HomeMy WebLinkAbout0107 DOLPHIN LANE - Health 107 DOLPHIN LANE, HYANNIS
A= 268.184
s I
ROY WILLIAMS
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection / (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
I'ropertj Address:
107 Dolphin Lane (' �14
Hyannis,MA
Owner's Name: Adam Hart
Owner's Address: P.O.Box 188
Dennisport, MA 02639 Q
Date of Inspection: March 18,2008
Name of Inspector: Troy M. Williams
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
South Dennis,MA 02660
Telephone Number: (508)385-1300
CERTIFICATION STATEMENT
I certify that 1 lave personally inspected the sewage disposal system at this address and that the information reported
t below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my
training and e)perience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
appi—o%ed sN si em inspector pursuant to Section 15.340 of Title 5(310 CMF2 15.000). The system
Passes
w" Conditionally- Passes
Needs Further Evaluation by the Local Approving Authority
Fails ,.
ti In pector sSignature: 5,�,�, .,,, Date: 3 /l S 10 S
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system_on the Date of
Inspection noted above.
�`•"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 pace I of Ii
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) '
Property Address: 107 Dolphin Lane
Hyannis,MA
Owner: Adam Hart
Date of Inspection: March 18,2008
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be re laced or
repaired.The system, upon completion of the replacement or repair, as approved by the Board of alth,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. not determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(wl er metal or not)is structurally
unsound, exhibits substantial infiltration or exfilhation or tank failure is ' irient. System will pass inspection if the
existing tank is replaced with a complying.septic tank as approved b e Board of Health.
*A metal septic tank will pass inspection if it is structurally noun of 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 t or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settle r uneven distribution box. System will pass inspection if(with
approval of Board of Health):
oken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The sys r required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspecti n if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 107 Dolphin Lane
Hyannis,MA
Owner: Adam Hart
Date of inspection: March 18,2008
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,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 Sup r,if any)determines that the
system is functioning in a manner that protects the public health,sa' y and environment:
The system has a septic tank and soil absorption systei AS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water suppl .
The system has a septic tank and SAS and tl AS is within a Zone 1 of a public water supply.
The system has a septic tank and SA nd the SAS is within 50 feet of a private water supply well.
The system has a septic tank SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". od used to determine distance
"This system passes if a well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatil rganic compounds indicates that(lie well is free from pollution from that facility and
the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteij are triggered.A copy of the analysis must be attached to this form.
3. Other
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
107 Dolphin Lane
Property Address: Hyannis,MA
Adam Hart
Owner: March 18,2008
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_✓ Liquid depth in 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.
_ i/ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
7 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 forma
D (Yes/No)The system faits.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 w 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 ove)
yes no
the system is within 400 feet of a surface drinking ter supply
the system is within 200 feet of a tributary t a surface drinking water supply
_ the system is located in a nitrogen s itive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply ell
If you have answered"yes"to any estion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the la a system has failed.The owner or operator of any large system considered a
significant threat under Sec ' n E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system ow should contact the appropriate regional'office of the Department.
4
Page'5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 107 Dolphin Lane
Hyannis,MA
Owner: Adam Hart
Date of Inspection: March 18,2008
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
Pumping information was provided by the owner, occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks'?
Has the system received normal flows in the previous two.week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back tip ?
Was the site inspected for signs of break out?
✓ _ Were all system components, excluding the SAS, located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
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)]
4 _
t i.`5
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Page'6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 107 Dolphin Lane
Hyannis,MA
Owner: Adam Hart
Date of Inspection: March 18,2008
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based.on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 4/0
Number of current residents: D
Does residence have a garbage grinder(yes or no); /No
Is laundry on a separate sewage system(yes or no):/ut, (if yes separate inspection required)
Laundry system inspected(yes or no):dLLIj
Seasonal use:(yes or no): 14)
Water meter readings, if available(last 2 years usage(gpd)): y7 �dey 4 1104,-t 6� �j8wvv IfiffVvi S
Sump pump(yes or no): ND
Last date of occupancy: Vp.ric.„f
COMMERCIALANDUSTRIAL
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 systeX(yor no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Alo n u u-h 4 w
Was system pumped as part f the spe�yes or no): Nu
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
/Septic tank,distribution box,soil absorption system
Single cesspool
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):
Ap roximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
- v
6 t,
I
Page'7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: Io7 Dolphin Lane
Hyannis,MA
Owner: Adam Hart
Date of Inspection: March 18,2008.
