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HomeMy WebLinkAbout0226 ARROWHEAD DRIVE - Health FY226,Arrowhead Drive nnis , a A 270 087 t, r r i e i i i y 0 1 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments-. 226 Arrowhead drive Property Address LABBE, ANN M Owner Owner's Name information is required for every Hyannis ' MA 02601 817/14 'z page. City/Town - State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your - cursor-do not Trevor Kellett ° use the return key. Name of Inspector Aardvark Environmental Inspections ab Company Name PO BOX 896 Company Address East Dennis - MA 02641 City/Town State Zip Code 508-292-1056 S113744 Telephone Number License Number B. Certification 1 certify that I have personally inspected the sewage disposal system at this address and that the ' information reported below is true, accurate'and complete as,of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site „sewage disposal systems. I am a DEP approved system inspector.pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes 1 ❑ .Conditionally Passes ,, ❑ Fails Needs urther aluation by the Local Approving Authority 8/20/14 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 is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3r13 Title 5 Ottldal tr,spec6m V... wage Disposal System•Page 1 of 17 r Commonwealth of Massachusetts _ - 'U r. � �r•I Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 226 Arrowhead drive Property Address LABBE, ANN M Owner Owner's Name information is required for every Hyannis ► MA 02601 8/7/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary. Check A,B,C,D or E/always complete all of Section D A) System Passes: 1 ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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): 1. _ .• f f ..� _, r f' � r ., - ._� !. , f. ' . I t5ins•3113 I , Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 1T .e Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Arrowhead drive Property Address LABBE, ANN M ` Owner Owner's Name information is Hyannis MA 02601 8/7/14 required for every H y ` page. City/Town 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 breakout 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 Heath): ' ❑ broken pipe(s)are replaced ❑ Y ❑' N '❑ ND(Explain below): -El obstruction is removed ' El Y, El ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y '❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health'determines in accordance with 310 CMR y 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 15ins•W13 Title 5 Offidal Inspection Form:SUbwdace Sewage Disposal System•Page 3 of 17 Q\ Commonwealth of Massachusetts Title 5 Official Inspection• Form ;•� �: Subsurface Sewage Disposal System Form-Not for•Volunta!y Assessments 226 Arrowhead drive Property Address , LABBE,ANN M Owner Owner's Name information is Hyannis, MA 02601 8/7/14 required for every H y - page. CityrTown•_ 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: - ti ❑ 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. , . 3 r ❑ 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. 41 • D) System Failure Criteria Applicable to All Systems: You must indicate"Yes;or"No':to each of the following for all inspections: Yes --' NO -❑y. ® 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 El ® 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 cesspool is less than 6° below invert or available volume is less than 1/day flow ' t5ins•3113 _ - 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 226 Arrowhead drive Property Address LABBE,ANN M Owner Owner's Name information is Hyannis MA 02601 8/7/14 required for every H y f ' page- City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes -No - - , ❑ ® Required pumping more than 4 times in the last year NOTdue 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. 7❑ ® f Any portion of a'cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This = system passes if the well water analysis, performed at a DEP certified laboratory,for fecal 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 ti 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. j. , , The system fails. I have determined that one or more of the above failure ❑ ® criteria exist as described in 310 CMR 15.303,therefore the system fails.The . system owner should contact the Board of Health to determine what will be necessary to correct the failure.' E) Large Systems: To be considered a large system the system must serve a facility with a design flow,of 10,000 gpd to 15,000 gpd. - For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D.'- Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection El ❑ Area—IWPA)or a mapped Zone II of a public water supply well 4' 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•W13 rMe 5 Official Inspection Form:Srbauface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Arrowhead drive IV,I Property Address LABBE,ANN M Owner Owner's Name information is required for every Hyannis MA 02601 8/7/14 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑. Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ❑ ® Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and.occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[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 t5ins•3113 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments - 226 Arrowhead drive - - Property Address LABBE,ANN M Owner Owner's Name information is Hyannis MA 02601 8/7/14 ' required for every y • page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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? '• •L ❑ Yes ® No Seasonal use? ` . "` ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ,� ,. x: ❑ Yes ® No Last date of occupancy: ~. current Date Commercial/Industrial Flow Conditions: - Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of'design flow(seats/persons/scl t., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tankpresent? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Mns•3113 Me 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 OfficialAnspection Form Subsurface Sewage Disposal System Form,:-Not forVoluntary Assessments :1c 226 Arrowhead drive 1 Property Address LABBE, ANN M Owner Owner's Name i infomlation is required for every Hyannis MA 02601 817/14 page, City/Town • p State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information „ • Pumping Records: _ • f Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped; H., r.,;� , , -.•'i gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy r. ❑ . 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•3113 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 8 or 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form'=Not•for Voluntary Assessments 226 Arrowhead drive ti ' Property Address LABBE,ANN M Owner Owner's Name information is Hyannis, '• ' r MA 02601 8/7/14 required for every H y ' page, 'City/Town State Zip Code Date of Inspection , D. System Information (cont.) :1V. Approximate age of all components, date installed(if known)arid source of information: 12-26-2000 per permit date Were sewage odors detected when arriving.at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade:. a : °. ,.r r. . 1.2 feet Material of construction: ` a 'r U: l '.❑cast iron ' ®,40 PVC El other,,(explar*I 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: " `'^ =.8 feet Material of construction: 7 - "- ®concrete ❑ metal ❑fiberglass D polyethylene'-'. [:]other(explain) r - If tank is metal, list age: ' years Is age confirmed by a Certificate of Compliance?(attach a"copy of certificate)• ❑ Yes ❑ No Dimensions: 1000 gal Sludge depth.-• S t5ins•3l13 Title 5 016dal Inspection Form:SUbsuface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts =- ;•, �: -, , . .�.:r ,rn ~ .3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-,Not for Voluntary Assessments-;t. ; 226 Arrowhead drive . Property Address LABBE, ANN M Owner Owner's Name - information is required for every Hyannis r, MA 02601 8/7/14 page. City"rown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle - 30" - Scum thickness .,, ; - 1 , Distance from top of scum to top of outlet tee,or baffle _ 8 Distance from bottom of scum to bottom of outlet tee or baffle 15' How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage;etc.): Septic tank is structurally sound and functioning properly with both tees intact and liquid at the outlet invert I , Grease Trap(locate on site plan): Depth below grade: feet Material of construction: +. i ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness + , f LL Distance from top ofscum 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•,3/13 Y Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official: Inspection%Form Subsurface Sewage Disposal System Form-:-Not for Voluntary Assessments 226 Arrowhead drive = -� Property Address LABBE,ANN M '% - Owner Owner's Name information is , required for every Hyannis ' r,. MA 02601 8/7/14 page. City/Town• State Zip Code Date of Inspection D. System Information (cont.) I., - . �1r. _; ,- . _: : • ;�, Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of'leakage, 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): r:a Dimensions: = Capacity: gallons a.. Design Flow. gallons per'day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in worldng 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•3M3 Title 5 016aal Inspection Form Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts .: " ' ? ;� ' -;•.