d. /�C vi Date u r u� Inspector L.. ._ _ _ No. U 0 I - 32 ! Fee7��7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS ,111i5pont J§p5tem Construction Verm t Permission is hereby granted to Construct X) Repair ( ) Upgrade ( ) Abandon �-�M ( ) System located at � 3 �� /�e'd� ��' ✓ 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: Co struetion must be completed within three years of the date of this erm' Q Date `I Approved by /� Town Of Barnstable Regulatory Services P Thomas F. Geiler, Director a Public Health Division a��o►Y+A'�°' Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office:.508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: o p Designer:__!)AVI12 ?� c` Installer: Address: . �4'S-T 5�4 PML4 Address: _ On �� was issued a permit to install a (date) I (instRIlPr.) septic system at T107_9 Rased on a design drawn by (address) �• M dated (designer) I certify that the Septic system referenced above was installed substantially according to die design, which may include minor approved-changes such as lateral relocation of the distribution box and/or septic tank. I certify.ithat the septic system referenced above was installed with�!,Wtjor changes (i;e. greater than`10' lateral relocation of the SAS or any vertical'reloaation of any component of the septic:,system)but in aecordance with State&Local'RegWations. Plan revision or certified as-bYY-tf by designer to follow. , Mgs +3► abAVID. (Installer s Signature) S n f . �. � h9ASON v No.1U66' .. • '9�@ISTE�F. . sgNl TmFk� (ll. er s Signature) (Affix' ei's$tamp Here) PLEASE RETURN TO 1BARNS7CAkE.'.PUBLI .HEALTH DIVISION. RTmc w. OF COMPLIANCE • NO. .•_ E : SSUED;UNTIL 'BOTI ff.-THIS aFORM AND BUILT CARD ARE RECEIVED B—TRE.BARNSTABLE PUBLIC U ' D DIVISION THANK YOU. Q: Health/Sept c/Designer Certification Four; Town of Barnstable 7�o of•tt� P# Department of Regulatory Services • �� Public �Iealth Division 2 �� ems. Date Ut,�°� 200 M`ain.5treet,Hyannis MA 02601 Date Scheduled �� S� U � . ' . �q.� Time.�L� Fee Pd. (UU Soil Suitability Assessment o7 Sewage D, sposal Performed By: " Witnessed By: L) �v /0 GENES, LOCATION & Location Address i,3��40z�Lo.r.%ltd0 � INFORMATION Owner's Name e, ,e Address Assessor's Map/Parcel: Engineer's Name REPA)It NEW CONSTRUCTION �/ Telephone#f ' - Land Use-- Slopes(30) Surface stones Distances from: Open Water Body-_ft possible Wet Area _�ft Drinking Water Well _eft Drainage Way ft Property Line Other ft SKETCH: (Street name,dimensions of lot,exact locations of test holes&.pere tests,locate wetlands fn proximity to holes) i v Parent material(geologic) O� Depth to Bedrock Depth to Groundwater. Standing Water in Hole: Weeping*om Pit Pace Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: Depth Observed standing in obs.hole: Depth to weeping from side of obs.hole: m, Depth to Sol]mottles: Index Well# Oroundwaeer Adjustment ft. Reading Date: Index Well level ft. Adj,factor AdJ,draundwater'L.evel observation y� PERCOLATION')EST bttte Tlmc Hole It ll Time at 9" Depth of Perc :-- Time at 6" Start Pre-soak Time @ vv* Time(9"-6") End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division ' Observation Hole Data To Be Completed on Back---------=_ ***If percolation testis to be conducted within 100' of wetland, You.must first notify Barnstable Conservation Division at least one (1) week prior to beginning. t he Q:\SP-PTIC\PERCFORM-DOC DEE,P.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Surface(in.) Soil Color Soil (USDA.) Other (Munsell) Mottling (Structure,Stones;Boulders. on istene % ,ravel DEEP OBSERVATION HOLE LOG Hole#Depth from Soil Horizon Soil Texture Surface(in.) Soil Color Soil Other (USDA) (Munsell Mottling (Structure,Stones,Boulders. nsistency,% ravel i DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Textur-- Soil Color Soil Surface(in.) Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Co aiatency.4' Gravel DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Surface(in.) Other (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consi ten I r Flood Insurance Rate Map: Above 500 year flood boundary No- Yes_ 'Within 500 year boundary No. ' 'Yes Within 100 year flood boundary No 7es . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervi rial exist in al areas observed throughout the area proposed for the soil absorption system? 'If not,what is the depth of naturally occurring pervi us material? ►^ j Certification I certify that on I� (date)I have,Fussed the soil evaluator examination approved by the Departmtof.Environren 1 P tec on a d that the above analysis was perf rm d by me consistent with the requng,ee 's a d e p ce cescribed in 310 CMR 15,0177,Signatur Date �✓ Q:\SEPrlC\ 1ERCFORM.DOC J Zj ASSESSORS MAP : z PARCEL TEST HOLE LOGS NOTES: //ttom� FLOOD ZONE: -CI y�i'�G/CCU SO I L EVALUATOR : A` I � , mu 6t'f" - - _._... - WI TNESS : q1 REFERENCE: /57 1) The installation shall comply with Title V and Town of Barnstable Board of DATE -. Health Regulations C PERCOLAT ON RATE: � IA 1 2) The installer shall verify the location of utilities, sewer inverts and septic components prior to installation and setting base elevations. TH- I NTH-2 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first Ley n 6 two feet out of the d-box to the leaching shall be level. t� T 1 4) This plan is not to be utilized for property line determination nor any other -! - ��— purpose other than the proposed system installation. Ltj 5) All septic components must meet Title V specifications. �i1W6) Parking shall not be constructed over H10 septic components. LOCATION MAP O - Z 7 The property is bounded b property corners and property lines. p p Y YP P Y p p Y 8) The property owner shall review design considerations to approve of total design flow and number of bedrooms to be considered for design. Receipt 1 of payment for the plan and installation based on the plan shall be deemed approval of the design flow by the owner. a 9) The existing leaching or cesspools shall be pumped and filled with material o� � per Title V abandonment procedures. Those within the proposed SAS shall o , 1 �`� 10 1 --- �� be removed along with contaminated soil and replaced with clean sand per �2 ,VZ 1 n �----,= 2�,5 y I Cg ,�- ,97 _ , S ��/`f ZZ j� 1 l L�` L � - �t �`�' ,. Title V specs. �2.100 10)System components to be 10 feet from water line. Sewer lines crossing the water line shall be sleeved with 4 inch SCH 40 PVC with ends grouted if SEPTIC SYSTEM DESIGN applicable. The proposed SAS is being installed below the water service line. The line is to be sleeved as aforementioned and maintained in place. k S FLOW ESTIMATE 11) If a garbage grinder exists it is to be removed and is the responsibility of the owner to ensure such. - - l` \ BEDROOMS AT )It) GAL/DAY/BEDROOM - GAL/DAY 12)The installer is to take caution in excavation around the gas line if such exists. � SEPTIC TANK 13)The installer shall verify the location, quantity and elevation of the sewer lines exiting the dwelling prior to the installation. s GAL/DAY x 2 DAYS - GAL USE 1100 GALLON SEPTIC TANK ` 1L ABSORPTION SYSTEM SIDE AREA: �' 'f' I?j Z 1 I "fw Z MASON m BOTTOM AREA: h✓ (� " IST � ' Lj 0 TIC SYSTEM SECTION ►� Zap �wlGl•1tM�rZl� NN�t`EU q yap ' 36 �� (gay �+al'�u� i �,� —=--L - �( �� IDC,7� GAL D-BO IN X �. _ p �'`-')V`-' SEPTIC TANK SITE AND SEWAGE PLAN LOCAT 1 ON : i3Z � D � L tigl►.►Ill I PREPARED FOR : ,I WTI 6 0 KIWI SCALE: z DAV I D B . MASON IZ,/:2 DATE: Ia DBC ENVIRONMENTAL DESIGNSFT W EAST SANDWICH . MA 3 DATE HEALTH AGENT Z ( SOH ) 833- 2 177