BUILDING SEWER(locate on site plan)
Depth below grade: $ `
Materials of construction: cast iron /40 PVC_other(explain):
Distance from private water supply well or suction line: A114
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: v1(locate on site plan)
Depth below grade:
Material of construction: /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: 6'AID.$
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: a
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;
How were dimensions determined:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):/V6 iJ,.,lt�, O ri' /a�cw al b/r CAC 'U'e
1L•w2_ ✓L..4.!!7:7TG M )A- L J Jr S I I N U"n 0,►1 e, GL(T ✓if L /
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction: _concrete metal_fiberglass col ylene_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 outle/andoutlet
r baffle:
Date of last pumping:
Comments(on pumping recommendations,inl tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leak e,etc.):
7
i
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 107 Dolphin Lane
Hyannis,MA
Owner: Adam Hart
Date of Inspection: March 18,2008
TIGHT or HOLDING TANK: (tank must be pumped at time of inspectio locate on site plan)
Depth below grade:
Material of construction: concrete -metal fiberglass olyethylene other(explain): }
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working orde es or no):
Date of last pumping:
Comments(condition of alarm and flo witches,etc.):
llISTRIBUTION BOX: (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.):
17 13U��laLS �t./c t' u Hal a wa✓lti �,� v,�st rr� ��o �v;G( �„ a
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 umps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 107 Dolphin Lane
Hyannis,MA
Owner: Adam Hart
Date of Inspection: March 18,2008
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,.ex cavation not required)
)
If SAS not
located explain why:
Type
leaching pits,number:_
leaching chambers,number: 13�� ►^'�`✓.
leaching galleries, number: j p, 4 2
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.): 1 /� (
J! ( w ca.. .� G li"1-c.v/i_..v/L. ..` C� J- T- V v�a^ 1.1 z1
_('�t_,lw t.. ca,�" '/��n �W�-L o �4.5 /n P �o.� tN, NO f/� �In c�..� u ty.�✓.s�.v/�L
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site'pI )
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 hydra 'c 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 fail ,Zlevelf ponding, condition of vegetation,etc.):
I :
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
-SYSTEM INFORMATION(continued)
107 Dolphin Lane
Property Address: Hyannis,MA
Adam Hart
Owner: March 18,2008
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.
A) �� 6
i or C' T-------T .
i
E O
(� f
= �6 , = 3a '
F - 33 y9 '
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: 107 Dolphin Lane
Iyannis,MA
Owner: Adam Hart
Date of Inspection: March 18,2008
SITE EXAM
Slope
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground waters, I '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:
,/ 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: ,t„;,_,2 y Zv yL c._. .(, ' 3,9
You must describe how you established the High ground waterr elevation:,
SG S ♦V'U✓�. N t✓ w.u.N�y v /Ju"✓N SD .� ✓✓ �s, �' - .
I
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a.�-�'C..h. ✓t..
S 1 l�v�ocJ « � GW� �1h !G✓c i i �� O/J �.
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11
Town of Barnstable
�p 1HE�pk
Regulatory Services
BARNSrABLE ; Thomas F. Geiler,Director
buss. .
9� 1639. p Public Health .Division
prED MA'S
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-190-6304
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/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s 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
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
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OF BARNSTABLE
LOCATION �` ® Old_ y. t SEWAGE # 9 —6 2-
VILLAGE vt L` S ASSESSOR'S MAP& LOT Ao —/Z 1 r
INSTALLER'S NAME&PHONE NO. G e-
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) t C (size) G-,6 Y 4
NO.OF BEDROOMS—
BUILDER OR OWNER f�_
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the ttom of Leaching Facility Feet
Private Water Supply Well and Leaching Facia+ (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 achin acility Feet
Furnished by
� �� � � �
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No. S7-7 Z e:..� 'f P" V' Fee ��y
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pprication for Miq poar *p5tem Cow5truction Permit
Application for a Permit to Construct(Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Add ss or Lot No. (0 Owner's Name Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
/I/-Z It e L e-
Type of Building:
Dwelling No.of Bedrooms 14 Lot Size '4 3 2- - sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Rep ' s or Alt rations(Answewhen te
a plicable) �� C s Co I N GE' J/®��'
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 iss d by is Bo Health.
Signed Date
Application Approved by Datel` 2 q 9
Application Disapproved for the following reasons
P� t N . '� 7 Date Issued 9 P Z 9
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Mi.4poal *p5tem Conmruction Permit
Application for a Permit to Construct(---)Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Add ss or Lot No. t d d P l r'I h Owner's Name Address and Tel.No.
Assessor's Map/Parcel .
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. p
L earn t�
Type of Building: T
Dwelling No.of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other, Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow: gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title •
Size of Septic Tank 44"�-�1 t Type of S.A.S.
Description of Soil
Nature of Rep or Alterations(Answwhen a plicable) ���l 5 �n t
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 operati6-until a Certifi-
cate of Compliance has been iss d by&isBo Health.
- -may �P
Signed Date
-
Application Approved by - Date
Application Disapproved for the following reasons
Permit No. 9 _G Z 7 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS 4
(Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded
Abandoned( )by
at /0 7 Do Sd AA%►, has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 r—i Z 7 dated ? 2.
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the sys ill t n as ddps' ne dr?
Date 7iS"�1 Inspector
No. / d t'y z 7---------------------------Fee ✓� •--//—
�oL
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
ri000aY *pgtem Con5truct"on Permit
Permission is hereby ranted to Construct( )Repair( )Up ade( Abandon( )
System located at Q 7 lw�i0 � �a��.. Trdt.�+
and as described in the above Application for Disposal System Construction Permit.The`)applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this s
Date: / J 2 y_/ Approved by � � �
i� 10/9N7
NOTICE: This Form Is To BeTsed For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated ��� `� , concerning the
property located at cti LL't I meets all of the
following criteria:
• There are no wetlands located within 100 feet of the proposed leaching facility
• There are no private wells within 150 feet of the proposed septic system
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the
proposed leaching facility will=be located less than fourteen (14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following: l
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) `
B)Observed Groundwater Table Elevation(according to Health Division well map) I�
SIGNED : DATE: `—�
LICENSED SEPTIC SYSTEM INST LER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
Y
C
Y
1 .
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9TOWN OF BARNSTABLE
LOCATION �d lT� c.i t SEWAGE # ,62
VILLAGE d1 L S ASSESSOR'S MAP & LOT L —/r4L
INSTALLER'S NAME&PHONE NO. l (G e,. e--O—.
SEPTIC TANK CAPACTTY _ 1 5 CO
LEACHING FACILITY: (type) "(� ,L� U1 (size)
NO.OF BEDROOMS
BUILDER OR OWNER _
PERMPTDATE: 9— l"L 77 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching FaciHy (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�j achin acility _ Feet
Furnished by �/
� C- 3 d � Se
G
1
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TOWN OF ,BARNSTABLE BAR-W` 4869
Ordinance or Regulation
WARNING NOTICE
0
Name of Offender/Manager . c �, �n �/AI1 dob
���
Address of Offender I/7Irl nn) P14 /C' �/� A/f:' MV/MB Reg.# 33�
Village/State/Zip f-F\IA A / _� Imo A ��1��C.a. A � , J� SS#
on 0
Business Name �•, I 2
Business Address ' '
S"ignyatur'd`.of jEnf'orcird...gLOlf�f�ic�e=r
Village/State/Zip "Wing
Location of Offense
E'nforcgDepvirson
Off enseel�II I ) hi 11r'/_ An �/ A nN l �.,- C_o' (hf `�
Facts n�►�I 1 f�jj f�+ r''� 'f� n, M�,(2,-- Q'�/ /.'l�l 1 A
"C - w•� % _".k 'O;—e " @ d W k -v . N a s p w a y a �, e grw 1 e x
Thus gill serve o�'nly as a waning. Ate this time�i�o, �1eg�ayl' action k�as�bedn taken.
it is the goal of Town agencies to achieve voluntary compliance Hof Town
Ordinances, Rules and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.-:
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER GOLD-ENFORCING DEPT.
TOWN OF BARNSTABLE BAR-W �t 6
Ordinance or Regulation _
WARNING NOTICE `
*� 0
Name of Offender/Mans er Ip -„�" ✓ fs
g
Address of 0ffender1` , "r � - " i �-fr �� 9 °Y�" N� /Reg.#
° . � Pt;''� ✓f � t t �w:.wa'Mw '��:
Village/State/Zip
¢' `� n ; r r. ,; ,-
u
E-C
Business Name ' WN71 r�'�` „L 6>61 ? am/rpm, on - 20
Business Address
Signature?.of(Enforci'rig, Offite`r r
Village/State/Zip
Location of Offense
�r (✓`1 Enforcing "Dept/Div"itision .
Offense ) , tk � , f' � r�-
Facts 1 f fit. t r `l : ',
1 :l ._. ' � 1f,- ).Al r ' i�
This 'will serve only as 'a wain i g. A"t" this tiaie'�`'`h6 legal' acti6ri-h°as'',.b"een taken"'
It is the goal of Town agencies to achieve voluntary compliance of Town
Ordinances, Rules .and Regulations. Education efforts and warning notices are
attempts to gain voluntary compliance. Subsequent violations will result in
appropriate legal action by the Town.
WHITE-OFFENDER CANARY-ORD./REG.-PROG. PINK-ENFORCING OFFICER �GQLD-ENFORCING DEPT.