� �,, Title 5 Officials Inspection-Foam * , Subsurface Sewage Disposal System Form-Not for Voluntary Assessments-t, 226 Arrowhead drive Property Address LABBE,ANN M Owner Owner's Name information is Hyannis f^, �. ' MA 02601 8/7/14 required for every y page, City/Town State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must b' opened)(locate on site plan): �° . . h Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D box level and water tight with no sign of caryover 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: t5ins•3/13 Title 5 Offidal Inspection Form:Subsurfaoe Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection- Foirn, " Subsurface Sewage Disposal-System Form-Not for Voluntary Assessments=..ti<"- 1! 226 Arrowhead drive 1 Property Address LABBE, ANN M ' Owner Owner's Name information is required for every Hyannis Hy ; MA 02601 8/7/14 •�" " r page. Cityrrown - State Zip Code Date of Inspection D. System Information (cont.) j•. r ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system ' Type/name of technology: "�3 •= Comments(note'condition of soil,-signs of hydraulic failure,-level of ponding,damp soil, condition of vegetation, etc.): (4)infiltrators in a 10k30k2'field with no high staining or standing 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 t5ns•W13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 a ' L Commonwealth of Massachusetts Title 5 Official; Inspection ,Form: Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Arrowhead drive Property Address LABBE,ANN M y Owner owner's Name information is required for every Hyannis ? MA 02601 8/7/14 ' page ,City/Town _ State Zip Code hate of Inspection D. System Information (cost.) ;c • ; . , ° i Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.),. Privy(locate on site plan): ^,j Materials of construction: _ Dimensions Depth of solids Comments(note condition of soil;signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 r Commonwealth of Massachusetts 1? 7. Title 5 Official InspectionrForm Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments 226 Arrowhead drive Property Address + LABBE,ANN M Owner Owner's Name - requir anon is Hyannis MA 02601 8/7/14' required for every y page_ City/Town 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 - .r; . 1 A - B 1 1 1 1 ' 1 1 1 I 1 1 1 C D 1 El A1)21.5'' A2)23' B1)26.5' 4, R. B2)24' C3)49' C4)43'. D3)23' D4)25' 15ins•3M3 Trtle 5 Official tnsperbon Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts t , �,• : � ,+ , :- Title 5 Official tlnspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Arrowhead drive , Property Address LABBE, ANN M Owner Owner's Name information is required for every Hyannis ► MA 02601 8/7/14 page. City/Town _ State Zip Code Date of Inspection D. System Information (cont.) -•� ,t ;' t Site Exam:`. _ • �: ; ❑ Check Slope ` Surface water ❑ Check cellar ❑ Shallow wells 1 Estimated depth to high ground water. 48 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: 12-26-2000 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation:- USGS Maps show test hole at 48 feet and plan on file says 5+ft of distance between bottom of leaching and adj groundwater Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5lm;•3113 - Trtle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 o117 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 226 Arrowhead drive Property Address LABBE,ANN M Owner Owner's Name information is required for every Hyannis MA 02601 817/14 -mge. 'City/Town State Zip Code Date of Inspection 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 System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17a4 No. 005 Fee / U UL", e 'HE-6MMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Rpplication for 33iopozal bpztem Cow5tructton Permit Application for a Permit to Construct( . )Repair(t/ )Upgrade( )Abandon( ) ❑Complete System L�Individual Components Location Address or Lot No. .+� �r`f�� LO ��' Owner's Name,Address and Tel. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ve- Ole �- 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) "ef�0�c�i 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 f Signe Date Application Approved by Date bz .�S' vs� Application Disapproved for the following reasons Permit No. P.00S 06 Date Issued �S` u 1 r No. ,2 n C 0U S --C/y 9- ` ».. Fee U U �H jCOMMONWEALTH OF MASSAdritSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS .. 0[pprication for 30i9;po!5al *p.5tem Construction Permit Application for a Permit to Construct( )Repair(V )Upgrade( )Abandon( ) ❑Complete System v Individual Components I Location Address or Lot No. �� ���� ��" Owner's Name,Address and Tel.N . Assessor's Map/Parcel �_ '40eP Installer's Z711��o dress,and Tel.No. Designer's Name,Address and Tel.No. 0//_% C©ems 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil /4e�ll�L't° s�c7�iDi1 D seC�� Nature of Repairs or Alterations(Answer when applicable) r 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 t is B ar - f Signed /1 E; Date Application Approved by VIAn Date Application Disapproved for the following reasons Permit No. U6 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the Ony-ss jje Sewa gz Di s osal System Constructed( ) Repaired ( M Upgraded ( ) Abandoned ) y ��s�• at r/ r�� f �'a���J� _has been construe ed in accordance with the provis' ns of Title 5 and the for Disposal System Construction Permit No. dated a 2 S u Installer �6—f,0/e)P. 1 Designer The issuance of this pa it shall not be construed as a guarantee that th system 1 fin`ion as designed. Date 0-1 to 5 Inspector No. dOUS �U6 � ---------------- --- --7 , Fee /W, , THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS y xMiqu al *pgtemon$truction Permit Permission is hereby granted to onstru-t )Repa} (✓)U gr e( )Aba don( ) System located at Z ���//teq /�r_ y���/_S 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 struction must be completed within three years of the date of t`is pe i , Date: Approved b �VW 1 6 7, Z �. I YO Date: T� TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM NAMEOFBUSINESS: AsIlvio e�Sar �� %RO . BUSINESS LOCATION: MAILING ADDRESS: �Q���ea J � P o���s_ Mail To: TELEPHONE NUMBER: 0 / O1 Board of Health Town of Barnstable CONTACT PERSON: q P.O. Box 534 EMERGENCY CONTACT TELEPHONE NUMBER: Ob' �t�c� Hyannis, MA 02601 TYPEOFBUSINESS: 11121/7-1& Does your firm store any of the toxic or hazardous materials listed below, either for sale or for you own use? YES >C NO This form must be returned to the Board of Health regardless of a yes or no answer. Use the enclosed envelope for your convenience. If you answered YES above, please indicate if the materials are stored at a site otherthan your mailing address: ,�/ ADDRESS: �Z / kl' yAd,- �/60 O4e- - //ya��/�S ' /�/� - O.7-0� TELEPHONE: �5Oy . zz / 0 Y/ LIST OF TOXIC AND HAZARDOUS MATERIALS The Board of Health has determined that the following products exhibit toxic or hazardous character- istics and must be registered regardless of volume. Please estimate the quantity beside the product that you store. NOTE: LIST IN TOTAL LIQUID VOLUME OR POUNDS. Quantity Quantity Antifreeze(for gasoline or coolant systems) Drain cleaners NEW USED Cesspool cleaners Automatic transmission fluid Disinfectants Engine and radiator flushes Road Salt (Halite) Hydraulic fluid (including brake fluid) Refrigerants Motor oils Pesticides NEW USED (insecticides, herbicides, rodenticides) Gasoline, Jet Fuel Photochemicals (Fixers) Diesel fuel, kerosene, #2 heating oil NEW USED Other petroleum products: grease, Photochemicals (Developer) lubricants, gear oil NEW USED Degreasers for engines and metal Printing ink Degreasers for driveways & garages Wood preservatives (creosote) - Battery acid(electrolyte)---- -- Swimming pool chlorine Rustproofers Lye or caustic soda Car wash detergents Jewelry cleaners Car waxes and polishes Leather dyes Asphalt & roofing tar Fertilizers 03 Paints, varnishes, stains, dyes PCB's Lacquer thinners Other chlorinated hydrocarbons, Of NEW C�/ USED (inc. carbon tetrachloride) 4l ` Paint &varnish removers, deglossers Any other products with "poison" labels � ' L Paint brush cleaners (including chloroform, formaldehyde, I Floor& furniture steppers hydrochloric acid, other acids) Metal polishes Laundry soil & stain removers Other products not listed which you feel (including bleach) may be toxic or hazardous (please list): Spot removers & cleaning fluids (dry cleaners) Other cleaning solvents Bug and tar removers WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS TOWN OF BARNSTABLE LOCATION Z��Tr�O� f SEWAGE # 2,4440--7y� VILLAGE /��ltrlrlt'S ASSESSOR'S MAP & LOT 2-7D ->,,**18'7 INSVA LLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY � qpd, C*L- LEACHING FACILITY: (type) �w�cr4,c�d. I ��/T_ (size) /O'/ 30 Xa NO. OF BEDROOMS BUILDER OR OWNER 14AK e PERMIT DATE:1121W , ', V'�640MPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Y,'edand and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by der ' ' b O O r y 0- 0"C No. ( v 7/ Fee J" THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for Miqool bpotem Construction Permit Application for a Permit to Construct( . )Repair(k/)Upgrade( )Abandon( ) O Complete System elI dividual Components Location Address or Lot No. it�.