HomeMy WebLinkAbout0190 DUNN'S POND ROAD - Health 190,DUNNS POND RD.
HYANNIS
A = 270 009
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'I
-\ 'COMMON TEALTH OF•-UASSACHUSETTS
EXECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS.
DEPARTMENT'OF EN 'PRO
VIRONNIENTALTECTION
TITLE 5
OFFICLAJ- INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM .
PART A
CERTIFICATION
Property:Address:
Owner's flame:
Owner's A'ddress:
-Date of lrispectinn: " 10
NameofInspecto (ple
Company
Mailing Address:
Telephone Number: _aL, `T�l 7.
CERTIFICATION STATEMENT
I.certify that l have personally inspected the sewage disposal system at this address and that the information reported
below'is true, accurate and.complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on:site sewage disposal systems;I am a DEP
-approved system inspector pursuant to Section 15.340 of Title 5(3.I0 CMR 15:000). :The system:
/Passes
Conditionally Passes
Further Evaluation by the.Local Approvina'Authority
Inspector' Signature:. Date:. t1
t
f The-systemiris. ector shall submit a copy ofthis 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 systen Owner shall submit the:report to the appropriate regional office of the
J DQ:MThe oriainal should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
" Notes and Comments
****This report only describes_conditions at the time of inspection.and-underthe conditions,of use at that
time..This inspection does not address how th•e system will perform in the future under the same or different
conditions of use.
Title,5 Inspection Form 6%15/2000 page 1
Page 2 of 11 .
OFFICIAL INS.PECTIO:N-TORM:-NOT FOR VOI U*NTARY.ASSESSMENTS' .
SUBSURFACE'SEWA.GE'DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 0..
Owner:. l
Date of Inspection:
Inspection Summary: Check A,B,C,D,or E/ALWAYS complete.all of Section D
A. System Passes:
�J I have hot foundany information which.indicates that any ofthe failure criteria described^in 310:CMR
15.303 or in 310 CMR 15:304 exist.Any failure criteria.not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components.as described in the"Conditional Pass section need to be replaced'or
repaired.The system, upon completion of the replacement,or repair; as approved by the.Board of Health;will pass.
Answer yes,no or not determined(Y,N.jND)in the for the following statements. If"not determined;"please
explain.
The septic:tank is metal and over 2.0 ye'ars,old or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial.infiltration or ex�iltrati.on or.iank failure is "imminent:System will pass inspection if the
existing tank is replaced with•a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20.years old is available. V
ND explain:
Observation of sewage:backup.or break out.or high static water level in,the distribution box due to broken or
obstructed'pipe('s)or due to a broken, settled or uneven distribution box.System will pass inspection if(with
approvaLofBoard.of Health):
broken pipe(§)are replaced
obstruction is-.removed ,
distribution.,box is leveled or replaced
ND explain:
The system required pumping more than.4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with.approval.of the..Board of.Health):
broken pipe(s),are replaced .
Obstnictianl 1is:remo Ved
ND ex a•
pl in.
Page_ of I 1
OFFICIAL INSPECTIONFOR,IM -.NOT FOR VOLUNTARY A.SSESSMEItiTTS
SUBSURFACE SEWAGE.DISP'OSA •SYSTEMINSPECTION;FORM
PART:A
CERTIFI CATION•(continued)
. 'Property Address: be�� AXA/aA�1/
Owner:
Date of Inspection: JOO-7
C. Further-Evaluation is Required by the Board.of Health:
Conditions exist which require Ruther 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 aimless Board of health determines in accordance with 310 C1YIR 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 ofa surface water
Cesspool orprivy is within 50 feet of a bordering vegetated wetland or'a salhnarsh
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'iis.within 100 feet ofa.
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 ]--of a.public water supply.
The system has a septic tank.and SAS and,the SAS is:within 50 fe'et 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 i
"This system passes if the well water analysis;performed at a DEP certified lalaoratory, for coliform
bacteria and volatile organic compounds indicates that the well is.free from pollution.from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis:must be attached to this-form.
3. Other:
3.
