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HomeMy WebLinkAbout0059 BETTY'S POND ROAD - Health 59 Betty's Pond in W Hyannis P Ian A = 290 087 o0 0 fi G u v o }Ii 0 No. Fee , y% THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 9pplitation for Misposaf *pstrm gAstrurtion permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(Xl ❑Complete System ❑Individual Components Location Address or Lot No 59 ��rN�S � �Zj Owner's Dame,Address,and Tel.No. M Y�4a�u is n 0)j F N(I_L.A� 'PeV c Assessors Map/Parcel a0j® O g — — - - Installer's Name,Address,and Tel.No.5p12—q7.—Tg 7`1 Designer's Name,Address,and Tel.No. �1vL©s e R►s 5 LL<- r�d� Type of Building: Dwelling No.of Bedrooms /U Lot Size -1,40- sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided A 6 gpd 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) Y4 �,yU &-1 tS-Tt&xX SE�Puc, '"97t9ti Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt . Signed Date (0 Application Approved by Date �6 Application Disapproved y Date for the following reasons Permit No. — l Date Issued Y14 ! 01 No. ("y I 1 Y r Fee �� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: , Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ftplication for MispoSal 6pstem C-QnStrUction J)ermit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon X ❑Complete System ❑Individual Components' Location Address or Lot No B6 �S �0�1A Rj) Owner's Name,Address,and Tel.No. MY,41V1JIS bc)1U E P14c Ak"t 'PEcK. Ili`"' Assessor's Map/Parcel a9 0 0 Sq PtM[Sj'.5 p ern R is tA VAJyj 1 "~ Installer's Name,Address,and Tel.No.$0J—c f7-1_�I g-7'7 Designer's Name,Address,and Tel.No. ' <WELO 6 eN Ajl- u-ir— N (fir 1 ,1 Type of Building: Dwelling No.of Bedrooms /U - Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) - IQ gpd Design flow provided AJA gpd 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) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Healt c Signed Date Application Approved by Date Z/ 6 Application Disapproved ry.1 Date for the following reasons Permit No. 170111— tog Date Issued Y116 17,61 y Tit E COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certifitate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( ) Abandoned(x)by CAPSW(bt=f at 5!Cj Z ) t4\,(4 &Jt5,' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. to B dated 4 � � wl LI �— 1 Installer d i40E_)1pe; ED�._7M4&j.( (_,(,C— Designer /A ,,r #bedrooms Qjl¢ Approved design flow Al ME .,* / i1 gpd The issuance of this permit shall not be cons rued ids a guarantee that the system will funcjtioon designeedde i Date � � Inspector /r(� ����1 C ��'i'i Y'4�% 61 y --------------------------1- 1 j/ 7----------- No. 1090 Fe THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS MispoBal 6pstem Construction permit ; Permission is hereby granted to Construct( ) Repair( ) Upgrade.( )„ Abandon System located at9 EFT y n 1ib R:h i4Y&))(J I S and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. / Provided:Con truction must be completed within three years of the date of this permit., / Date 11116 I (i-r Approved by �f / i �SME T� Town of Barnstable Barnstable v Regulatory Services Department e`caC j BAMSTABM 6' __.----._-Public_Health-Division & -.- him -00 Main:Street, - yannis WA 02-60 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL#7012-1010-0000-2848 -0042 March 28, 2013 DONALD &HILLARY PECK 59 BETTYS POND RD IMPORTANT NOTICE HYANNIS, MA 02601 Map & Parcel: 290- 087 The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. This letter directs you to connect your dwelling, at 59 Betty's Pond Road, Hyannis, MA, to public sewer on or before 3/30/2015. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining to the sewer connection, please see the reverse side of this page. PER ORDER OF THE OARD OF HEALTH s A. McKean, R.S., C.H.O. Agent of the Board of Health Cc: Barbara Childs,WPC/Roger Parsons, Town Engineering, DPW Enc. QASEWER connect\Letters Stewart Creek Sewer Connects\MA11.ING LetA Sewer Up Merged 3-28-13 Yr2015.doc Public Health Division March 28, 2013 ADDITIONAL INFORMATION AND REMINDERS FROM OTHER DIVISIONS: SAVINGS AVAILABLE/GRINDER PUMP: A reminder to those of you who need a grinder for your connection: Department of Public Works (DPW) sent you a letter in December 2012 stating the town, for a limited time of two years, only from the receipt of the DPW letter, would provide you with the pump at no charge. (This can save you thousands of dollars.) Please note: You must pay the installation cost through your own contractor. Please make your contractor aware of this, if interested. Also be aware: this is a shorter deadline than the Public Health Division's deadline on the reverse side of this page. SAVINGS AVAILABLE/PERMIT FEE: The Town offers a waiver of the residential sewer connection fee of $420.00 for those properties that connect within two years of the receipt of the DPW December 2012 letter. LOANS: For loan(s) available, please see the enclosed brochure, or see the town website: http://www.town.barnstable.lna.us/cdba (under the "CDBG Programs", see "Sewer Connection Loan Program). For loan specific questions, you may contact Kathleen Girouard, Growth Management, at 508-862-4702. CONTRACTORS: Information on Licensed Sewer Installers is available on our web site at www.town.barnstable.ma.us/PublicWorksTecii/sewgrinstalIers. Contractors, approved to perform sewer connection work in the Town of Barnstable must obtain and file a Sewer Connection Permit with DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis —contractors, please call Dave Anderson at (508) 790-6244. FOR ANY QUESTIONS /ASSISTANCE: Len Gobeil at the Town Manager's Office is available to provide you with direction you may need in reference to the Stewart Creek Sewer Connections. You may contact him at 508-862-4701. QASEWER connect\Letters Stewart Creek Sewer ConnectsWAILING LetA Sewer 2Pgs Merged 3-28-13 Yr2015.doc COMMONWEALTH OF MASSACHUSETTS UD Z EXECUTIVE.OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION RECEIVED NOV 6 Z003 TOWN OF BARNSTABLE ' TITLE 5 HEALTH DEPT. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: `, J� ��� l QYF'I �. r IVIAP Owner's Name: r kayi Owner's Address: :�� PARCEL LOT Date of Inspection: � o Name of Inspector: (please print) Company Ni Mailing Address: , 64 Telephone Number: 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: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails 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. Notes and Comments ****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: 07 " P Y 0,1 : Owner: Y ✓� Date of Inspection: Inspection Summary: Check A,B,C,D or E./ALWAYS complete all of Section D A. System Passes: z� 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;tlo G Tnc-a f;^"17^—4/1 Vlnn I 2 Page 3 of 11 OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection-. 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 heaith,safety or the environment. 1. System will pass unless hoard of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning'l(T a manner which will protect public health,safety and the environment: Z _ Cesspool or privy is witlirc�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 Heal h.(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a'surface wateh,,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 aseptic tank and SAS and the SAS is les 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 ertified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free om pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less an 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to thi orm. 3. Other: J Titles t Tnenarfinn T:nrm 411 VAIN 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A' CERTIFICATION(continued) Property Address: e tJ r`� i"a l'LGC r44 Owner: Date of In pection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes �! Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ 7 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 cesspool is less than 6"below invert or available volume is less than''/z day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ :Z 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 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.] JC (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'io 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "Yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Tiflo 1;T—.n fine Fin—4/1 rr)nnn 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: iPi, . ✓�(/l Owner: ,i Date of Inspection: 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 V/ 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? v Were all system components,excluding the SAS,located on site V, 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 P _ 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 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(3)(b)] T;tlo Tncnartinn Ti-4/1 G/7nAn 5. Page 6of11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: Pawl ! •, ' Owner: 0 Date of Inspection: r FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): ? 1 DESIGN flow based on 310 CUR 15.203 (for example: 110 gpd x#of bedrooms): 7 L Number of current residents: Does residence have a i finder es garbage (Y or no): Is laundry on a separate sewage system(y s or no): [if yes separate inspection required] Laundry system inspected(yes or no): . Seasonal use: (yes or no): JO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy:-®� COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,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: 4 6 9e r PollC Was system pumped as part of the inspection(yes or no): If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: T_7E OF SYSTEM 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: Were sewage odors detected when arriving at the site(yes or no):A/_ Title G 17nrm 4/1 Vlnn l Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: �/ Gl Owner: 4 Date of nspection: rIV BUILDING SEWER(locate on site plan) r� Depth below grade: Materials of construction: cast iron 40 PVC other explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence f leakage,etc.): In . A SEPTIC TANK:—(locate on site plan) Depth below grade: 1 Material of construction:V 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: Sludge depth: Distance from top oi��ludge to bottom of outlet tee or baffle: 49 Scum thickness: 3 11 Distance from top of scum to top of outlet tee or baffle: Y i Distance from bottom of scum to botto of o tlet tee or ffle: (s 1 How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert, ide a of leakage,etc.): C r v M P 106, d I Yl-r G- 1rarT„j tic,(IV 5ailn - , 1-8yel •e t. GREASE TRAP: i�alocate 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.): Titlo C Tnenortinn 17^—4/1 VIAM 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: Owner: �V Date of Inspection: 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 Uolyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date f last o pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:. P )(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): 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.): T41a G Tncnarfinn 7P^ m f/1 r, nnA 8 Page 9ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: elf, Owner: Date of I spection:� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: - overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): f. o �/ ova 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.): Titles S Tnenartinn Fnrm 411 S/7nnn 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued). Property Address: Owner: pdu,ufj lyh. Date of Inspection: 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. it Titles C Tnv A�f;nn Rnrm 411 VIM11 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:,,) Owner: 9 Date of Inspection: jv SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground wate;.- 5feet 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: 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 establighed the high ground water elevation:) 1 Ll iC �r�1l��i� 6 q2— T41. Tnon fine T+' A./1 VIA01) 11 Sewer Permit No. Location -G S h st lkr's Name nd Address ►�o u t . -YAK F �S Builder's:Name and Address 49D _x Date.Fermis;¢ sued: Dale Compliance issued: i ° t ODD srpztc 't-Ary ic r } 3 F ow p t �sSa;Qs ,i • Sewer Permit No. Nance or Location `G i S O A Installer's Namc and Address �- PY ov ►5 a -(�((Q ✓ln iiGt► (�S Builder's Name and Address Date Permit Issued: ' ®ate Complimwe Issued: W O 1 T V_ o N � C a � �1 �o Fxs... ..._............ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE ' ApplirFation for Elhipvii al Works Tonotrnrtiun lirrutit Application is hereby made for a Permit to Construct ( ) or Repair ("'al Individual Sewage Disposal System at:,J Q '... &_.W.mD..........•...•...•--- ---------------- -- ---------------------------------------------------- a Lo ation-Address or Lot No. Ownerdd Add(r ; a ............. 4 --�SL4Sl.4a = 4Z....-- cLt- {---------- .............. ".4....... kS�!!A11 .Installer Address d Type of Building Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms.....-----------------------------------Expansion Attic ( ) Garbage Grinder ( ) U 0.i Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures -•-•---------------------------------------------- W Design Flow........�_5.-cS'_________________________gallons per person per day. Total daily flow....... C)........................gallons. WSeptic Tank—Liquid capacitytCW—_gallons Length.... Width....q........ Diameter---------------- Depth................ x Disposal Trench—No... Width.........:.. __ ........ Total Length__ a •.... 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.....:_-------.......... (? Test Pit No. 2................minutes per inch Depth of Test Pit.........-- Depth to ground water........................ a --------•---------- --------------••--------------------------------------------•-----------------------------------------------------•---------------------- 0 Description of Soil.....----•----------------•-•-•----....---------•-------•--•••--•••••------••.........-----•-••----=-----------------------------•-•-----------------------•----------- x W ------------------------------------------------------------------------------------------------------------------------------------------------------------•-------••---•---•.....-•••--......-•••---- V Nature of Repairs or Alterations-Answer when aplicable._Zt� 1L713 .�c AC_ ..... Agreement: 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 Com 1' ce has een ' d by the board of health. Signed ------------------- Daze Application Approved BY V 7 8 - Da"�C�= Application Disapproved for the following reasons- ----...................................................................................................