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Home My WebLink About0194 BEARSE'S WAY - Health 19.4 Bearses Hyannis -- 09 ::030 A = 3 R\ rug 24 15 07:32p 4 p.1 M� 3D � -030 Commonwealth of Massachusetts . Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M. ' 194 Bearses Way Property Address 1 Carole Rebman Owner Owner's N information is ame/ H annis MA 02601 8-17-15 r--a required for every y page. City/Town State Zip Code Date of Inspection .4 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 ��ttuntunr r NiA filling out Forms OF A14 on the computer, S/# /1 U9� use only the tab 1. Inspector: ao?:' -Cyr; key to move your JAMES •u' cursor-do not James D Sears = ' use the return SEARS :tnc Name of Inspector key. # _Ca ewideEnterprises,LLC - �`'• ° Q Company Name �� `F 5•1 N S-- r, 153 Commercial Street '�''��rr►+rre►u+��```�� Company Address Mashpee — MA 02649 City[Town state Zip Code 508-47 7-8877 S 1623 Telephone Number 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 16.000).The system: Passes ❑ Conditionally Passes ❑ Fails i ❑ Needs Further Evaluation by the Local Approving Authority 8-24-15 pector'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. P'Sm'a Title 5 Otriciai Inspection Form:Subsurfage Drsposal System-Page t of 1T �' f Aug 24 15 07:32p p.2 CommonwealtFrdf Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 194 Bearses Way Property Address Carole Rebman Owner Owner's Name informatrequired is Hyannis MA 02601 8-17-15 required for every _. page. Citylrown 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: ® 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: The system is a 1000 Gal. Tank D Box and five infiltrators. 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. II ❑ Y ❑ N ❑ ND(Explain below): I i 191ns•arla TiW 5 OfWal Inapection rorm:Subeurfeco Sege Dlapoaal Syzrom-Pago 2 of 17 Aug 24 15 07:32p p.3 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 194 Bearses Way Property Address Carole Rebman Owner Owner's Name information is Hyannis MA 02601 6-17-16 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumpstalarms not operational. System will pass with Board of Health approval if pumpslalarms 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 ❑ NO (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): i 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, i 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 t5ns.3/13 TiUe 5 Ortt ial Inspection Forth:S%baurfece Sewaes Dlapwel S7atem-Page 3 d 17 Aug 2415 07:33p p 4 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 Bearses Way Property Address Carole Rebman Owner Owners Name information is required for every Hyannis MA 02601 8-17-15 page. Cityrrown State Zip Code Date cf Inspedion B. Certification (cant_) 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning iri 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 10.0 feet but 50 feet or more from a private water supply weir*. 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 foram. 3. Other: J I 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 ❑ ® Liquid depth in Is less than 6" below invert or available volume is less I than Y2 day flow /tfi'�'Nin%� tSns•3113 Title 5 Official Inspection Farm:Subsurface sewage Dlspowl Syslam-Page 4 of 17 Aug 24 15 07:33p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 194 Bearses Way Property Address Carole Rebman Owner Owner's Name information is required for every H annis MA 02601 8-17-15 y page. City/Town State Zip Code Date of Inspection B. Certification (cant.) 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. ❑ ® 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 and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more"of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. i 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 El ❑ 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 16.304. The system owner should contact the appropriate regional office of the Department. tslns 3113 Tile 5 0rridal Inspection Fornc Subsurface Sewage Deposal System•Page 5 of 17 Aug 24 15 07:33p p.g Commonwealth of Massachusetts Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments j 194 Bearses Way Property Address Carole Rebman Owner Owner's Name information is Hy MA 02601 8-17-15 Hyannis required for every State Zip Code Date of Inspection page. Cityrrown C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (if they were not available note as NIA) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® 0 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 II Wins-31`13 Title 5 omciai Inspection Form:Subsurface Sewage Dispo"I Syaten-Pogo 5 or 17 F Aug 2415 07:34p p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 194 Bearses Way _ Property Address Carole Rebman Owner Owners Name information is required for every Hyannis MA 02601 8-17-15 page. Cityrrown State Zip Code Date of inspection D. System Information Description: The system is a 1500 Gal.Tank D Box and five infiltrators Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (include laundry system inspection ElYes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑. Yes ® No Water meter readings, if available last 2 ears usage 2013-63,750Gal 9 ( Y 9 {gPd)) 2014-63,000 GaI s Detail: i Sump pump? ❑ Yes No Last date of occupancy: Present 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/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 i Water meter readings, if available: i5ins•3113 Tilla 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 i Aug 2415 07:34p p.8 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 Bearses Way Property Address Carole Rebman Owner Owners Name information is Hyannis MA 02601 8-17-15 required for every y - page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use. Date Other(describe below): General Information Pumping Records: Source of information: 5/11112 Was system pumped as part of the inspection? ❑ Yes ® No i If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool Cl Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes, attach previous inspection records, if any) ❑ Innovative/Altemative 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): I51ns•3h3 Tillo 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 17 Aug 2415 07:34p p.9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 Bearses Way Property Address Carole Rebman Owner Owner's Name information is required for every Hyannis MA 02601 8-17-16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1995- Permit # 95 - 37. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 16" Depth below grade: feet Material of constructon: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints,venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH-40 Septic Tank (locate on site plan): i 8" Depth below grade: feet Material of 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: 1500 Gal. Precast H-10 Sludge depth: 4" t5ins 3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Aug 2415 07:35p p.10 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 194 Bearses Way Property Address Carole Rebman Owner Owner's Name information is required for every Hyannis _MA_ 02601 8-17-15 page. Cityrrown 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 26" Scum thickness 2n Distance from top of scum to top of outlet tee or baffle 8n Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Asbuilt-Tape Judge Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level.Tank and cover's at 8" below grade. In and outlet tees. No sign of leakage or over loading. Note: Maint pump after inspection. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): i 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 TWO 5 010d l Itspectkm Form:Subsurface Sewage Disposal System-Page 10 of 17 Aug 2415 07:35p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form } - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 Bearses Way Property Address Carole Rebman Owner Owner's Name information is required for every Hyannis MA 02601 8-17-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: --- ---- -- — Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 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.): r " Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No f I t5ins-3/13 Title 5 Oftal Inspection Form:Subsurface Sewage Disposal system-page 11 or 17 I f Aug 24 15 07:35p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _194 Bearses Way Property Address Carole Rebman Owner Owner's Name information is required for every Hyannis MA 02601 8-17-15 page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 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 is 16"x21"-14" below grade. Box is clean and solid w/two line's out No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order 0 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: 1.51ns 3113 TWO 5 Official lnspamon Form:Suosunace Sewage Disposal System•Page 12 of 17 i Aug 2415 07:36p 0.13 Commonwealth of Massachusetts kiwi, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 Bearses Way Property Address Carole Rebman Owner Owner's Name information is required for every Hyannis MA 02601 8-17-15 page. Citylrown State Zip Code Date of Inspection D. System Information (cons.) Type: ❑ leaching pits number ® leaching chambers number. 5 ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. — — y ❑ 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.): Leaching is five H-20 infiltrators w/2' stone.Chambers are 26" below grade. Ck D Box and camera out to chambers. No sign of over loading. 2"water in chambers. I 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 1 Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No I51ns•3113 Tale 5 Orficiai Inspection Form:Subsurface Sewage Oisposar System-Page 13 of 17 Aug 24 15 07:36p p.14 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 194 Bearses Way Property Address Carole Rebman Owner Owner's Name information is required for every Hyannis MA 02601 8-17_15 page" City/town State Zip Code Date of Inspection D. System Information (cunt.) 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 rr11e 5 Otrdal I rnpetlian Form:Subsurface sewage Daposel System•Page 14 of 17 i Aug 2415(07`.36p p.1 5 �\ Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _194 Bearses Way Property Address -- Carole Rebman Owner Owner's Name -- information is required for every Hyannis _ MA 02601 _ 8-17-15 _ 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 I � . 3.5- i R 31 __ i i 1 ti 15mr.•3/13 Title 5 Offida!h5pomion FORM:subsurraw Di sal System•Page 15 of 17 ' Aug 2415 07:37p p.16 Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form-Not For Voluntary Assessments 194 Bearses Way Property Address Carole Rebman Owner Owner's Name information is required for every Hyannis MA 02601 8-17-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells P 9 9 10' Estimated depth to hi h round 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: 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: T.H. hand Auger 10'no G.W.. Bottom of chamber's at 4'-6"below grade. Hottom of chamber's at 5"-6"above T.H. Depth. Before filing this Inspection Report,please see Report Completeness Checklist on next page. i5ins.Y13 Title 5 Official Inspection Farts.SLbcurtaoe Sawago Oispmv System-paga 1s d 17 Aug 2415 07:37p p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 194 Bearses Way Property Address Carole Rebman Owner Owners Name information is required for every Hyannis MA 02601_ 8-17-15 page. Cityfrown state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater i ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file [Sins-3113 Tills 5 Official Insp ection Forth Subsurface Sewage Disposal System•Page 57 of 17 l 9 i AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION \J��CS W�Y(�. SEWAGE VILLAGE Vl,,,frr\CS�5 ASSESSOR'S MAP & LOT.74 ClOG INSTALLER'S NAME & PHONE NO. 1-rt,�/��/,, �7J �JS / SEPTIC TANK CAPACITY S—V V CYCAL LEACHING FACILITY:(type) J I nt1}ctNCl{CS (size) �rJ a�lf S 40 NO. OF BEDROOMS PRIVATE WELL OR UBLI WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No as 3-7 4,o as rt��-- Q�o 3 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=309030&seq=1 8/14/2015 TOWN OF BARNSTABLE LOCATION IN `JCC'lrbCS �P( SEWAGE # VILLAGE L / - ASSESSOR'S MAP & LOT-740 9,7 ''LS INSTALLER'S NAME Sz PHONE NO. � L�/\Vl. SEPTIC TANK CAPACITY S V V � LEACHING FACILITY:(type) �L r% (size) i NO. OF BEDROOMS PRIVATE WELL OR UBLI WATER QQ6 BUILDER OR OWNER DATE PERMIT ISSUED: 1 , 1'� V-1 ` DATE COMPLIANCE ISSUED: /,'/eA ' =✓ VARIANCE GRANTED: Yes No l� V� . � c 7 � o r , 30,� U C� No. Fas........... `: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allpfiration for Di-tipmi l Workg Towitrnrtion jrrmit Application is hereby made for a Permit to Construct ( ) or Repair lV ) an Individual Sewage Disposal System at: •-.............• • . . c5 =---------------•--•-------•----•---•-••-•-•-•------•--•. ------......................•--- R -L/ocatio�n \ddre `C�l 1p or Lot No. -� -------------- Owner Installer Address d Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms._____`' ________________________________E�pansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ..........:................. No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------------------- - - d WDesign Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity-_ galIons' 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 ( ) - o: Percolation Test Results Performed by........