HomeMy WebLinkAbout0258 COMPASS CIRCLE - Health 258 Compass Circle
A=310-394 ti
Hyannis i
m
e
TOWN OF BARNSTABLE
LOCATION Cotyl p255 Ct M ' SEWAGE# OrI09,0—/'70
VILLAGE ASSESSOR'S MAP&PARCEL 3 iO
INSTALLER'S NAME&PHONE NO. tr tV)C0y ,3 InJC
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) a 5_OOo ,,n CkO46_5 (size)
NO.OF BEDROOMS' J
OWNER iffy Oe- (,g
PERMIT DATE: COMPLIANCE DATE: "
Separation Distance Between the: /IjON��#'�iswe
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility O fC 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
1 FURNISHED BY"_b C_ok
Z N
f-
ELL
13
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No. � � Fee &V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Apphtation for Disposal 6pstrm Construction permit
Application for a Permit to Construct( ) Repair(")/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Ad ess or Lot No. 2<66ex4p +Ss ZA,-C/& Owner's Name,Address,and Tel.No.
/I ycV4,%
Assessor'sMap/Parcel Pe rat
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
V A 5rCW1V-TVC S - dO-K3 valid A4s6,j
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building )?-V l(�n1 f'/Ct No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) '3 30 gpd Design flow provided 3 yy gpd
Plan Date S^oZ(� -a�c�l0 Number of sheets J Revision Date
Title
Size of Septic Tank xj /N Type of S.A.S. .2 N {0 (ak/S tol- ,6we
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)_„ IV/) 42-//-/0 SW" 'If A71 C''/J,8.3 I`
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signed Date 4'-7-,90dj
Application Approved by Date �' O
Application Disapproved by Date
for the following reasons
Permit No. P--,o �L a I Date Issued —(0 — /2`�
jj•'$. '. fir._. . . t � ''F� «., _ ` �.
` F
No. V ? Fee 0 V
THE COMMONWEALTH OF"MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION.- TOWN OF BARNSTABLE, MASSACHUSETTS
fiplication for disposal *pstrm Construction Permit
Application for a Permit to Construct( ) Repair(,-�/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 2 5'8tcmjoo s 61 r&le Owner's Name,Address,and Tel.No.
d Y&V viS
Assessor's Map/Parcel 3za /� f� /G C
jf
Installer's NName,Address,and Tel.No. Designer's
1N me,Address,and Tel.No.
VA, / cwl,^ ;. c s -t1do-" VU d%(l G Al
Type of Building:
Dwelling No.of Bedrooms .3 "� / Lot Size �� v �sq.ft. I Garbage Grinder( )
Other Type of Building o5 drrj f/G/ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) :3 30 gpd Design flow provided 1 yy gpd
Plan Date ,S" 2(, a��.h Number of sheets Revision Date. 4'f
Title ' L
p Type
Size of Septic Tank �xi f/N< T e of S.A.S.
Description of Soil r r`
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 Health.
Signed Date
Application'Approved by_ Date /.0
Application Disapproved by Date
for the following reasons
Permit No. �9--0 /L 0 — 177 y Date Issued 6—(o 2-C)
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS "
BARNSTABLE,MASSACHUSETTS
CPrtlfirate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by a1L"V 1,1.4r
at V�9� /;-W A< f1,ic r ii C le has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.e���' �dated —
Installer��A,1�(n�t�Il NC Designer �,,,.1, / /�MA
#bedrooms 2 Approved design flow gpd
The issuance rro thi permit shall not be construed as a guarantee that the system i `€unc� on as des'gned. rn
Date P t l 1 Inspector
No. 2.v Q Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
1 MIsposar *pstrm Construction Permit ~.
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at
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:Construction must be completed within three years of the date of this permit. ITZt �M C
Date �n= ''i'} Approved by �;,�17 ( J
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DAVID
M
COMMONWEALTH OF MASSACHUSETTS
EXECU-TIVE OFFICE OF ENVIRONTMENvI'AL AFF^7RS
` J DEPARTMENT OF ENVIRONMENTAL PROTECTION
1 7 _tl
d
o,M SYOv`e
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME\TS
SUBSURFACE SEWAGE DISPOSAL SYSTEA1 FOR11
PART A
CERTIFICATIO
Property Address: z?:,- o#-74A." Co 4e-
.,yv S�,, I C7)
Owner's Name: f G Leve,-v N
Owner's Address: Grr
// oa c o
Date of Inspection: c! c)
)� / di
Name of Inspector: (please print) zz
Companv Name: Z; f tvli
Mailing Address: c
Oa 6 Z/12. ,T
Te ephone Number '- S_ 79�?
CH�RTIFICATION STATEMENT
I ce3trfy that I have personally inspected the sewage disposal system at this address and that the information reported
b lc r is true, accurate and complete as of the time of the inspection.The inspection was performed based on my,
o a ;ng and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
oved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
V Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 2?1 /4-z7," Date: 611110
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 approz-ng
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
i
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS�IENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-1-81
PART A
CERTIFICATION(continued)
Property Address: C� sy 1! O �-u
// __ A h�� i¢ OaZ p
Owner: Lel���n , '
Date of Inspection: !/
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sjvs asses:
Vp
I have not found any information which indicates that any of the failure critr
eria described in 310 CNIR
15.303 or in 310 CMR 15304 exist.Any failure criteria not evaluated are indicated below_
Comments:
B..(. System Conditionally Passes:
V 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.Svstem 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(truth
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 s:-stem ED
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
f
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO\ FORM
PART A
/CERTIFICATION(continued)
Property Address: SSA
a on'
Owner: p r
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 health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 C1VIR 15303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ 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 I 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 pprr 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 aiSSESSMI E.NTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNI
PART A
CERTIFICATION(continued)
Property Address: C;z Li? CO 07 ASS 6111C le
/ N 0,2601
Owner: L�fi2ro
Date of Inspection: // OF
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
logged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
esspool
iquid depth in cesspool is less than 6"below invert or available volume is less than day low
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).\umber
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
eater supply. .
ty portion of a cesspool or privy is within a Zone 1 of a public well.
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]
/" O (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)
ys
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—M;7P ) or a mapped
one II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant throat,or ans-,�,ered
"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 xk,�t'n-1_0 C!Vf-R
15.304. The system owner should contact the appropriate regional office of the Department.
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS-A11ENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: S9
�, v►Hi O,Z 60l
Owner: Zekyl- 4
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes =o
/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?
V Has the system received normal floats in the previous two week period?
V Have large volumes of water been introduced to the system recently or as part of this inspection ?
r/ Were as built plans of the system obtained and examined?(If they were not available note as\,A)
Was the facility or dwelling inspected for signs of sewage hack up? .
Was the site inspected for signs of break out?
Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
L' _ 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 deters iced based on:
Yes
Existing information.For example,a plan at the Board of Health.
f
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)]
Pate 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS'IN'IENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNT
PART C
SYSTEM INFORMATION
Property Address: a Sg �O�''? o+SS �i rC /e,
►�h OoZbO/
Owner•
Date of Inspection:
IFLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual): "
DESIGN flow based on 310 CMIR 15.203 (for example: 110 gpd x_#of bedrooms): .3.20 -4--
Dumber of current residents: ()
Does residence have a garbage grinder(yes or no): /VO D
Is laundry on a separate sewage system(yes or no):AIV [if yes separate inspection required]
Laundry system inspected(yes or no):kV F,le
Seasonal use: (yes or no): /f"O /fo
Water meter readings, if available(last 2 years usage(gpd)): /J
Sump pump(yes or no):�j�
Last date of occupancy:
4
C0NLVIERC LA,L/I3SDL STRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Crease 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 IiV-FORMATION
Pumping Records /
Source of information: /(/° 7`' �-4-,A Cf OZ � � �mot— e
Was system pumped as part of the inspection(yes or no): /U
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pu ping:
TYP 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 conTact(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components, ate ' talled(if knowW and source of information:
Were sewage odors detected when arriving at the site(yes or no):i(/O
T:41a G T.,._-_+._
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: C;2rOw'S �r
�.nrtr O�ib O/
Owner: Love".,
Date of Inspection: rp 111447
BUILDING SEWER(locate on site plan)
Depth below grade: �� /
Materials of construction:_cast iron _16 PVC_other(explain):
Distance from private water supply w--ll or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(� locate on site plan)
Depth below grade:
Material of construction:_cZ/onerete_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: 0
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle: 027
Scum thickness: l—a �/
�i
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bolt° 9f outlet toe-or baffle:/
How were dimensions determined: p o Z' R` - Y`�Vf e—
Comments(on pumping recommendations,inlet and o tlet tee or baffle condition;structural integrity, liquid levels
as lated to outlet invert;e idence of leakage;etc.): 441
N d'7 r h O or 7 .5 (WI
/t d a ov, � �a✓I, /l/'0 20.
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 mite gri , liquid level
as related to outlet invert, evidence of leakage,etc.):
741. 1Z 7...... C.._� cncinnnn '7
Paae 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR-1
PART C
SYSTEM INFORMATION(continued)
Property Address: c rG
G N.al DoZ-LO/
Owner: H
Date of Inspection: / 0�
TIGHT or HOLDING TAI K: IV (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(ex:plain):
Dimensions:
Capacity: gallons
Design Flow: Qallons/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: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:e6/-Vt'1 c;;,�—
Comments(note if box is level and distribution to outlets equal,any evidence of solids carnTover.any etridence of
leakage into r out of box,etc.):
�oY_ L-evr,A, 7l/49 so/rCs
PUMP CHAMBER: /y (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.):
A
T:fte G Te
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS?-TENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORXII
PART C
r-F SYSTEM INFORMATION(continued)
Property Address: �J
01n( o2)6o/
Owner: ,�2fio�oti jltpl-
Date of Inspection: '6 /
SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Tvpe 6 x 6 ee - C�►s
leaching pits,number: // )
leaching chambers,number: A, 7'
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.):
0 Si o �Gk A F--r k,-e.
CESSPOOLS: /y (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 vegetanon_etc.):
PRIVY:/!i (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 veae:tariou. etc.';:
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNT_XRY ASSESSNIENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA=I
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner: A/O/o✓�.
Date of Inspection: /
SKETCH OF SEWAGE DISPOSAL SYSTEM
Pro,6de 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.
2_
eta- 1
/�j - a3
Z3 - Zf/
T;tle c T—..a..+,...r,....... 411 ci^)nnn 10
Paee 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS-IMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
P ART C
SYSTEM INFORA'IATION(continued)
Property Address:
Owner: Ldv�ra�I
Date of Inspection: // n
SITE EXAM
Slope
Surface water�ip
Check cellar V r
Shallow wells
Estimated depth to ground water feet
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:
Ob ed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: - f
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You mu de ibe how you establish d e high around�; ter elevation/: '
o kv w/ SCE rT ON ( ' e- Id- /LO
Town of Barnstable
GF tNE 1p�
Regulatory Services
* BARNSTABLE, ; Thomas F. Geiler,Director
39- A Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number
of bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
Q:\SEPTIC\Disclaimer Private Septic Inspections.DOC
LOCATIO SEWAGE PERMIT NO.
VILLAGE
INSTALL R'S NAME & ADDRESS
'BUILDER OR OWNER
DATE PERMIT ISSUED y .oZf
DATE COMPLIANCE ISSUED
;` # ; r
4
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THE COMMONWEALTH OF MASSACHUSETTS /
a BOARD OF HEALTH
�R�P.� -9isL
�Appliration. for 11ispustt1 Works C onstrurtiutt Frrutit
Application is hereby made for a Permit to Construct ( 5<) or Repair ( ) an Individual Sewage Disposal
System at:
................. •......ddre...
.......................... ...... ............ ----••-•-------------•----------•----•--...........-••-••----............
cati n,- ddres or Lot o.
•... 4 ?...... 4--------------•---------- ..... 7../ 4AV ,�,� ... y�!!��Sl
Owner. .. ..a f
Installer Address
d Type of Building Size Lot..../.its_ r?......Sq. feet
U Dwelling—No. of Bedrooms.......2................................Expansion Attic ( ) Garbage Grinder ( )
Pk Other—Type of Building ............................ No..• of persons............................ Showers (p(,) — Cafeteria ( )
Otherfixtures . ------------------------------------------------
------------------------
w Design Flow........3_3.o........................gallons per person per day. Total daily flow...........3..3_G.....................gallons.
WSeptic,Tank—Liquid capacity-.ftsta gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No--------------------- Width.................... Total Length.................... Total leaching area-----N S.Z.....sq. ft.
3 Seepage Pit No----------_--_---- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'•' Percolation Test Results Performed by.... ................ Date...
04 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
rx, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Q+' •--••-----••••-•--•-•••--•-••--------•-•.................................................•-•••...--..........................................................
O Description of +-----...... ...... ..........�......r", _ .................................................
x
w
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
.• ••. •••----•---•---••---------------••-•--••-••-•-•-••----......--••--••...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TL IT .;=. 5 of the State Sanitary Code—The under igned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the rd f hea h.
Signed---=,/ f- _ _ `O..7f
Date
Application Approved By-------- A ll-�`'- .,7 .
Date
Application Disapproved for the following reasons:................................................................................................................
.. •-••-•................•----•••••---•---••••-•--•-_...•-•--•----•---•--------------•-----••----•-•------•-•-•••-----._._........................
Date
Permit No......... U_._.... ....-----•..... Issued.....'-1----1-__/' -• ................
+ Date
No......... _ .. Fizz • .r am-Oo
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-• ...................................... .................:......r...........-•-------................••••-
Aptiration for Dtsp i al Works Tnnitrurtion Vamit,
:VA Ap�ficatton is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage, Disposal
System at:
S ..............rt........ ':fP.: '',�A+.C7-s .��I........................`1—i r ......................................�� .. .............................. __
.........:...... ...._.._...
L&ation yAddress`1 r� f -• or Lot No
: ....................
• " �= •l-_t .`:.. �'`�=-f== �' ..°•' .......................... ........ ...ice• ......••.........= �......••••... .....
I J Owner : ' Address
W --�.. �......
Installer Address
Type of Building Size Lot..... .....Sq. feet
U Dwelling—No. of Bedrooms.........:..................................Expansion Attic ( ) Garbage Grinder ( )►�
04
'4 Other—T e of Building No. of persons............................ Showers Cafeteria
a' Other fixtures -------------------•---•...-•-•• .
W Design Flow........_'.. ...?.......................gallons per person per day. Total daily flow__._......................................gallons.
WSeptic Tank—Liquid capacity..!.._._._gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.......... ..' q, ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by....r-. ....:.....f..:. . ..'�rt.� Date.... � .y.... ,._:!_7.- r-._.
a
Test Pit No. I................minutes per inch Depth of Test Pit ................. Depth to ground water........................
Lr, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil. c,l,e i , i',r=i. F.._ ..,f ✓f� r�
x . . •••--........0.-----...•• ............................ ---_• -••--•--••-•.... . ..................................................
U •......••••-••----••••••••-••-••••--•......-•-•..._.......••--•-•••-•••••••••-•----•-•-•_......•••••..........-•-••--•-------•••-----••••-••-•-•-•--•••-......-••••...:................•...................
W
-----------------•-•-••-----•....•••••••-•------•---•--•-•-•-••••••••••••---••-------•-..................•---•••••••••-•••••-••••-••--•-•--•••••••-••---••••••••...•••••••-••-•--••-•-•.............•--
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
••--------------------------•----------------•--•-•-----•--•------------•--...-•------------••.....•--.........----------------------...--••-----------•-------.........................._..._....-•--••
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of:ITL
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... ------11"'_`/.G^•.... .
Date
Application Approved By............: .".? .....___. �''� . f .. 7 ".
-•-•.............•-----•----•.....-••---••-•--------........... .-- -- .
Date
Application Disapproved for the following reasons:..............--------------------------••------•-•-----•--........................•........................
.....--•---------------------•-----........--•----...--------..............------•----•-•....-----•-•••••'--------------•-----------•------••----...---------------------•---------------•---------------
Date
Permit No.......... ` `.............................................. Issued_
Date t
TH;E'gOMMONWEALTH OF MASSACHUSETTS '
BOARD OF HEALTH
...................... OF..........r. .:.. r...: ...................................................
y. Trrtifiratr of Titntphattrr
THIS IS TO C RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
:. .....
Installer �✓
has been installed in accordance with the provi Is ons of TITLE N, j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated.......e....11::A ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector..................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH '
.�� . fir» !��%r ` -.---
•
No............... ••.... FEE.... ..�$.......
Disposal Worka Tonotrodion Prrmit
Permission is hereby granted....``i P_,,- ?` ' 1`4.`j
to Construct or Repair ( �) an Individual Sewage Disposal System
1' Street
as shown on the application for Disposal Works Construction Permit No.....I. . ..... Dated....... .. ..:....................
' ...............•••--•----•---•--------------------------•-----------•---••----.........._._--•...••.---•-
Board of Health
DATE.
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
LL°Y.. rT f'n'(-.®K.w:a,c. .V� .'R_-. /e.Mi14•'�M":MM"YiaNL. s. r..Ail, �.'V'A.K•za.'i•a...rw•..: +Na:" .• .. - ♦a♦ .:b
,�L`� -Ytf n.h_,•.:uP•. .'> �.w h TJ.•.T•.,..L•- JL9/ .. ,'w:r•rt:• w.. •Ae:M'Y... - .. IMa....•�.L'A.'J'a:Ye..4. .. JlQ. i g-W_X% -M/• .. - .. ..
MAP
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12t7V `s" '�C' � ---- - -- _- . ._ _ ___ .. .... - __ .__ . ..-.w.... ._..�....a. • . , , With �. atc E n.Itonrr�:�r,t�!I .. _ ,tr � ::�� "�`c3?)
i r?. yt 1 ` �i• r �r � �' rnSta'rari�?►1 Si'1dr{ :lii{y W h tnea �i. �L' f'n�►. T '� 1- r
", `'Mrd of Health Regulations ,
1 , �� ; ''.'. t :a:.:. �11 t- .�'T'"�'L/ �(a . "f _ Z% Ti'� septic VSte i 3 -o used on Ws i I r, >� d until a lkC ._ised own ;n%ta'!�r i
_ �,.,r � _ @fit' S R' ; 5 p p i; an 5hc1), nut. �2 ins
receives approval and an installation pt�rmit from the town.
t DATE : - _ _ _.. :;� Prictt to installation,lf,e installer shall,.-,rrfy thn iocaticr 0, itilities, See_',' ',,:e se;�Ler Ji I,
vv Z
C ! •- w '` '` �._ I 01)d existing septic components phor tr, instaiii�inr..
t� P ,t ,� j4 1 *i r l A!I gravity sewer pipi(1€;i5 tc ✓?a Ir1Ch j, [ ii! ll7 PVC_ at ?,rLf}" ,If'r foot. "he first feet
J � -:het
- -,e distribution box steal{ b� i@vei• All -:cling connections be glues:.
l,is Sept ir.design olan is n-*It to be :.it for property,in• d,�,Prmittalion or for i:ny;ath.'.
� t 43
, 2� ' ; purpose othHr then the proposed Septic syster,• iostaltatio,
8 LO C- 9'-'s--�-` 5 + All Title V om rents are io meet Title V specifications.
}} � � PQ P
..crr!••arraYrr.•ww�.�+rs►al/iM�/L/1A1I�"r.".` •"- �e�ar� 14-
j t ntcn' f 1 j ,_ Perking, steal)he ptohit�ited aJer Title V cemp,>n�r�ts u t ...• �nCs are i11 cadeci.
! ON KA
�, ' _. 8) The existing ieaching or cesspack shall be pui='ii(`d and €illy'a with-, aterial per T:0? %' '!
abandonment procedures Leaching and cesspco!is) and contaminated soils within the
Proposed SAS shall be removed and set:laced with r.:ear sand Per Title v speci(ica±;-r,:. ;
`--r C� i C( l 7 ; 9s Septic cornporients are to t>e 10' from a �..ater service iirl( sewer limes crosfiing a '.NatA_( Ftit`
r � be sleevedwith an appropriatelysized :=:l,edule u•p PVC withends grouter: ThF '.4'ater serv.e:•.
Pr' civ Inn septic line can be sleeved with the s:ef-vn i'g a distance of 1.0 an
l4C! ----L-1,—, - � J't'-i i�It� rn:isi►1gt' e 'ine
�j~-'�✓ "t" 7r 1'; tf - garbage grinder exists In the structure, It is to be removed if the septic, systern i5 net
de�ignQd to accommodate a garbage grinder.
lh-_ installet is re,,punsible for care of excavation around �' r all utili:ies on the r:� eelr 1•l t
1 �i...1, � �...• a- .,i T lamr}'�^,��'jjj r '.�Iw. 1�•.� l '�.� . ,
pCotecting the structural integrity of all struct,ares aur•ng the installation proc;:s;: 'y� •;ht -,eel .
system.
12; Ti, c,t reCrPSFttts that a septic system car be installed on the property -r,=.F,t.nrg Titir-, '•
3 2 rt:,ciuiremen.ts
�Ir E�RC2gM'~ ATi C'Ar_,t- ``i 1%R00 /SAY 13) The property owner shall review design•, criteria to approve t}'e total number of bedroC:m;20C'
r idesign floov. irista+ialico of the septic system as proposed and receipt of pay, mr-n! for the-
ir cie�.i�•
-- '-TrtNlC .•. shail be deemed approval of the design criteria by the property owner or,agent of.
r, v �, �, 0 `rite val;dit of this ran stall expire with the ex irLition of tits own installation! nermit. issued fort i
- - _ 'i tlt;t plan or the valldit%,of this plan shall expire an the expiration of`the Cer ica~�• �f Co mpliancJ,
}
for ti'ie iflstallat of the propo5(-.-o systp . t:-i this pluo
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