��O��Lp Owner's Name,Address and Tel.No. U o A 9 4j. p Assessor's Map/Parcel . ��� ta Installer's Name,Address and Tel.No. / Designer's Name,Address and Tel.No. 27/-�3Q9 Type of Building: Dwelling No.of Bedrooms�—� Lot Size sq. ft. Garbage Grinder(_Od Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow �J� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /��D90it'f✓�7`/�� Type of S.A.S. �I—/%t . GQh' 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 Certifi- cate of Compliance has been issued b s Boar of H lth. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. 2 f--> 04'^' Date Issued No.Z6,0V Fee •�/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ?' Yes PUBLIC HEALTH DIVISION -,TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYicatfon for Oigpaal *p4tem Construction Permit Applicition for a Permit to Construct( )Repair(")Upgrade( )Abandon( ) El Complete System Y dividual•Components Location Address or Lot No. wner's Name,Address and Tel.No. Assessor's Ma arce ' t ie C--' Installer's Name,Addresfss�and Tel No. }� 10517 Designer's Name,Address and Tel.No. 77/`f0l 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 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank IODD�� Cit'iy7iy� Type of S.A.S. Description of Soil 0 3DX Z 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 Certifi- cate of Compliance has been issued b is oV of alth. _ Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. ' t�ly3 Date Issued ZZ C3 - ------------=-------------------------- THE COMMONWEALTH OF MASSACHUSETTS Z ?d`-0Y 7 BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT�Y', that th On-site Sewage Disposal System Constructed( )Repaired ( , )Upgraded( ) Abandoned( ) y CEO/ �O � at has been constructed'in acc rdance with the provisions of Title 5 and the for Disposal System Construction Permit No. �' 7 y , dated Installer Designer The issuance of this pemiit hail not-be construed as a guarantee that t e-s ��'wiill function;as�gned. Date "'w � rP, Inspect— ,�' Z�.!� ��� --------------------- ^67FF 70 No. e 2 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS ligooal *pgtem Construction hermit Permission is hereby granted to Construct )Repair( )Upgrade( )Abandon( ) System located at Z 7.0/ 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 of special conditions. ' Provided: Construction must be completed within three years of the date of e t. Date: /�S/ � Approved by IL�- rim of Off/.. 10 X 3° M" NOTICE: This Form Is To BeVsed For the Repair Of Failed Septic Systems. Only. _ CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRIICTION PERMIT(WITHOUT DESIGNED PLANS) ere�y certify that the application for disposal works construction permit signed by me dated Z!/ix/©� concerning the property located.at /ZJ eets all of the following criteria:. she failed system is connected to a residential dwelling.only. There are no commercial or business uses associated with the dwelling. ✓�ne soil classified as CLASS I and the pe.,oiadon;fire is less than or dual ;o minutes pe: inc2 V ;"fie:e ares no we•,lands within 100:ee;of;he proposed septic 3 stem •J :e are no arivate wells within.l:0 fee;of the proposed septic system. /ae..e is no tn�....se:n flow ana/or change in use proposes There are no variances.r. /Tile"bottom-of quested or neeaed. the proposed leaching:ac1ry will not be located less than Lye fee;above the maximum adjusted.groundwater table elevation. (Adjust the groundwater.table.using the Frimptor /if method when applicable]_ -the S.A.S. will be located with 250 fee,of any vegetated wetlands. the bottom of the proposed leaching facility will not be located less than fourteen(14)fee;above the ma.-timum adjusted groundwater table elevation Please complete the following: A) Top of Ground Surface EIevation(using GI•S'information) B);G.-W.ElevationZt� + MAX High G.W. Adjtistment. . DIFFEREN(g BETWEEN A and B SIGNED : DATE: l (Sketch proper pLan of rfstem on back]. ¢huM&kkr wt TOWN OF BARNSTABLE ` l ZooD--7y/ LOCATION �Zo���Ole�d� �T' SEWAGE # VILLAGE /�VQ�M/-5 ASSESSOR'S MAP. & LOT 2- -s 7 INSTALLER'S NAME& PHONE N0. 4464, / ,-0 Zalzu' y1` T" I SEPTIC TANK.CAPACITY 444 LEACHING FACILITY: (type) l•vhG �.-J _ (size) /O 3a Xa 1 NO. OF BEDROOMS BUILDER OR OWNER I-AAK e i PERMIT DATE: �" (54OMPLIANCE DATE: I�" Separation Distance Between the: C Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. Feet.— _..:.-.::.. wells.exist... .. 1. Private Water.Su 1 Well and Leaching Facility (If any PP Y°. �. Feet' on site or within 200 feet of leaching facility) Edge of.Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by 6�Y 1 rh � O �Q LO CA T ION SErA C E VEArIT so. fS �I'IIACE . INSTA LEWS NAMlE . t Aoselss -o - owls ER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED ���� � ' ;g '. ' � "Y �' ,yam '' ��� .`.� �'� .,,*..r ++i j .. .� ��: ' .✓ .4 : : �.. .^� „�, �: � 4 • � � � :y ""� O ;,,. ._. � � �� . . � ;�, -� � . � _,.� ._. k ���. • :y,, ' c..,(// - � 4ai: � .:i• g. u THE COMMONWEALTH.OF MASSACHUSETTS BOARD OF HEALTH :..................... ..........0F.-.......r �.c�.C�. --.............. /• .............. Application is hereby made for a Permit to Construct ( ) or Repair ( )-an Individual Sewage Disposal System at: a L Address or L ot No. . ........... zn. . .. ..TOW ..---.....1 /�t2:� ..... � ....... ^----.-.n...�.... ---------..........--- Owner Address .... •------- .�..... Z . 7 - Installer Address *2 x/! Type of Building Size Lot......... Sq. feet U Dwelling—No. of Bedrooms____ Garbage Grinder.............................Ex ansion Attic ( ) ' aOther—Type of Building .............................No. of persons..........--................ Showers ( ) — Cafeteria- Otherfixtures -.............-----------------------••••••......---•- ......................................................... .... W Design Flow..........................................:.gallons per person per day. Total daily flow....................._._....................gallons.: ; WSeptic Tank 'Liquid capacity............gallons Length................ Width................ Diameter.........--- Depth................ . x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.............-- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation'Test Results Performed by-••--•••••••--••-------•••.................••--------....-•••-----•----.. Date......................................... Test Pit No. 1................minutes per inch Depth of Test Pit.--................. Depth to ground water.--.................---. (X4 Test Pit No. 2................minutes per.inch Depth of Test Pit.................... Depth to ground water-:-..........--......... ----•-----------------------------•-••-••--•-------•--••---•--.......------..............••.................................................................. Descriptionof Soil :.. ---•----•-- --------------------------•------------------------------------------------------- U ---••-•-••-----•---••••----•••-•..............•----••....••••--........-•---------••------------•-•-----..........•--•••......-•------- W .............•-----•----•---......-•-•••----••••--•-•--•-•---••-----•--.._.._. --------.- _ txj Nature o Repairs or Alterations Answer w n pli e.-- -_ . .-.. ...... .. . .. ..-_..!� '1_- .�` - : ......•--------------------•.------•--............---• Agreement: J The undersigned agrees to install the aforedescribed Individual Sewage.Disposal System in accordance with the provisions of TITLE 5 of the State Saint Code— he undersigned further agrees not to place the system in operation until a Certificate of Compliance ha b en s d t boa of health. , —Signed .------ ..... .. ......................... ,..................... 't Date Application Approved By. ...... • .•-••-. -- •-• ...1PIA • ...... _" � .:..... Date Application Disapproved for the following reasons:.................;. ..........................•........ -_-_..•••-•._ ............................................................................................................. -----------------------------------------------••-•---------••-----...Date..-------- .. PermitNo......................................................... Issued_...... � ....... Date" No._........ Fss.�................... THE COMMONWEALTH OF MASSACHUSETTS F BOARD OF HEALTH. ....................... ...........O F..........