-................................................................. Date........................................ Test Pit No. 1................minutes per inch Depth of Test.Pit..................... Depth to ground water......... L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ RS -------------- ----------------------------------------------------------------•---•........-•••.•--•.......--•...._......------............................ 0 Description of Soil.......................................................................................................................................................................... x , U ----•-------------------•-•------------•-••----•---•--•---- .........................................------•---------------•----•---•---•---------------------------------•-----.......-----••--•....... W ------------------------------•---------. .:.. rc.................... - -- - ------------------ U Nature of Repairs or Alterations—Answer when applicabl t�� l,. ......... d_... r^... n----- �s` ?K. C� ... Y` -...--- Agreerhent: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code.—The undersigned further agrees not to place the system in operation until a Certificate of CompliVcs b n ' sue the board of health.Signed ...... .................... ... .� ......................... Dare ^� Application Approved B .. ...... ! r ...�' fJ ....................................... :.....1............ ... Dace Application Disapproved for the following reasons: .............................................. ....:..........................,..............................---....................... ......... ........................................ Permit No. .... .... � ti ................ ............................ Issued .............................�...... ...... Dace No. �^ � Fps... `..ail THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratimit for Di-lip 1sal WArk.6 Towitrnrtiun Permit Application is hereby made for a Permit to Construct ( ) or Repair lV ) an Individual Sewage Disposal System at: ...ley s �S ------------------- -- ... ......... Location- \ddre or Lot No. e�.lr r Mgt...�-}....--•----•------------------------ -•--cG,,,,.-�------------------------.....-----------•---•--..............---......... Owner dd�ss` -�� c a y Pt�,. ct '---�-------------------------------- Installer Address UType of Building ` Size Lot.................... Sq. feet Dwelling— No. of Bedrooms.......... ................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons----_....................... Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------•--------------------------------••------------------...---•--.._......----------•-•-•--•--•---•-••--•---•••----.........--_.. W Design Flow.......................................... .gallons per person per day. Total daily flow......................._....................gallons. WSeptic Tank—Liquid capacity.ASWgalIons 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 ( ) 1.4 Percolation Test Results Performed by.......................................................................... Date........................................ ,.a Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water......................... fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a --••-------•------------- --•••--•-----••--------••-•-••------------•-•-•-------•-----------...........------------•------•------•-••-•-•------..............- Descriptionof Soil........................................................................................................................................................................ x - U •-•--••--•---------•---------------------•-•-------------------------------------•-...-•-•---------------------••••••-•----•---•-------------•-••-•--------------------------------....----------------- w ... ••-----•--------------------------------•---••-••........---------------------•-----------•---•---- U Nature of Repairs or Alterations ' Answer when applicabll. n�,CG�. ...........A.__.../. d.._. �^r�� - ...__. Agreefent: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli ce has b n ' sued the board of health. G i Signed ........ �117.1 / �. . .................. Date _� Application Approved B " ........................................ .............. Dare Application Disapproved for the following reasons: ....................................,................................................................................................. t ................................................................................................................................................................................................................ ........................................ Permit No. ......... ......... ........................... Issued ........................................... .. Dare THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CPrtifirate of (gIImplian>ce THIS IS TO CURTIFY, That the Individual Sewage Disposal System constructed ( .) or Repaired by .............Sv.�Cl.......r .. --..................................................... ............................................................................................................................... cInstaner at ........`..�....u...... ............t'I.� . .......lS..................................................... ..................................... -- .................. has been installed in accordance with fhe provision s of TIT I, of e State Envir. nmental Cpde as described the application for Disposal Works Construction Permit No. �.... ----,7^ dated /...``... ..7:7.. L� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED_ AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. -° � .DATE.........1" /....................._................:.......................... Inspector ..._..... .. .................:...............-------------...............i...... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No......................... ................... � FEE----......a....... � Disposal Works Tomitrurtion Permit Permission is hereby granted----- ---------------- -----------------------------------------------------------------•---........-•--- to Construct ( ) or Repair ( an Individual Se age Disposal System atNo............................................ ..... ............. L4-------...... T. S jam. ------.... n-!3.................................. Street / as shown on the application for Disposal Works Construction Permit F!�� Dated._....1..`�.1.........' / Board of Health DATE.------1. / ---- FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS