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Home My WebLink About0247 BEARSE'S WAY - Health (2) ��earse's,Wayso ,Hyannis P 41 Iq `31'0 003 A p A v 0 n b a ,r I P TOWN OF BARNSTABLE LOCATION ZY7—,6,y r5i� FS cawa SEWAGE# VILLAGE -01�1/On 0/5 ASSESSOR'S MAP&PARCEL 3/4-D 0� INSTALLER'S NAME&PHONE NO.,i-8?-4KZO-Q�3�✓®St{��i �'� �s�/"r®S SEPTIC TANK CAPACITY /000 LEACHING FACILITY:(type) 'SOO VrO* W/Y11Y (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: ��^/G _✓y 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 Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �® Feet FURNISHED BY . s, .o �i _;a• ' d •W, y•1n`• r• � 1 _ e 3 -------------- q �' Ll .(/,. i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF,ENVIRONMENTAL PROTECTION RECEIVED q p�M SvOv JUN 0 6 2003 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: #237 Bearses Way (A.K.A.as#247) MAP Hyannis,MA Owner's Name: Maria Mainini PARCEL Owner's Address: III Dean Street LOT _ _ __ Taunton,MA 02780 Date of Inspection: 05/13/03 Name of Inspector: (please print) Mr.Carmen E. Shay Company Name: Shav Environmental Services, Inc. Mailing Address: 34 Thatchers Lane East Falmouth,MA 02536 Telephone Number: (508)-548-0796 CERTIFICATION STATEMENT 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: XX Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authori S a o Fails A { E Inspector's Signature: Date: 5/13/03 u 0 FpTlF OP The system inspector shall submit a copy of this inspection report to the Approving Authority(Board o 1cjgpE� DEP)within 30 days of completing this inspection. Ifthe system is a shared system or has a design flow o 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. Notes and Comments Probed Stone around SAS and surrounding stone area. No evidence of hydraulic failure noted. ****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. Title 5 Inspection Form 6/15/2000 page 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: #237 Bearses Way Hyannis,MA Owner: Maria Mainini Date of Inspection: 5/13/03 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: XX 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. Answer yes,no or not determined(Y,N,ND)in the 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. ND explain: 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 obstruction is removed distribution box is leveled or replaced ND explain: 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 obstruction is removed ND explain: T .. 1 . .,..,.,.,,.,. 2 Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: _ #237 Bearses Way Hyannis,MA Owner: Maria Mainini Date of Inspection: 5/13/03 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(l)(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 2. System will fail unless the Board of Health and Public Water Supplier, if an determines that the Y ( PP � Y) 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: #237 Bearses Way Hyannis, MA Owner: Maria Mainini Date of Inspection: 5/13/03 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool XX Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped XX Any portion of the SAS,cesspool or privy is below high ground water elevation. XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. XX Any portion of a cesspool or privy is within a Zone I of a public well. XX Any portion of a cesspool or privy is within 50 feet of a private water supply well. XX 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] NO (Yes/No)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• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. ' Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: #237 Bearses Way Hyannis, MA Owner: Maria Mainini Date of Inspection: 5/13/03 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No XX Pumping information was provided by the owner,occupant,or Board of Health XX Were any of the system components pumped out in the previous two weeks? XX _ Has the system received normal flows in the previous two week period ? XX Have large volumes of water been introduced to the system recently or as part of this inspection`? XX Were as built plans of the system obtained and examined?(If they were not available note as N/A) XX _ Was the facility or dwelling inspected for signs of sewage back up`? XX _ Was the site inspected for signs of break out? XX _ Were all system components,excluding the SAS, located on site XX _ 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? XX _ 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: Yes no XX _ Existing information. For example, a plan at the Board of Health. XX _ 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(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM i PART C SYSTEM INFORMATION Property Address: #237 Bearses Way Hyannis,MA Owner: Maria Mainini Date of Inspection: 5/13/03 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 I DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 2 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no): Yes Water meter readings, if available(last 2 years usage(gpd)): 2002— 100,000 gallons Sump pump(yes or no): No 2001 —93,000 gallons Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: None on File Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons-- How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM XX 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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Sept.3, 1998-per Board of Health & Owner Records Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #237 Bearses Way Hyannis,MA Owner: Maria Mainini Date of Inspection: 5/13/03 BUILDING SEWER(locate on site plan) i Depth below grade: 16" Materials of construction:--cast iron XX 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): No evidence of leaks or damaged piping. Venting noted on roof. No odors noted. SEPTIC TANK: XX (locate on site plan) Depth below grade: 24" Material of construction: XX concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 5' deep x 5'wide by 10'long (1500 gallon) Sludge depth: 4.75' Distance from top of sludge to bottom of outlet tee or baffle: 3.00' Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 14" 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.): Structural integrity of tank was ok. No evidence of cracks, leaks, or water infiltration/exfiltration. 4" PVC Tee present and in-good condition. Outlet Tee also in good condition. Liquid level equal with outlet invert. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): . . .„�,. 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #237 Bearses Way Hyannis,MA Owner: Maria Mainini Date of Inspection: 5/13/03 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:—Present . (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: equal 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.): One outlet to leaching Infiltrator Trench. D-Box in good condition. No evidence of solids carry over. PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no):__ Comments(note condition of pump chamber,condition of pumps and appurtenances,etc._ .,..,. R r Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #237 Bearses Way Hyannis, MA Owner: Maria Mainini Date of Inspection: 5/13/03 SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: XX leaching trenches,number, length: 1 Trench—10' wide by 28 feet long,2' deep. 4 Infiltrators 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.): No evidence of hydraulic failure, ponding damp soil or stressed vegetation. Probed stone with no evidence of hydraulic failure. 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 or no): 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.): 9 i Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #237 Bearses Way Hyannis,MA Owner: Maria Mainini Date of Inspection: 5/13/03 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. Septic Tank (1500 Gal.) A 0 H a m 3 Br Swing Ties: p House s A-Tank IN—26' h B-Tank IN—29' i B r TD-Box e 1° I A—D-Box—59' B—D-Box—25.5' A—Leach Trench—67' 1 B—Leach Trench—30' Leach Trench 1 r . Bearses Way i 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: #237 Bearses Way Hyannis, MA Owner: Maria Mainini Date of Inspection: 5/13/03 SITE EXAM Slope Surface water -None Check cellar -Yes Shallow wells—None Estimated depth to ground water 30 feet below grade. Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: XX 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) XX Accessed USGS database-explain: Plate 3 You must describe how you established the high ground water elevation: Checked with Ouadrangle of USGS Map. Per USGS MAP PLATE 3: Elev.of Ground=30 Feet Elev.Of Groundwater= 15 Feet Elev.Of Bottom of Leach Trench=25 Feet Therefore: 25—15 = 10 feet separation between Bottom of Leach Trench and Groundwater. Groundwater Adjustment using Index Well AIW30 : 2.4 feet Adjusted Groundwater Separation=25'— 17.4' =7.6 feet (Refer to attached work sheet) Grade=Elev. 30 feet E::]� �� Leach Trench D-Box Septic Tank Bottom of Leach Trench=Elev. 25 feet Adj. Groundwater=Elev. 17.4 I Permit Number: Date: i Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Site Location: �2C�CSQS I�Q.V Lot No. Owner: TAP% _\q-��11(yA�Ntr^1 i Address: f} Contractor:Skill &kSt0MC0N_-Q\ Address: O A Notes: STEP 1 Measure depth to water table tonearest 1/10 ft. .............................................................................. .Date 5 O mont /day year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: q�W OAppropriate index well.................................................... OWater-level range zone ..................................................... 1 STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... mon /year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 26) determine water-level adjustment o�.y STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) .................................................... .......................................................... I; Figure 13.--Reproducible computation form. 15 I 1 1 s 2 3 43 �, a3 ao TOWN OF BARNSTABLE i LOCATION SEWAGE # 1 VILLAGE_ ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) Ad (size) 1 I�hgd4� t- NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: -1-7 �,' COMPLIANCE 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 Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by rr. TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE_�� +.A ASSESSOR'.S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACEL=: (type) (size) IV,&-j4 y Ade NO.OF BEDROOMS , BUILDER OR OWNER �PERMUDATE: 7 , COMPLIANCE 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 Wetland and Leaching Facility.(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � � �, � � � � �� _ � � Q �� j a N -_ �' '� 1 _ No. Fee . l _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0[ppYication for Mi5po5al *pgtem Cow5truction Permit Application for a Permit to Cons ct( )Repair( )Upgrade( )Abandon( ) complete System O Individual Components Location Address or Lot No.a � tiJS.,P S U-0t6— Owner's Name,Address and Tel.No. I I Assessor's Map/Parcel r3 0_0 D 3 Z) ��q—: 4 � Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Qi= SIeF 9%t L moo' 1�w 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 Flow30 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. NA%,Qv, cc, �- Description of Soil Nature of Repairs or Alterations(Answer when applicable) T'cA-S i',9-�\ \ �Cu jL5 t� v— t S Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of-Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has b y t Signed Date —98 Application Approved by Date Application Disapproved for the following reaso Permit No. Date Issued No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIpplication for )Di-4poal *p!5t$em (Construction Permit Application for a Permit to Cons ct Repair Upgrade Abandon t?f;Somplete System 0 Individual Components r Location Address or Lot No. U—,Pt— Owner's Name,Address and Tel.No. Assessor's Map/Parcel r3 1 0—0 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. (\A cA C,C S'iEE7 91, 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. Calculited daily flow gallons. ay. ",,_ --7,1-k C� Plan Date Number of sheets Revision Date Title Size of Septic Tank IScro _s-rl ----Type of S.A.S. o Cr4 Description of Soil Nature of Repairs or Alterations(Answer when applicable) OjSQ- E:,�C_- 0 --.�o V?S -S 0_V_, Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 53 of the En ir3onmental Code and not to place the system in operation until a Certifi- cate of Compliance ha e yt is g Date -6.,CT-99 n Si' ed. Application Approved by Date 5? a :2 Application Disapproved for the following reaso Permit No. J-6--3 Date Issued -------------- -——————————————————————————————_——————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed Repaired Upgraded()Q Abandoned( )by— at p-VA, Z)I-k cj.,_rseS L-kcA,,A_ 4s4 C4 tN&5-S has been constructed in accordance with the provisions of Tide 5 and the for Disposal System Construction Permit No. Il-SS3 -dated Installer Designer--- The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector —-----———————————————————— No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 'ig;poe;al *pg;tem Cong;tructton Permit Permission is hereby granted to Construct ))JqLair,( )Upgrade )Abandon System located at 4-W *:: and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permit. Date: Approved by