�f.. ...u-.... .................... :7 r ......:...... ApplirFation fur DhipasFal Workii TnmUurtion Famit Application is hereby made for a Permit to Construct ( ) or Repair ( .) an Individual Sewage Disposal System at: .... a __. 11�1 N !���......1� '.:. ..._... .......................................... .�^ Lo ati Address or Lot No. ...20-z l^1.......... ----42?T -�••_... ....... ... .................. ' !'i ' ........................................................ Address .. :... C^ �...�:�f..'ri ..... ...r?�................................. .............. .. Installer Address `77 X/'/' Type of Building Size Lot_____....Y,0F�?.......Sq. feet Dwelling—No. of Bedrooms......... ............. ________________Expansion Attic Garbage Grinder ( ) '4 Other—T e of Building No. of persons...______................"_: Showers — Cafeteria a' Other fixtures -----------------------------•_• ' W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity.___._..____gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet..................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) - ---- --r- __ Percolation Test Results Performed by---------------------------------------------•-•----•-•-----•--•-•----•-• Date........................................ Test Pit No. 1...............:minutes per inch Depth of Test Pit.................... Depth to ground water......................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ---------------- ------------------•........................................._........ .......__.............____-•--•--•-•-----•--•......-------•--•-••••-- 0 Description of Soil.......................................................................................................................................................................... x U ------------------------------------•------------------------------------------------.._..-------------•--•---- ------- ----- ••-•--•--•---•--- Na ure of Re air or terations Answer w n, li �e____ _.... _______ __ ____________ U P P Gchvl l .. j ...... ........................ Agreement'.` The undersigned agrees to install the. aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITL-J 5 of the State Sanit Code— the undersigned further agrees not to place the system in operation until a Certificate of Compliance ha b nPdbboa of health.igned .'.'v'_--•--------•-----1..................... .... J•- DateApplication Approved By •-•• C....... 1 ....................... d . Date Application Disapproved for the following reasons:.............................................................................................-................. •--•........................................................••----•-•-•--------•------...._.__.._..........------------------•-•-----------•----•---•-••----------•---•--...-•---... --•------...._ Date I PermitNo.......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ 4r� ..OF......... ......................................................... f TrrtifirFatr of Tomphattrr THI47 IS TO C RTI ', T,at•the Individual Sewage Disposal System constructed ( ) .or Repaired by... 1�`�.Q -tTa1,1,er-- ..................... ....._..... ---- -•----____ ---____ at......... ...G1�lZ� ......i --_lb.--• -°�' ----- " N-. f 7:---- = has been installed'in accordance with the provisions o5 of The State Sanitary Co e as described in the application for Disposal Works Construction Permit N /�. "_._._.___. dated__...._.'... �' 'U_______________ THE,ISSUANCE OF THIS. CERTIFICATE'SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM,VIL FUNCTION SATISFACTORY. DATE.:.:...:.. '.� ..... I-----------------------------•--_. Inspector------••• ---:•---• -- .... 4074.. :.. 7 THE COMMONWEALTH OF MASSACHUSETTS BOARD O HEALTH ox,,� y �1.� u~C_ No............:l._.:l�: FEE....Y_-._.............. Maps 1 IVirk � � �trttnn rrmi� Permission hereby granted--•••-'••�� -:.. `'��+� .......................... ............... .............. to Const ct r Re a r I diviH/ualew Disposal stem } � �� at No. !b�---�!} d2�+.-:. _-_-•-----_-• � 4:0'W`'--`�G .__.... = % ........................................ • Street � � �� • as shown on the application for Disposal Works Construction Pe 1Vjo ..;_ ______ Dated_._.._._._._.._..�__._:__...____._._.... -----.... r -41 . .....................-------_ Board of Health DATE.......•-----------!l/-=----•---------------------------------•••-=••--••--------- FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - • c .. ��� . � ��:. o � .�" .� � , . w 1 � � ... .� o -_ '�-�� �- � _ � �� - � � � � ... �.: � , �� � . : g , . . .. � l . � '. . . 11 -. ..: �