Page 4 of.l I
0,FFIC.IA:L INS.F'ECTI.ON.TORM-..NOT F.OR VO]LU1 dTARY ASSESSMENTS '
SUBSRFACESE'W:AGE DISPOSA S: 'STEi 'INSPECTIOi'd.FORM
PART
CERTIFICAT10N(continued)
Property.Address: V.J ip
Owner: l 7L
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
NY Backup of sevage;into.facility or system component due to overloaded or clogged SAS or cesspool
Discharge.or Pon ma of effluent to the.surface of the ground.or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid 1'evelAfi the distribution-box above.outiet.invert due to an overloaded or.clogged SAS or
cesspool
_ V Liquid.depth in cesspool is'less.than 6"below invert or available volume is less than %day flow
Required pumping more.than 4 times in.the last year NOT due to clogged or obstructed pipe(s).Number
J of times pumped
V Any portion'of the"SAS,cesspool or privy i.s..below high around water elevation.
Anyportion,o f cesspool`or privy is within 1--Wfeet 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.
_ Any portion of a cesspool.,or privy iswithin.50 feet o€a.private water supply well.:
Any' onion of a cesspool or•privyis:less than 1.00 feet but greater than.50 feet.fro.m a private water
supply well with no acceptable.-water-quality analysis .['Phis system passes-if the well water analysis,
performed at::a DEP certified laboratory,for colifor.m bacteria and:volatile organic compounds
indicates that the.well.m free from pollution-frorii that.facility and the.presence of ammonia
nitrogen and;nitrate nitrogen is equal:to-or less than S ppm,.provided that no other failure criteria
�l are triggered:.-'A:copy-ofthe analysi".must*be attached to this form.] "
(Yes/No)The system-fails.I have.determined that one or more of the above failure criteria exist as
described in 310 CMR 15303,therefore the system fails. The.system-owner.should contact the Board of
Health to-determine what will be necessaryto'correct the:failure.
E. Large Systems:
To be.considered a large;systern 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 Iarge systems.in addition to the criteria above)
yes no
_ - the system is within 4.00 feet of a.surface drinking water.supply
the system is within 200.feet.of a tributary"to a surface drinking water supply
— _ the system-is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If you have,answered".yes"to any question in Section.E the system is considered a significant threat, or answered
Yes"'in Section D above the large system has failed.The owner or operator'of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner,should contact the appropriate'regiona] office of the Department:
Page 5 of 111
OFFICIAL INSPECTION.FORM=NOT FOR VOLUNTARY ASSESSIVIENTS
U3SURFACE`SAGE UISI'OSAI,: YS'FEM INSPECTION FORM
-PARTS
CHECKLIST
Property Address:
Owner:Ale of Inspection:
Check if the following have been done..You must indicate"yes"or"no"'as to each of the following:
Yes. No
Pumping.information was provided by the owner, occupant, or Board of Health,
Were any of the system components pumped out in the previous two weeks
t//Has the system received normal flows,in the previous two week period-?
V Have large volumes of water been introduced to the system recently or as.pa_rt of this inspection?
Were as built plans of the system obtained and examined? (If they were'not availa.ble'riote as N/A)
Was the facility or dwelling inspected for signs of sewage back up ? '
_ Was the site inspected for signs of break out? y
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
k6hb—affleso or tees; material of construction, dimensions, depth of liquid,.depth of.sludge'and depth ofsc 'm? .
Was the facility owner(and occupants if different from.owner)provided with information.on the proper
/airien_ance of subsurface sewage disposal systems
The size and location of the Soil Absorption System-(SAS)on the'site has beee'determined based on:
Yes o V
Existing information.For example, a plan at the Board of Health.
Determined in the f eld.(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
i
5
Page 6 of 11:
OFFICIAL INSPECTIONYORM NOT.FOR VOLUXT:ARC:ASSESSMENTS
SUBSITRFAGE SEWAGE:DISPOSAL SYSTEM INSPECTION FORM
PART.C
SYSTEM:INF.ORMATION
Property Address: Y Z/x01 --3 0-c''
Owner: /v /CI
Date of Inspection: Cj7 �a3007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms.(design): Number.of bedrooms(actual):3
DESIGN flow based on'3 10'.ChIR 15.203 (for example: 11:0 Qpd x f b oedrooms)
Number'of current residents:. a/�, d do
Does residence have a garbage grinder(yes or no):
Is laundry on.a separate sewage systerri(ye,.or no): .jif yes separate inspection required]
Laundry system inspected(yes,or no):d
Seasonal use: (yes orno):
Water meter.:readings, if available(last 2 years usage;(gpd)):
Sump-pump (yes or no) �
Last date of occupancy
ALI/
C OMMERCIAL7IND USTRIA41
Type of.establishment:. ;
Desien flow(based on 310 CMR I5.2031): gpd'
Basis of-design flow(seats/persons/sq#,etc.):
Grease trap present(yes:or.no):
Industrial waste holding;tank present(yes or no):—
Non-sanitary waste discharged to the.Title 5°system (yes or no):_
.Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source-of information:
Was system pumped.as part of the.inspection(y or no):
If yes,volume pumped:__gallons--)low was quantity pumped determined?
Reason.for pumping:
TY 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 copyof the DEP approval
_.Other.(describe):
roximate age ofall cod onents, date i st ]led if known) and source of information:
Were sewage odors:detected when arriving at the site (yes or no)G/
6
Paae 7 of I l
OFFICIAL INSPECTION FORM—NOT FOR'VOtUNTARY ASSE$WENTS
8UBStjRFA-CE SEWA—'G DISPOSAL.SY'STEM.INSPE.'C. FORM.
PART:C
SYST 1 .I;NFORM_ATIO?�(continued)
Property Address: jqO / tz 4z�
Owner•
Date of Inspection: 7 -
BUILDING SEWER(locatz on site plan)
Depth below grade: .
Materials of construction: cast iron 40 PVC other(explain):
Distance-from private water,supply well or.suction line:. .. .
Comments(on'condition'ofjoints, venting, evidence of leakage, etc.):
SEPTIC TANK: I cate"on site plan)
Depth below ara
Material of•construction:. icrete.metal_fiberglass_polyethylene
_other(explain)
If tank is metal lisfiage:_ Is age confirmed by a Certificate of Compliance(qes or no) (attach..a cosy(if.
certificate) yrr
Dimensions: xCP S
Sludge depth:., �
Distance from top of sludge to bottom o outlet tee or baffler.
Scum thickness: e;?
Distance from.top.of scum;to top:of outlet tee or bafilz:. .
Distance from bottom of scum to bo o , of outlet-tee orb ffle:
How were dimensions determ,ine.d
Comments ('on pumping recomri ndations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
related to outlet invert,.evdence of leakage, etc. '-
41
GREASE TRAP: (locate on site plan)
Depth below;g-rade:_
Material.of construction:, . concrete. metal._fiberglass Polyethylene_other `
(explain): —
Dimensions:
Scum thickness:
Distance frorn top of scum to top of outlet tee or bale:
Distance from bottom of scum to bottom'of outlet tee or-baffle:
Date of last yp mping:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,-evidence of leakage, etc.):
Page 8 of 1.1
O.FFTCIAL, INSPECTION FOSS NOTFOR VOLUNTARY..ASSESSNIENTS
SUBSUR-FACE-SEWAGE DISPOSAL; SYST M I SP CT OPSI FORM
PART C.
SYSTEMINFOPWATION(continued)
Property Address:
Owner•-
Date of Inspection: 7
TIGHT or HOLDING TANK:A/(tank aust:be pum.p ed at time of inspecdon)(locate on.site plan)-
� .
Depth below grader
Material of construction: concrete metal. fiberglass_polyethylene ather(expIain);..
Dimensions:'
Capacity: gallons
Design Flow: gallons/day.
Alarm present. y es or n0):.
(Alarm level: Alarm in working order(yes'or no
):
Date of last pumping; _
Comm entsi(condition of alarm and float switches, etc.):
DISTRIB TION BOX:�_(if present must.be opened)(l.o/cate on site.plan.)
Depth of liquid Ievel above outlet invert: _"ouilet
Comments(note if box is�Ievel and distribution- qual-an.y.;evidence of solids carryover, any evidence of,-.
akage.into or out of box; tc.):
A40 .
PUINIP CHAMBER:. locate on site plan)...
Pumps in working.order(yes or no):
Alarms in workm g,.order(yes or no)..
Co meets note condition of.pum. cha ber, condition ofp44sand apo nances, etc:):
Lip 410L ,112 Y
Page 9 of l l
OFFICIAL INSPECTION F'ORM-NOT.FOR VOLUNTARY-ASSESSMENTS
STJBSURI{ACE--SEVIAOE`:DISPOSAL SYSTEM INSPECTION FOR AI
P-ART.0
SYSTEM INFOR A-TION(con"tinued)
Property Address: go & A'
Owner:
Date of'Insnectioi : 7
SOIL ABSORPTION SYSTEM (SAS): locate on site plan, excavation not required)
If SAS'not located explain why:
Type _.
leaching:pits,number:.
•Ieaching chambers,number:
1eaching.galleries, nu„ber:
ching trenches,number, length-
leaching rieids,mumber, dimensions:_ I L.
overflow cesspool;number:
innovative/altemafi.ve system- Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soils condition of vegetation;
etc.):
qY
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth*—top of liquid to inlet invert:
Depth of solids layer:
Depth.of scum Iayer:
Dimensions of cesspool:
Materials of construction:
Indication of.groundwater inflow.(yes or no): .
Comments (note c-ondition•of soil; signs of hydraulic failure,.level of ponding, condition of vegetation, etc:):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of'solids:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):.
I
9
Page I0 of l l,.
OFFICIAL 1NSIPECTIONTORIYS;=_��T. FQR.VOLUTIN Y ASSESSMENTS .
SUBSURFACE SEtiVAGE:DISPOSAL SYSTEM-INSPECTION FORK
SYSTEIYS NFOR-MATIO N::.(continued).
Property Address: _Caw ✓` L "
Own er:77
Date of Znspeciion:.
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 1'00,feet.Locatz:where public water supply enters the building.
vA
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cal l o ) Z�oi
rn c
t,�ne Lee
Page.I I of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION'FORM "
'PART C
"SYSTEM-INFORMATION(continued)
Property Address:
"Owner: l /'
Date of Inspection: L2,C3700 -7
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated.deptfi to ground water` &ef - y
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(abuttirig property/observation hole within 150 feet of SAS)
Checked with Iocal Board of Health-explain:
Checked with.local excavators, installers- (attach documentation)
—/Accessed USGS database-explain:
You must describe how you established the high ground wa#er elevation:
L�
a
11
Permit Number: Date:
Completed by:
HIGH GROUND-WATER LEVEL COMPUTATION
Site Location: ! C/ I!" Lot No:
Owner: Gl�i�'�l�J,�� Address:
Contractor: , Address: Y.,�✓/ '«� G!'S zzy
Notes:
STEP 1 Measure depth to water table may'
to nearest 1/10 ft. ................... ..................................................... .Date Z�LIi t�
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate site and determine:
AO Appropriate index well................................ ...................
OB Water-level range zone ......................................................
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ...:....................... �
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 213)
determine water-level adjustment .......................................................................................... r
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water /t level at site (STEP 1) ........................................................................................:.................... /
Figure 13.--Reproducible computation form.
15
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TOWN OF BARNSTABLE
LOCATION _/�d /✓i �.�Syh 1`'i SEWAGE`#
"— -ASSESSOR'S MAP & LOT —0-
T .INSTALLER'S NAME&PHONE NO = �� v`"�. �1? .S�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUU-DER OR OWNER
PERMITDATE: COMPLIANCE DATE: e"
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
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"i TOWN OF BARNSTABLE
LOCATION A�96 S P6m SEWAGE.# J�/)
O
j VILLAGE lvw2ft n 0", ) ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE N0.
SEPTIC TANK CAPACITY -DO( G.f
LEACHING FACILITY: (type) RC cl (size)
NO. OF BEDROOMSi_
BUILDER OR OWNER
PERMTI'DATE: COMPLIANCE DATE: v
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
a Edge of Wetland and'Leaching'Facility_(If.any wetlands exist .
within 300,feet of leaching facility) Feet
Furtushed bye - °:
--------------
L
j 03 -�
&900 Fee
- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
. " 01pprication for Migpogal 6p5tem Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrad ( )Abandon( ) 1:1 Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Ten.No.
Assessor's Map/Parcel s iy
Installer's Name, ddress,and Tel.No. 3� Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms _ Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
N tore of Repairsor Alt ations(Answer when applicable) r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and ma' tenance of the afore described on-site sewage disposal system
in accordance with the provision e 5 o t Environm al Code and not to place the system in operation until a Ce 'fi-
cate of Compliance has bee 'sued b s o alt .
Sgne � Date
Application Approved-by Date
Application Disapproved for the following reasons
Permit No. Date Issued
1 —No.
Fee
THE.COMMONWEALTH OF MASSACHUSETTS "Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
0ppYicatton for Miopozal *pztem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrad ( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /5 a -Pve — Owner's Name,Address and Te.No.
Assessor's Map/Parcel 2 70 [;
� f
Installer's Name,Address,.and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
� 'lei �I
. I `Nature of Repairsor Alterations(Ans er when applicable) \ F_ !9 ,
z. !
e
Date last inspected:
Agreement:The undersigned agrees to ensure the construction and mat tenance of the afore described on-site sewage disposal system
in accordance with the provisions, f e 5 of t Environm al Code and not to place the system in operation until a Ce tj
sate of Compliance has bee/ *ssue b, s o Malt,.
Signed m / �' .., Date o
Application Approved by f __ / & Date
Application Disapproved*for the following reasons
E r •
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERT , t t the O site S wage Disposal System Constructed( )Repaired(X-")Upgraded( )
Abandoned( )by_!
by
at D 1 / has been constructed •ifi a c rdance
with the pro n f or Disposal System Construction Permit No. dated d
Installer Designer
The issuance of�P *aall not b�nstrded guazantee that th sy'te will fuunction as des�nedivDate Ins ector ( 11 A /�V L
p
No. / � � — e -----------------------Feed
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION . BARNSTABLES MASSACHUSETTS
1wtopoar 6potem Construction Permit
Permission is hereby granted to Construct( )Repair(X)Upgrade( )Ab don
` System located at
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:ConSttru tion Vust be completed within three years of the date of t e t.a,
Date: i�O d Approved by
h -s 1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems.Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, , hereby certif that t.e application for disposal works
construction permit signed by me dated ®2 d� , concerning the
property located at 4 meets all of the
L
following criteria: It
✓• This failed system is connected to a residential dwelling only. There are no commercial or business
/ uses associated with the dwelling.
/
V • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
L/• There are no wetlands within 100 feet of the proposed septic system
L/• There are no private wells within 150 feet of the proposed septic system
f4 There is no increase in flow and/or change in use proposed
�/• There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
applicable]
If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
:groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
. B) G.W.Elevation +the MAX. High G.W.Adjustment, )*a 6L
DIFFE TWEEN A and 0
SIG ED : DATE: e
[Please etch proposed Ian of syste on back].
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
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VAIIV
C.A T`ION SEWAGE PERMIT NO.
AGI
&YIIAJ Iv/5
I N S T A LLER'S NAME & ADDRESS
GUILDER OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED O
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No CR- .6.4....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
..._.......TOW?........OF...... ter. �s �. 1. ...................................
Appliratinn for Bi-spuiial Workii Tonstrnr#ion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( L) an Individual Sewage Disposal
System at:
.....1..20__Joamn _5...--- a ....14'- ------------------- ----------------------------------------------- ...........................................
Loc n-Address or Lot No.
Owner Address
%.P.1. 12COM-.a r . mac..... ....... C -�. ��1�,...................
r
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.............................. .. .....Expansion Attic ( ) Garbage Grinder ( )U
aOther—Type of Building ............................ No. of persons...............:............ Showers ( ) — Cafeteria ( )
Other fixtures ..................................
-------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
Test Pit. No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
�+ .........
------•. ...................•--------.........-----•-----•-•---•--...............................................................
ODescription of Soil....................... ....... .).av -t----•------------------------------•---•--------------------------........-----•-------•-•--.
x
U .....----•-•--•--------------------------------•-----------•-•-•--•------------------.........----•••----...---------•-------•-•------••----------••----•-•---•-•-•-----•---•------------•---••---...----
W ------------------------------------•------------------------•-------------------------....-----------•-------------------------------- --• •-• . •-•••-_...
-----------------
- � }
U Nature of Repairs or Alterations—Answer when applicable._._._.J:.—l �G�__�_,C�...___.1.1 ./ ..........................
..... . ..... .-----•----------•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iT i'L% 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance ha been issued by the board of health. 1�
Si ned...... .\ I QQ `� �✓ l��lc� f.
Date
Application Approved By....... -- �_. -_••clyl --------------•-•------
-
Date
Application Disapproved for the following reasons--------------------------------•----------------------...--••-------------------•-•-.....----•----•-.........._
--•--------------------------------------•-••----....----•----------------------------•-------------•----••-----------•----•-•-•-----•••----•-•-••----------•••-------•-•--------•••-----------••-
Date
PermitNo......................................................... Issued.......................................................
Date
No. /. ... Fims................261..___
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........... / tr'J.... t.:?`.A.L r�'.......OF...... ,, i ? z`�-i�.E'.?.. ................................
Appliration for Disposal Works Tnmunrtiun Vrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( w) an Individual Sewage Disposal
System at x-•
'..-•:.................... .....................•---.....•-•-•---....._....... ... - .................
Location Address j_ or Lot No.
----• �'y�r='✓x J `. _ s?E'- .Ead,+ :":-................................. ...........:. .✓t f r r- ..........................................................
p Owner
.
r j k - -Address
W` _ ; , j af� n�Y i >JfY f!f .�✓'� t Ss s/ Bf f n
Installer Address
Type of Building Size Lot.....................
....... feet
,., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building Cafeteria
04 Q, Other fixtures -"-"----•....................."----"----..---.•••"----------------•-------------------------..........._............._•-•-•-"--------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length............... Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width..................... Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
►-' Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth. of Test Pit.................... Depth to ground water........................
r Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ix ...........•-----............................................................................................................................................
® Description of Soil-"----------------- .
x
UNature of Repairs or Alterations—Answer when applicable._______,I_ ._'f?t 'F -C,4K1.12_.._._/.Z ...........................
--""--------------------------•----------------------------•"----••••--"-••-•""--"-...._.....•-••"•"-""-"•-••-"---•-------•"•-•--•-••----•••-"-•--••--•-•-"----"•"•"--•--•--"••-•••....______.---
,t
Agreement:
The, undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I'T S:SLL. y g g p y
5 of the State Sanitary Code—The undersigned further agrees not to lace the system in
operation until a Certificate of Compliance has,been issued by the board of health.
Si ned `= 1 t` ..........
..... ................. ..."--•. --"•----- "-__..- ....
j Date
zr,.. Application Approved By""-"-"-• --- ....._�.}�!+. "" .............."-""-•. ............
•"-••---DaY......-----•-•"
or e
s.g
Application Disapproved for the following reasons:----------••"--"------------•--•"-"------------------"--------"------------"----"-"-•-•-•---..."--....------••--
i Date
PermitNo......................................................... Issued----------------------................................
Daze
I �
.' THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
. ...........................................
�rriirttle off�nrntlinrle _
THIS IS TO,CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( �}
b}I '4.... .... ... x�r �bl� t�v .. ._ ... ......... ..
J ..... ___..
�+-t Installer "'1
at .. .l CB
r ✓ _ A / Mt fwl f e
......... ...............
has been installed in accordance with the provisions of TI/ > f he. State Sanitary Code as described in the
application for Disposal Works Construction Permit No._ ._ . .............. dated................................................
THE ISSUANCE OF THIS,CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE......................... i: ...................... Inspector.....R-_1f
THE COMMONWEALTH OF MASSACHUSETTS
_x BOARD, OF HEALTH I
�.....✓f-.N st"d e:rt: f,P„iEi (wJ"
N 8r'..�" ... .........................................
............. . ........ .........OF....:....... .... ........
FEE .....--•- -........
Permission is hereby granted...........'. _.._ r ...... !.__. .-_:�_.-- -F-�f,a-----
---------
to Construct g( ) or Repair (� ) an Ind>vidual Sewage Di ppsal System l
4 }} x > j ' �` d }�f fa sV / ems° `J-
atNo.-- - �.' fir'__.._..- ' -•.......................- "- ... •"••---•••---""" --"•-""
treet
Permit No..................... Da ed,--•-••------••...... ....................
as shown on the application for Disposal Works Construction erm• � M
Bo Health
DATE........•" --•-"•-"••-"--••..:..............."_----
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS