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HomeMy WebLinkAbout0007 CHRISTINAS PATH - Health 7 Christina's Path 71 Hyannis A=.250-097 f 0? 2 - DATE: ? I' PROPERTY ADDRESS: •7 Clt4•stinals Path Hyanrris ,Mass . �� Vol 1 1 02601 . 999 `ri o,� 6 On the above date, I Inspected the septic system at bove addr '6"8 Thls system conslsts of the tollowing: E 1 . 1-1000 gallon septic tank . , 2 . 1—Distfibution box. 3 . 1-1000 gallon leaching pit . Based bn my Inec�actlon, I certlty the following conditions: 4 . This is a" title• fivd septic system. •(•••76r Cold ) ' 5 . The septic system ,-is in . proper. wo•rking order at the ,present time/ 6 . Pumped septic tank as part of inspection . 810NATUM7, Name : J P_Macomber Company:_J. P.Macopber & Son' 'Ync • i r _Q2b32 Phone: __:.S48_.LZ7��338_______ •. 1 THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANT Y TJOSEPH P. MACOM�BER '& SON; INC, T+nkkCs u pool i-Le achIIaIdi . PUmp+d 11 Instilled ' • Town Sewer Connectlons P.O. Box 66' Centerville, MA 02632.0066 I 77.5-33M M7 412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commi ioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 7 Christina ,' s Path Name of Owner Steve Pereira Hyannis ,Mass , 02601 AddressofOwner: 7 Christina ' s Path Data of Inspection: 2/12 9 9 Hyannis ,Mass . 02601 Name of Inspector:(Please Print) J o s e p h P M a c o m b e r J R. I am a DEP oved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: J T Macomber & Son Inc . Ma&VAddress: Box 66 Centervi11e , Mass - 02632 Telephone Number: 6 0 R—7 7 5—3-318 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: 4�Passes Conditionally Passes _ Needs Further Evaluation By the Local Ap oving Authority _ Fails Inspectors Signature: .+ Data: p /v The System Inspect all submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (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 Department otrEnvironmental Protection. The original should,be sent lovte system owner and copies sent to the buyer, if applicable, and the approving authority. . NOTES AND COMMENTS revised 9/2/98 Page 1 of 11 i1 Primed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Christina ' s Path Hyannis ,Mass . Owner: Steve Pereira Date of Inspection:2/12/9 9 INSPECTION SUMMARY: Check A, A C, or A A. SYSTEM PASSES: .. t I have not found any Information which Indicates that any of the failure conditions described in 310 CMR 16.303 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. Indicate yes,no,or not determined(Y, N. or NO). Describe basis of determination In all Instances. If "not determined", explain why not. The septic tank is metal,unless the owner or operator has provided the system Inspector with a copy of a Certificate of Compliance(attached)Indicating that the tank was installed within twenty(20)years prior to the date of the Inspection; or the septic tank, whether or not metal,is cracked,structurally unsound,shows substantial Infiltration or exfiltration, or tank failure is Imminent. The system will pass Inspection if the existing septic tank Is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass Inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced • The system required pumpirfg-more than four-times a year dua to broken or obstructed pipe(s). The vysrsm vAt-jMss-- Inspection if(with approval of the Board of Health): - - -- broken pipes) are replaced obstruction is removed r revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 7 Christina ' s Path Hyannis ,Mass . Owner. Steve Pereira Date Of kwP*cdw: 2/12/9 9 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 protsct the public health,safety and 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.WILLPR01ECT THE PUBLIC KEALTKAND SAFETY AND THE EMaSONMENT: t//4 Cesspool or privy Is within 60 feetof surface water �14 Cesspool or privy Is within 60 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPUER.IF ANY)DETERMINES THAT THE SYSTEM tS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 60 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 60 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well Is free from pollution from that facility and the pres9nce of-ammonia nitrogen and nitrate nitrogen is equal to or less than 6 ppm. Method used to determine distance (approximation not valid).- 3) OTHER NA NA Ally revised 9/2/98 Page 3of11 I SUBSURFACE SEWAGE DISPOSAL AYSTEM INSPECTION FORM PART A CERTIFICATION (coffdnued) Property Address: 7 Christina ' s Path Hyannis ,Mass . Owner: Steve Pereira Date of Inspection: 2/12/9 9 D. SYSTEM FAILS: You must Indicate either "Yes" or"No" to each of the following: Q I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the faflure. Yes No/ Backup of•taewage irrtoiaci6"r••eTetemcomponertt•due tto an overloaded orclogged-SAS,•or-ceaspvd. =�•-- ZDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or dogged SAS or / cesspool. Y Static liquid level in tl�e distr' ution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ Liquid depth in ceespoeHs less than 6" below Invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Q. Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy Is within 50 feet of a private water supply well. it 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for ••coliform bacteria, volatile organio•compounds, ammonia nitrogen•and nitrate nitrogen. - E_ LARGE SYSTEM FAILS: 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: A)D The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system Is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No /j I the system Is within 400 feet of a surface drinking water supply ill _ the system•I&-within 200 feet•o�arY-to asuctaoadrir►kisaQ awtar-wpplY•�••- - -- - 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. i revised 9/2/98 Page 4of11 I i i i SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 7 Christina ' s Path Hyannis ,Mass . Ownw: Steve Pereira Data of Inspection: 2/1 2/9 9 Check If the following have been done:You must Indicate either'Yes`or'No' as to each of the following: Yes No,� Pumping Information was provided by the owner,occupant,or Board of Health. _ None of the systemcomponants iwmw:b sn poa►wd4*PatJaasi two•aw9Ww and`the'rystam hasbaeoasceisiwy weasel flow rates during that period. large volumes of water have not been Introduced Into the system recently or as part of this Inspection. _ As built plans have been obtained and examined. Note if they are not available with N/A. z _ The facility or dwelling was Inspected for signs of sewage back-up. ZThe system does not receive non-sanitary or industrial waste flow. 4 _ The site was Inspected for signs of breakout. _ All system components,lieluding the Soil Absorption System,have been located on the site. _ The septic tank manholes were uncovered,opened,and the Interior of the septic tank was Inspected for condition of baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge, depth of scum. The size and location of the Soil Absorption System orrthe site has been determined based on: Existing Information. For example, Plan at B.O.H. _ Determined in the field(If any of the failure criteria related to Part C is at Issue,approximation of distance is unacceptable) (15.302(3)(b)) The facility owaar.(and.a•crpsat-.1f diffareci ff0[Ji--narJ.Wara4xauWa with[nfnrMRTjOMDn tha Pinnur mnlr,tar+..,.•e Qf SubSurface Disposal Systems. I revised 9/2/98 Page Sof11 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Prop"Address:7 Christina ' s Path Hyannis , Mass . Owner: Steve Pereira Date of Inspection: 2/12/9 9 FLOW CONDITIONS RESIDENTIAL: Design i-ow:� -g.p.d./bodrQpm. Number of bedrooms desig ) Number of bedrooms(actual):9 Total DESIGN flow Number of current.residents: Garbage grinder(Yes or no): Laundry(separate system) (Yes or o : J&; If yes, sepamte-Inspection.required Laundry system inspected ( es Or(9 Seasonal use(yes or no): Water meter readings,if ava liable(last two year's usage(gpd): ho Sump Pump(yes or no): Last date of occupancy: 4 -4 CO M M ER C IA LIIN D U S T R IA L: Type of establishment: Design flow: AIA gad ( Based on 15.203) Basis of design flow Zd Grease trap present: (Yes or no)-&If Industrial Waste Holding Tank present:(yes or no)V Non-sanitary waste discharged to the Title 5 system: (yes or no)-AR Water meter readings,if available: yA Last date of occupancy:—(Z OTHER:(Describe) Last date of occupancy: IfIll GENERAL INFORMATION PUMPING R CORDS nd source of information: ,Uno 7✓ok AF 7,50,e oZ System pumped as part of inspection: (yes or no) !� If yes, volume pumped: also s �n1 Reason for pumping: )' JCLf/yl �CJSIye�S' TYPE O SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool 7 Privy Shared system(yes or no) (if yes, attach previous inspection records,if any) 1/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank /���,,DD Copy of DEP Approval Other APPROXI TIE AGE of all components, date installediif known)-and source of4nformation: Sewer odors detected when arriving at the site: (yes or no) I revised 9/2/98 Page 6orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Christina ' s Path Hyannis ,Mass . Owner: Steve Pereira Date of trupection:2/1 2/9 9 BUILDING SEWER: (Locate on site plan) Depth below grade: Material of construction: cast iron Z0 PVC—other(explain) Distance fro private water supply well or suction line Diameter Comments: (condition of joints,venting,evidence offeakage,-etc.) - Joints appear t ' ventecl ttirou4li the house SEPTIC TANK• lt, (locate on site plan) Depth below grade: Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is(natal,list age Js.age.confumed by Certificate of Compliance(Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee orbaffle: Scum thickness:_ r Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottoloh of outle tee or baffler How dimensions were determined: Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles, depth of liquid level In relation to outlet invert, structuroHntegrity, evidence of leakage,etc.) Pump tank every 2-3 s p a r.g T n l e t & e tl t1-e t tees are inplace . Thp tank ; g atr1irturally seuad , ale evidenee of 1pakaoP GREASE TRAP: /e, (locate on site plan) Depth below grade: Material of construe concrete metal /jFiberglassN4Polyethyleneflother(explain) Dimensions: 114 Scum thickness: _ Distance from top of scum to top of outlet tea or baffle: Distance from bottom of scum to bottom of outlet tee or baffler Date of last pumping: lix I Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) Grease trap is nnr Irp.gpnt revised 9/2/98 Page 7or11 SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Prop"Address: 7 Christina ' s Path Hyannis ,Mass . Ownw: Steve Pereira Dou of InsPection:2/12/9 9 TiGHT OR HOLDING TANK://. L(Tank must be pumped prior to, or at time of, Inspection) (locate on site plan) Depth below grade: Material of construction:�concreteNRmeta) /�Rberglas4.(APolyethyleng4�iother(explain) Dimensions W —_ Capacity: d2d gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:YesVf NoW Date of previous pumping: A•h_ Comments: (condition of inlet tee, condition of alarm and float switches,etc.) 1Q t or holding tanks are nnt _lrPcant DISTRIBUTION BOX:-k-l", (locate on site plan) Depth of liquid level above outlet Invert:�� Comments: (note-If level and distribution is*quad, *videnoo of solids carryover, evidence of leakage Into or out of box, etc.) — — Distribution box hng nnp Intpral Nn pvirlcnrp of golids PUMP CHAMBER-/f�� (locate on site plan) Pumps in working order:(Yes or No) NA Alarms in working order(Yes or No)_N A Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) uMD chamber is not prPGent _ i revised 9/2/98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART d SYSTEM INFORMATION(c rd wed) Property Address: 7 Christina ' s Path Hyannis ,Mass . owner: Steve Pereira Date of Inspection: 2/12/9 9 SOIL ABSORPTION SYSTEM(SAS): &0a (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: ! leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields, number,dimenslons: overflow cesspool,number: 0 Alternative system: /,� Name of Technology: &/a' Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil, condition of vegetation, etc.) Loamy sand to medium fine sand , No signs of hydraulic fni 1 iira nr i nnr)i ng Qni 1 i Q nnt- rgmp Al 1 Al nn 3.8 Fi Of f$a-1 . CESSPOOLS:&Jt/E' (locate on site plan) Number and configuration: _ Depth-top of liquid to Inlet Invert: AA Depth of solids layer: Depth of scum layer: Dimensions of cesspool: AA Materials of construction: _ Indication of groundwater: Inflow(cesspool must be pumped as part of Inspection) esspoo s are not -present . Comments: (note condition of soil, signs of hydraulic failure.Ievel of pondiny,condition of.vagetation, etc.) Cesspools are not present . PRIVY:Ab4lL (locate on site plan) Materials of cons u tion: Dimensions: Depth of solids: Comments: (note condition of soll, signs of hydraulic failure,level of ponding, condition of vegetation,etc.) Privy is not present . revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 7 Christina ' s Path Hyannis , Mass . Owner. Steve Pereira Date of Inspection: 2/1 2/9 9 SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes Into house) I revised 9/2/98 Page ioorn SUBSURFACE SF DISPOSAL SYSTEM INSPECTION FORM PART C SY: ; INFORMATION(continued) P.op"Addre": 7 Christina ' s Path Hyannis ,Mass . owner: Steve Pereira Date of kupeation:2/12/9 9 NRCS Report name Soil Type_ Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow r. :rate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater Feet Please indicate all the methods used to determine High G: Nater Elevation: Obtained from Design Plans on record Observed.Site(Abutting property, bservation hole. :meat sump etc.) Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records / (/ Checked local excavators,installers Used USGS Data Describe how you established the High Groundwater Ele. (Must be completed) Used water Contours Map . Gahrety & Miller Model 12/16/94 revised 9/2/98 page llorn op ]•.RtT1TI rnrrr•rr's.arrmr•nTRrrTlm rerrs+lrr.7e•rt�sr►tA*�*nm fnT.Pa=.+a7r.a�l.rs Tsr•nrr-1rT+e�:..t-.r•.,F TOWN OF Barnstable WARD OF HEALTH 1 �- �-•rn-r••.-: —�,,T�.-�,)SUIIFACR SEWAGE-DISPOSAL SYSTEM INSPECTION FORM - PART D^- CERTIFICATION '• -TYPE Olt PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 7 Christina ' s Path Hyannis ,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL # OWNER' s NAME Steve Pereira PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber Jr . COMPANY NAME J. P.Macomber- & Son' Inc . COMPANY ADDRESS Box 66 Centerville ,Mass . 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: t// Systeui PASSED ` The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con Lcted has found that the system fails to protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature �� Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the I30ARD' OF HBAL711. * If the inspection FAILED, the owner or operator shall upgrade the eyetem within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 . 305 , partd .doc TOWN OF BARNSTABLE LOCATION 7 Cx�o,, (S SEWAGE # VILLAGE n!I S ASSESSOR'S MAP & LOT �• 'S NAME&PHONE NO. Ida SEPTIC TANK CAPACITY /OOO LEACHING FACILITY: (type) 000 (size) NO. OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 31s 199 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 � I TOWN OF BAR.NSTABE LOCATION � a R i S T l f 1 R S i ,W SEWAGE* Pt(- VILLAGE, t Y H/)Y)i S ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. t�► C.� Can s fi �`'��' C� SEPTIC TANK CAPACITY l DOO i LEACHING FACILITY: (hype) ' ick �j� (size) 6;< NO.OF BEDROOMS `` 016. BUILDER OR OWNER -�J 6 K e— PERMTTDATE: COMPLIANCE'DATE: '�� .�_ Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 ' } 1 i . No. ` L C O v7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for )Digpogat *pgtem Construction Permit Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and Tel.No. Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures I Design Flow gallons per day. Calculated daily flow -3-3 D gallons. Plan Date Number of sheets Revision Date Title Description of Soil li'!tl-e_C-,S V-t-0 Nature of Repairs or Alterations(Answer when applicable) lay( Q 1 — (1✓1�l �g01n�. '`(—Q &� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Bo Signed Date Application Approved by + Application Disapproved for the following reasons M Permit No. �" Date Issued---------------------------- s ...,.ti�. ..py. ,,. . .. - ��„.....- ro.n»*r• �.....x.wnr.-.. r-�-.. .:.—.,.;'4ti-�ti+�et'..-,... .. s,.. �..` ,.. .. .- - - r�?. No. / ,� .`J l./ 0(:�7 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION TOWN OF BARNSTABLE, MASSACHUSETTS w 01pplication for �Ditpogal *pgtem Congtruction 3permit Application is hereby made for a Permit to Construct( )or.Repair( an On-site Sewage Disposal System at: Y: Location Address or Lot No. Owner's Name,Address and Tel.No. I f Installer'sName,Address,and Tel.,No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 'Garbage Grinder( ) Other Type of Building t No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallon per.day. Calculated daily flow C� gallons. Plan Date Number of s"I�et 1 `etsionDate Title Description of Soil _Q } Nature of Repairs or Alterations(Answer,,when np�licable) 0 (P Ale, L Date last inspected: " fit' s Agreement: r Sir �t. V}� ("! r z 1 r f� fir- � ... . The undersigned agrees to ensure the construction an at an of the afore describe on-site sewage dtsposalsysterr ` in accordance with the provisions of Title 5 of the Environ: en al Co to' T�ce Che s, stem in operation until a Certifi- cate of Compliance has been issued by this Bo ©f-)Ie t Signed Date /c Application Approved by Application Disapproved for the following reasons Permit No. "'° Date Issued e a. 1 THE COMMONWEALTH OF MASSACHUSETTS � PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Certificate of Con�Priance THIS IS TO CERTIFY,that th n-site Sewage Disposal System installed( )or repaired/replaced,( )on .a by for S►la k-2_ VV C- ft c,,q a iV as r --r-t S v4T f�- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.? dated Use of this system is conditioned on compliance with the provision forth below: .r F No. °'°" �� e� THE COMMONWEALTH O MA&SS CHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE. MASSACHUSETTS Mi!5Po!6a1 6 stern Construction Vertnit Permission is hereby granted�to � to construct( )repair( an On-site Sewage System located at 2 C ir 1 •SC �wTlf- 14 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. All construction must be completed within two years of the date below. Date: Approve yam• i .i CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION I'ERi1111'(WI TIIOUT DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated '�� j-�i(� , concerning the property located at 7 CAX s i«.5 meets all of the following criteria: • There are no wetlands within Soo reel of the proposed septic system • There are no private wells within 15o rector the proposed septic system The observed groundwater table is 14 rect or greater below the bottom or the leaching racillty • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. SIGNED: DATE: -`f`�� LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch plan orthe proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submittcdl. J s, ��' 1 e Q � � _, � � �.� ____ � ® o �� O � �1 a o ,� 'r i o � C q� O 1 G iih / f S .Al. <, o a. j lc4 t 'Z�7 1' ik '1D- Ar, /rafuvt ` L�X��rt/0Tt r�jt � + _01� k y"y,. +�'{a7a.�* F�� h. ��',� i l ��a :ti$ l Y x::• 3�k�k iiry� Y4 NI iJaJ. r W M .i•"kA+^S°','wF,'d•+Yr "wi; » i>! r _.�• •S '4' a J a r u+.Y'ka„f y lFst41° f l 1Y as _/ T Ir' h �yL //7 �� I /, h,d�sk r F 9�';w, ��.�" "N n i f '� .t 'r a • i �^0oleI S T W' r } i CERTIFY THAT THIS PLAN.' HE TwS- THE ACTUAL LOCATION OF STRUCTURE ON THE LAND AND D F .�iy �Ta u.5` etrr'ek � :;tr- ;tiy-,L ' 7•t Y> Js�1 S "1 THAT IT CONFORM---�ViTH—TH BY-LAWS OF THE 7WN loll!17�, .-,A OF A1,41WK � FRANK 14 r^ c FRANK -+ to d CONERY a CONERY ;A No. 6513�O No. 6232 40 `• V�FG/sT 1p! p' sT��` o� \Fss�oN.��E` SCALIE 1 iN !7 1) SURv