---------------------------------- ..----_--_--..-_..........-_...................................... .........------------------------------------------------------------------------------------------------------------------- ----------- ' Date-------------- PermitNo. .......... Q.... /-.�7.............. ... Issued -----------------------------------------_...................... Due x No .3-y-`'--- Fmc.............................. THE COMMONWEALTH OF MASSACHUSETTS s BOARD OF HEALTH - TOWN OF BARNSTABLE Appliration for Di-oposal Works Tonotrn.rtion ramit X Application is hereby made for a Permit to Construct ( ) or Repair (k,�an Individual Sewage Disposal System at,-.5-9 Location-Address -or Lot No. Owner A W dress Installer Address � S � Type of Building Size Lot___________________________ q. feet U DwellingNo: of Bedrooms...._�............................:....Ex Expansion Attic— � p ( ) Garbage Grinder ( ) aOther—Type of Building ............................. No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures -------------------------------- ----------••---------------•-•--•--------------- ------•------•-------•------•--•------------••---:............--- W Design Flow........' ! .......................gallons per person p`r-day. Total daily flow------- : .......................gallons. WSeptic Tank—Liquid cape. Z gallons ITength................ Width&-•fit....... 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 ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I....... .......minutes per inch Depth of Test Pit.................... Depth to ground water---._.................. f34 Test Pit No. 2...............minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 --------------------------------------------------•-----•-•---------------------------------.----------------------- -........ .-------- -----------..... Description of Soil .. ------------- ---•---------------------------------------------•-- --•- ------- ......-----------------i------------.....'��` � � U Nat re Rep Js o ltcer(t-n.§ A sv�e wh` �ppli�ca i�e�`z !�/� .......................... ----------------------------........................................................................................................................................................................ __. Agreement: e* 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 C6n+P7fia:n: e has- (e is Ie iD4 s d d f health. Q 3 Z O I Signed -------- ----- ............... ....... ... ........................---................... ........................................ Application Approved B � 8 [r^qG pp pp y ------. ..... v ... ---------------------------------------- Date_3 Application Disapproved for the following reasons: .. --- ----------------------------------- ------------------------------------------------------------ j. Date PermitNo. � ............................................. Issued ------------------........------------------------------- .-- -- Date � i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (ger#tftrate of C ontlatinure c� THIS IS TQ C&&V,TIFY, the jp4irjdukKSewage Disposal System constructed ( ) or Repaired ( ) by .................................................. ......... ..........................-. ���.. 16st6 cr' at -------------------------------------------------------------------------------------------....................................................... --------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 o he Sat. nvironmental Code as described in the application for Disposal Works Construction Permit No. .............0................--- ----------- dated -------------........------ ------...--- -- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. Q / v DATE............./--"' ../.�f................. h'S - Inspector ? s�-- ....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 35' No...... FEE........................ Movasal � nix �erntt# Permission is hereby granted..4—�••-•...............................•...----•--•----•----........---.....................---.................................... to Construct ( ) or-!eNir (,6�ap-710vidijX;ScWage DiVa§al­SYsterfi atNo...............................•-----..........---•--...........--•---......-----•------........_.......---------•-----------...-----...---•-----........--•---.-•------------.-------- Street yjr��i L— as shown on the application for Disposal Works Construction Permit No..../..!_/._. / J Dated.......................................... --------------------------------- Board--of-- -----ealth--..:.........................---......... H DATE............................................................................... FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS