HomeMy WebLinkAbout0059 FIFTH AVENUE (HYANNIS) - Health r 59 FIFTH AVE., HYANNIS
A = 246 183
No. ` / ! Fee l �/ -21
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OFjBARNSTABLE, MASSACHUSETTS Yes
application for Vspo8al 6pstrin (Construction 3permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 59�� ABC 7 Owner's Name,Addres and Tel.No. S08-6,rS
q�9 a
p y�6 - is �3 �w
Assessor's Ma -
Installer's N e,Address,and Tel.No. Designer's Name,Address,and A.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building G AkA6 F No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank r Type of S.A.S. ,��/�
Description of Soil „T
Nature of Repairs or Alterations(Answer when applicable) 77 a A45c✓ 6
I o
� e— C,0A1ti r+ ('D WI)MAC g, �'✓l rv;M.
cD�o S[rvc�vr2c
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 Boar ealth.
Sign Date /7g� 6, aoz/
Application Approved b Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
,_ —
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--------------------------------------------------------------------------------------------------------------------------------
No. � / ( Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �.
Yes
PUBLIC HEALTH DIVISION'=,.TOWN,-OF BARNSTABLE, MASSACHUSETTS
Application for Vsposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. $ f.y 7/1 1)v C Owner's Name,Address,and Tel.No. .So8_Ge 5
Assessor's Map/Parcel �/� /.�-� ��.3 /•yr°l�, w, ���a: r;", ;,
Installer's Name,Address,and Tel.No. Designer's Name,Address,and I(el.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(min.required) gpd Design flow provided gpd
i
Plan, Date Number of sheets Revision Date
Title
Size of Septic Tank `fi ,q Type of S.A.S. j/��iZ
Description of Soil
i �1
Nature of Repairs or Alterations(Answer when applicable) -7-1 e A(Cc✓ U�1s_C 6 ill�/ t'X f`� _
;1X°4/' c
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
o
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.o ealth. //
Sign Date / lh 7 a i C"'I
Application Approved b k Date /
Ii
Application Disapproved by Date
for the following reasons
i! •
Permit No. Date Issued �O
I -------------------------------------------------------------------------------- -------- _-------------------------------------------
j THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded( )`
Abandoned(, )by S.i'!(-,Cc C"- \
at .i 9 1, j n 6 r ( has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No.Za /^/31 dated
Installer FP I c c �InC r-/f, `, . ? Designer
#bedrooms Approved design flow gpd
The issuance of this permit shallsnot be construed as a guarantee that the system will funcfionas designed.
Date ? ; i ! Inspector "`lm».�s "�=--�
-------------- ------------------------------------------------------------------------------------------------------------------------
No. /�" ,� Fee (
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction Permit
Permission is hereby granted to Construct(/ ) Repair( ) Upgrade( Abandon( )
System located at j 9'
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 ust be completed within three years of the date of this permit.
Date � �� I Approved by
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
�i
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: S / '* aklc
Owner's Name: �, e✓ Tqc soh
Owner's Address: 5 F, V-L, Gr✓g--
Date of Inspection: /o o EREED
Name of Inspector. (please print)IP�ar h� / o el/,. 2001Company Name: /f/Y�O — i ECMailing Address: U O� /d STABLEM (p�,L EPT.
Telephone Number. sod _ 77 '- 994cq
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuan=Passcs
' 15.340 of Title 5(310 CMR 15.000). The system: r
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fail
Inspector's Signature: Date: �� 0
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 I0,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
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Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
n CERTIFICATION(continued)
Property Address: E7 F ei4 ake,
l.✓QS �iNNrfDo/ Od6��
Owner. J��lrSo✓�
Date of Inspection: i o a1 0
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Syst 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 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 exfiltmtion or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
'A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11 I
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION ION(continued)
Property Address: S-9 � -7-'f' ave,
Owner: .Tp4t" oo—° r
Date of Inspection: 10 7a 7-0
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 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 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
t
— The system has aseptic 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 ppm.provided that no other `
failure criteria are triggered A copy of the analysis must be attached to this form.
3. Other:
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Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: -� ! ak-c-
tvef � �o� /l�9 od 6 701-
Owner: a e 4- 0W
Date of Inspection: /0 O
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
_ u 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%: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.
v 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.
�/Alny portion of a cesspool or privy is within 50 feet of a private water supply well.
ny 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.]
//0 (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)
yes no
the system is within 460 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 Vou have answered"yes"to any question in Section E the system is considered a significant threat.or answered
"yes"in Section D above the large system has failed The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
Page S of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: F-4A at-e
Owner.
Date of Inspection: v dl 0
Check if the following have been done. You must indicate`ves"or"no"as to each of the following:
Yes o
Pumping information was provided by the owner,occupant.or Board of Health
ZWere any of the system components pumped out in the previous two weeks
_ Has the system received normal flows in the previous two week period
_ Have large volumes of water been introduced to the system recently or as part of this inspection
_ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_ Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out
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
_LZ_ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
i
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yesl no
Existing information.For example.a plan at the Board of Health.
Determined in the Feld(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)]
M
Page 6 of 11
I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address• j 4 Fi 71'4 alre
Owner. a�loh
Date of Inspection: (o a o
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CUR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents: d2
Does residence have a garbage grinder(yes or no):/VU
Is laundry on a separate sewage system(yes or no):lii10 [if yes separate inspection required]
Laundry system inspected(yes or no): /l/0
Seasonal use: (yes or no): AV
Water meter readings,if available(last 2 years usage(gpd)): OW (? o 00 ),0 0 0- /oa po0
Sump pump(yes or.no):l(�� / J
Last date of occupancy:
COMMERCIAL/INDUSTRIAL '
Type of establishment:
Design flow(based on 310 CUR 15.203): 9Dd
Basis of design flow(seats/persons/sgft,ctc.):
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:
i
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: r? ,F _
Was system pumped as part of the insp&tion(yes or no):
If yes,volume pumped: Zallons—How was quantity pumped determined?
Reason for pumping:
TYP"F SYSTEM
Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were selvage odors detected when arriving at the site(yes or no):14/10
Page 7 of 11
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: r f`r 741,
Owner.
Date of Inspection: /0 0/
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction:_cast iron _�PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
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SEPTIC TANK:Zoocate on site plan) i
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,l/0 - /S00
Sludge depth: a '/
Distance from top of sludge to bottom of outlet tee or baffle: -?Lt
Scum thickness: /I'
Distance from top of scum to top of outlet tee or baffle: 9
Distance from bottom of scum to bottom of outlet tee or baffle:J
How were dimensions determined: Ave /2Gti deice
Comments(on pumping recommendations.inlet and outlet tee or baffle condition, structural integrity, liquid levels
as elated to outlet invert,evidence of leakage,etc.): _ !
I
!'�t�din ✓!O ✓7eec�sc� �� '►U �r�''�e /ah�i— Gr,�c� �G ES �i
/yv Liu 4-s c,c2c CJ yoty-
GREASE TRAP:oocate on site plan)
Depth below grade:—
Material of construction: concrete_metal_fiberglass_polvethylene_other
(explain).
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: S 9 F f0-� ave
Ire yr..gto f 0 oa
Owner: J Gc'w.�O"
Date of Inspection: /
TIGHT or HOLDING TANK: //(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass_polyethylene other(explain):
i
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no): s
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:
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.):
90X is eve% Flo -/o or/le7/s e(Q ua o
PUMP CHAMBER 4/(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.):
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Page 9 of 11 {
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) j
Property Address: J
i
Owner. u c -1'o u
Date of Inspection: O of
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
CD 6 W d�S>{mNC j (D-A S ono.
Y�
leaching pits.number: �o �,�j u� 3j'� �(io
T
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length: t
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.) I
Soy GN� S7oHe ei�o��� ��s C�Puti Qw� d� /t/c7
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CESSPOOLS:/✓ (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation.etc.):
PRIVY: Al (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.):
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C I
SYSTEM INFORMATION(continued)
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Property Address: 59 F A✓e
Owner. (ro,c�-J:71
Date of Inspection: /o d 01
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.
4
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: F �T h aye
Gve aH of ¢ Cb) �a
r. J Owne o c - w1
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
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:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain: Yew" vti Rgj1
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain: zo e
You h hi ed the st cribe how ou establis y #t � ground water elevation /
ee es A O,� ` 7. Blow
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fep�G Tgri�� 0 0 0 'il i f 000 O z
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L-0 CAT ION ; . SEWAGE PERMIT NO.
`VILLA�//AGE
ff/lo9/VA r.s. 7--
I N S T A LLE 'S NyA+Ill E i ADDRESS
BUILDER
DA T E PERMIT ISSUED
DATE COMPLIANCE. ISSUEDf� ) C
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NoJE .I:..'to Fxs......!_�
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THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
OF.........................................................................................
ApplirFation for llispoii al Vorkg Tnntrurtiun ranfit
Application is hereby made for a Permit to Construct ( ) or Repair Vj an Individual Sewage Disposal
System at:
�1........__ s% �1yA,erivi� r9�
...... . • •- -----------------------�-----�-- ........... .........._..._.
r- Location-Address or�.ot No.
ll... /Tc J k sue-✓
Owner Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms._._____....................................7 Expansion Attic ( ) Garbage Grinder WE)
U
'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................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
i" 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------------------------
rZ4 Test Pit No..2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a •----•----••-----•••---------•------•.................•----•---•-•••-------------...----.....................................................................
0 Description of Soil........................................................................................................................................................................
x
V
----•-----•-------------------- •-•••-••-•-----•----•------------------•-•------•----•----••......---------------- -------------------••---------------•----------••-•--•••-•-•--•--------•----.._......
UNature of Repairs or Alterations—Answer when applicable._./S o_79 s►--v'_--_� L�' >� r�__a...............
-----------------------------------•-----------------------•-------------------------......------------------------......-----------•-------------- ....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of i1Tl:E 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 boar of li
------ ••--- •--•---• �---- i�---=---� �•-
Dat
Application Approved B ��=. � ... =-----_.. ...... h�----
-_ Date
Application Disapproved for the following reasons---..............................................................................................................
-•--•-----•----------•-------•••--•----•--•-•-----------------•-•--------••---......--••--•••---•-•------•-----•--------•--.------•---------------•-•-•--•.........------•-----..........•-•--•-•--••--
Date
PermitNo........pc,- •46�--....................... Issued-.......................................................
Date
No. l.'` -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................................... .......OF.................................................................
.........._..._..........
Appliration for BigpooFal Works Tows rur#ion thrmit
Application is hereby made for a Permit to Construct ( ) or Repair (/�)an Individual Sewage Disposal
System at:
Location-Address or Lot No.
Owner Address
T'
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.................................. .Expansion Attic ( ) Garbage Grinder W)
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;e'9.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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water--_-----___---_•-----_..
a ---------------------------------------------------•----•--•--------•---••-----------•••••-••-------.........................................................
0 Description of Soil........................................................................................................................................................................
x
v •----•--•-------------•--•-•••-------•-------•-•........••-•-•••-•-•-•--••••-----•---•-----....---••-.....--- ---•----------•--•-••---------••---••---------•........-•-...------------••--•------------
w
-------------------------- .............................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable.__/_5' U 7 r>..-h r _ c�) u
••-----•----•--------•--•---••----•--•••----•--....---•-••••-•------••••------•-----•---•.......-----•----•----•--•-••---•-------•------•-•----•----------•-----------•----•--•••--•----•---........-••-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 hheealtthh.
Signed. .......................................-� _ - -�-'/ - / /�`��
........................................ �
Application Approved By........ .......................................� .� �.:.---
----------
Date
Application Disapproved for the following reasons-------------------•------------•-----------•----......----------------------------------------••----.......----
.........-•-------•----------•-------...--•-------------•---••-------------••--••------.....•----------•---•---------------•-•---••------------•--------••--------------•--•-•--------•--------•-------
_ Date
Permit No-------- ' ..•.C�
...............•....... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................O F..............................................................I.....................
.
C�rdifiratr of f'umph aurr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired {� )
.+
Installer
..............................................................I.....................
has been installed in accordance with the provisions of TIT I 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No-____:_..I-_-•.-_-__ �� _._.._.. dated------- __!�._�_ "`:`.'�...............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FU ON�TISFACTORY.
DATE....................... / Afka........................... Inspector........` --•-•-••------•----•---•--••-...-----------•--....--••••-•-•--•----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH 1_� '-! U ,
L ...........................................OF........------............ ..............__._........_.........................
No...................... FEE...!. : = .........
Disposal Workii Tinoir ion Trod#
Permission is hereby granted........Z�q«.-`._...cor's T
to Construct ( ) or Repair (,,-'-)-an Individual Sewage Disposal System
at No s - .r r s �. T
.................. r1......_._.__�...........�:_........_.....w....../.......!.._-.-. ._.__..,.......__............_._...............-----.........-.......................
Street J
as shown on the application for Disposal Works Construction Permit No..................... Dated.......---
.!---
. _..::
- Board of Health
DATE........ I
FORM 1255 HOBBS & WARREN. INC.. PUBLISHER) -
,
1P�g S iPA3e To
TOWN OF BARNSTABLE
LOCATION 5( f'M &c. SEWAGE# Q20//- /,3/
t VILLAGE A✓• ASSESSOR'S MAP&PARCELo?Y6-/a 3
,>+iB
INSTALLER'S NAME&PHONE NO. J/,,iaca//.s/�"
SEPTIC TANK CAPACITY 1S06 G/TI CE'Yrs!, J
LEACHING FACILITY: (type)) lWce4i7� -6 x 6 (size) 6`X1 /=ACEI- aS;bKc
NO.OF BEDROOMS 4 .
OWNER ItylujW/9 J)f
PERMIT DATE: COMPLIANCE DATE:
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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1- :
t :.. ._ "W—' — ... •�• '.. i .i. - -_ ___ - ._ .. - - DBA JOHN L.TRACY DESIGN SOnOtubes-
• -- """ "- -
1 2 Upper Hampden Road
el O '__. -.. „> - � _Mons MA 01057-9734
/ I ..
Ins.V ld ted O.H.Door D I ..: :_.. .,...... (413) -5860
I
9Nlf II-®E --�
�-n►' .etc.
asra
PLAN•A //59AO9/0
: SCALE /
SNEEY P /o t 4
JOHN L TRACY x
REs1DElvruL-coNsucnNo
qkj
1Q UPPEfl fKMPDEN ROAD
i � MONSDN,MA 01057-8794
TEL fi132Br-5880
' l"E✓f3€D o-� �
i
• �l� �Oluc� s'� 3 �
---GENERAL L NOTE'S-__
"36° , r The General Contractor, G.C. and All',3.6\ De {'a. ',. '6 n . d�r6 bncr.k II f� 4 Bub-Contractors, S-C.'s are Visit the Sit, All Structural Lumber used Is tc
narnPorc c d concrctc _ _ (t
3/2>/0` I. Pad ------__-__--__-.ig` 0 4 and Review and Verify the complete Plans KD Spruce or better as might be req
2Y 8-/6'oC 6� p0U1 - - —,. Lei 00 and Specifications before finalizing Bids ANY Lumber used in the construct
0,¢C{t-above - - — DJ I _ _ ,and An Construction begins. The G.C. and �.Decks, Exterior Stairs or in direct
- —- SiLrr4 tQ gt_� ,!0` — /3'0,} All S.C_'s are to be familiar with all '.tact with Concrete of
.T rt PrguI ad on5lfe - I All
Local and State Code's and Mini- the Ground to
.y - I ._I, •• „ - _— mums and follow them or the Plans which- re ure- eated
' 4` 6., I _ I I I -- W-&tqqr t-LQhf ever is the Greater. No Changes, Deletion, P Pressure-treated.
tt
`1- o I - --__- + / Da 11,l aid and/or Substitutions to be made unless There-ages,
to e Ridge
Venting ins
�„ btall
6 q _ I I -' (otherwise agreed upon in the Ori nies Con- 1 ges, keeping
,Manufacturer s p g the Roof solid a I �ttact/Agreements or in Wri tting anytime pecifies, from adlacen
ini the construction period. ?-ends, Walls and Roofs.
dur
bl
I ' - Materials Supplies, and/or uip-
All s
in
,. 3 -p. ,- __, .Tim-tl - .-„I•_-.. I I I I - .�.m,. - t1UCod� Applied, and/or-Ine Celled to in talledith is to have Vinyl Venting
,-_ -- ��t•• ',, _. M 28. 4.2 -- be nos 'S an or Minimums or Proper s e Total length
ling
oP
t - - ,. -__ �- ors- 606g - 3 2_-.-. Construction methods require or as any h of Al o
j
FW_G
' I Wa -' - Manufacturer and/or Suppliers specify. _ pi of
to e
All 3/4"
' Hy drz n9 1 - =•'-'� If An -d to the Joist and be Gluded am
:7 I LF I•' 6x6(�� fore Anyyconstr�cfionrbegi-S. JO-DY3DEbe Lawn Faucets, L.P.or Surface b lo,
! i I - I I I• �J O SIGNS, INC., db John I„ Tracy Designsto be Freeze r,
and St's Employee's are Not responsible. . and have Shut-Offs, p
V for Any Errors and/or Omissions found
Y # after An construction begins. If Any Questions arise during the
v I c F ia� I Y struc tiPn
l 4 COrj e,r¢fa °i r r2 8� _- _ o \ period ontact the Design G
pa — _ - before oceed g y forth _
f / / o m -i : I , An rus es, LVL Beams, or Trusses An
T s
60 6' `0 ./0; , I N. - .f? -- used in the cons tructlon to be_ designed er
Y __ I Ij
Q I
/4' 7 e r in
1
pO'1 0 ned Manufacturers P,E, and All Engi-
F I; — ; O ni Ue Shop Drawings and Calculation sub-
mi ed to the Building Department and G.C
T®P
ff
is %2"� I -rA G,E 2^ "-. .- - .their Approval. _
0
Latly '' /2 Lzll 1 Ij goofing is to be a 30 Year Architect--
' - IY ual S in le 1 yed over 1 p Felt and ha
(5 C y " �� •31.a�1y I Ice &hRain Ba rier in All Eaves, In All I
•' H ' ' ._ J 9. - Valleys and o complete Roof surface
re the Roof has Less than /7 pitch
W/zr3�6 -7 ®EF�:.EE N ac z 1cn
x y Sfcc.l � �a I _ -
- I: ry "� 2�4�
{
Vd®.f_04•SH P: b G r 'n e =
�9} 0�
` n L.
r-
v 'v n o I .I
-..L� .
; OzN.D000r I t i i•,.:., I �I �r �.,. - _1'�
I
a
282 28 42 I _ _ JO-DY DESIGNS.INC.
,
� HH 7RACYIDEBIGN'
f I It - 2 Upper Hampden Road
Sho - -- _-_ _- _ t —4 / ,�A�1���r�� ,,•i, f�, Monson.413)2 758809734
SW/Dkahou ld W,n�bovc '� 5 p}. --- j- - A, P_EAItl' ELE��Ti®N -
= _ 8anch holflhf. tyllfrc,a t I -.•, _
I,�
,.1
I LVL . ..- � _ �
..� 5 6' 4 4
3 6 0•_.
JCi QY DESIG S,INC.
6 � DfBfA E�®� - :IOHN L.TRACY DESIGP
- N 1) F F®®R P W 14 RESIDENTIAL-CpNSULTIM1
?. 14�2Uytt�PE�R.HAIIIPDFJr ggfj
B9 �p._ Ti 1-
jl
/01.Oa \
4`6`` ----- - Ind,c a ter,
- — /2°o Conc.rNc
• ! ��-' SOnotuDes.
66 ".P.7": Pos+. /--2Idye V¢nt,np
e 1
.r.6 ie r i^2110
II 2N4,y oc` �/ R,dp a 2*8^!6°cc i
Stagger onRIdge
/2 � "API y' ,/�...
R.u'boEFnooP•g 3,
-4.5 fYooP hingles,.
. Li fit. A Carl /; i � I ;:5 8 0`Co
_
2kG
omp
• ;. . 6 rav c I' /2 Yy8 -r6`oc
I o 1 ,R-38 Ins, + 12 '
`� a is D .A,• P p ta�,`t aB..
etatl
• .. �• 2x4c�./6 or
m / 8�
It`
..y. /' '• —� .�.- R- /9 < C6 oc / Not Cr.. S.m JNetc trim Line3 4 �\
l
tiu: o .y Co4umn v -�•'•,�: ' 4� l' z'x/Oti/ �.
II F o o T.i,n>p ./ =g x -—a-
R- 30 Ingu l
a .e ��'k �2 i7/O''FrF+'` _-
1P' -
If, LVL Beam
if '.i - o 3/62�a1 II 6yDBum -B adrd On , " tf alts I�f i LVL r a;n II t
aft Beam o,W0to and _ "� �- �`t' Gy pS�e rn 9e arrJ oh Beare �: 2x 8^�oc
Ce.
I,npo to Code ----�Et dt B .. J, iv `Nall, Cf 1I1✓19S' To cc,de I
li V.C6` 1- R-/9 Fnout --6x6
COI 44`Copc rete
' I •• P', C'h 6ro6 dr0�10 min alb I --Alum
9 I
os7 C0 lAnchorCla CO.
- "
,. � m,I �`� ,
Sti - . ... •" 5
o
oto berrelr
o -7--
.. ..
a tv
_.__ -
, - ; r r _.!6 Com c1¢d gravel
.pis u_ .. - min
AV4—S E C T 10 "A\
min n�/
i _ PLAN# A //59A09/0
36:..0.. SCALE-/4"I /` C
SHEET# 3 of 4
.11,a1 �
JO-DY DESIGNS,INC.
D/B/A
JOHN L.TRACY DESIGN;
RESIDENTIAL-CONSULTING
142 UPPER HAMPDEN ROAD
__ . .._.. MONSON,MA01057-9734
�r>so p 41&2875680
s
j-•:Ra fte rs sPeel f1 ed .-pk. Detdi I 'B_/ t —.
..-V2�Pty Eln lsh to�rinp
dnd�or ndle.rlaym.fn _ l.,h Flooring D¢ta,1 °B"
r. D e.idll "B
' .. . _',-15 felt 1 t ;. •,rd..8 n -� .t 3 tq,. R r - - .--_ 1
J/2 Pl Yisco rc \ :I w� - 8`m _,3/4..
\ F I n
i . a I r
Tt6
/9^t ell ;-`�Roa fln.p sPec�fled - '� ., /� PI-.Y,� I rY � Sea er
�- Grddc U
• ic.e td5 now t FIo{dr 1015 I �' - t rd�
R-38 mbn. In•.,v l a. 7 -PO _ y Iene
�` r .. I o e �-'S�Yo nyO(iO
1 6rd de t
..� -. o e nd ad � t .. s r6 pT 31 11 ly eth
. Inry Iat1 Roo.irn p a^ .Gyp;vm ;.; {aG ! F '?a'nd-9ea1•e-r
p 51 1 � �
0 dE r...
Barrier .. S ' 'tif1 J board / . :rH :,. .. m ,+lt'`p ;rye . R=/9 .. _ ..
De. ed T'0 Code \=' aPro.per V.e"rlt r !/2'E2!a,ti'.., R_/y �7`�/2'a• b .l nsu late on
t' f: !
Aluminum .VIn. l / Insuldhon 'a� 6 O'ocje, Gutter, ' r
y 6 �
land Downs pouts - o-a ,y}/ r� O
.-. 2 .. seal .allya'dt. �,246� 't v� ,:� 58) .. 20 0� ` ' ^ '^ Cc
/ R-3.B. min. C._ Q.. �...._� :�,_ i.1 c1 >t .fP"":3r ..ri_ .• c - _ Concrete 5 8 � b pact ed
1*nsu Iatlon ' �. ^t,;� •.../ ,Dolt:` �DD '/•.m• ,{ s_/3;I'n^,u Ia. ` )C o!pol QE" ,9#n -Yhtck clean rave
_. -. appl -J;,iQl1 � .o d ::7r .�,,.,; 7' /0. Pour or R ..fit: "7 Y ;b?: � •'Beadbe'atd the D
1S
G.o.ntinuou^ 3//T-Jy���f ... �.. - Foun�ea In;n 'Pol'y4lhylene 8s, specY fiedfled ! _ oom.plefe peFlmoiec:
f�1S offet v'en t�1 np �Codt1 n9-. " v
Duo tarvl .'180 -
_ �8.Q�c I f 1 e a ,�1 f,".rt"r �y'2 o f:�4 -----
\,\
• "` re bar .5 3 Co ni,o.to ! 8-'
:��t�;)I`� B otep I O:d•l yt7 Fi.
A
.1'��
4 -
to
F1'o0r JOI st
s '
...... C..i - --
i /2^•of 3�q\St-one` R.In9.v..la lone 'i
- �5l$.� wan de min:.' :0:e to 1 B`` L- _To be de rm
I. /0" wall;-( B w.tde mLn , l: __. .
!. �E p'� I 6;G: w` Window 5.up i11 0.
_ -1 8"min
DETq.l4 SHEET NOTES ' li'. and Seater _
,• _� �2rG.1 F6d oe ..
` {I Zx4 /:6c oc _ All Materials supplies ,and/or equip- - - Grade _
! L2,-/9 Ina'vIa. 4 .. bent Used A fled. andlor S¢staller� ;to _'�.' ,[0 r[ V Y^ p Suppliers and/or plSSnnfaled illrs .^
.. I Y` R--/3 Insu la_. J/2�Pf <to re ;eras thQ Su i
I b' y D cIa,I B Reecomends`or
'P 9,1. ¢ih. lane' I
A PPe.o VC 'Po a y e't by Iene _.-. A —,
I �+ F 9 These Detail: ' ' R-/3 1n 0u la.
._..S Hov^awls �, .PPro-ved Fgn�s h. ` •Drawin s ar sealdFl -,e
loorin )' Polyethylene
-6� ° p H O U:�$E W R�A P d n d 0 r u h d G t{ay m t !as.a refeience b the gG.C.eand SeCu�sd T✓e fi'O(Ok 6f c6-
: .Y f 1 0'mCo d e i'.d :- B. i
..� yPSum 6:oa rd �. _ y. n
o Co-0'e .. /' -1/4 .fi 4-as-specified on"'otheir sheetsl of the ian¢
' .- i .d I n r 'r I c k /. P I'y 5, and may ¢e�changed as mi ht;tie re a
SPC,cifled V a^ g 9 idea -o a cpslt hQ 21 Co nc re to
{ F'b"n I:r,.h B I:O;opl ri fl '' i'- '� 3.p e c r f1 e E N¢ t d r - !Sitectual condition. found oq the acljial _ 5 Jg`¢`'/' o/Poly e P h y
3
and/or under lay meant F,:tilah Flcorin.Y !� M1�--• Only those"Details
specified on other ss.I- JL)Qy DESIGN&,7N8� _
' n airs/o r u n:d lay rrye n t - .. _ 'Sheets of the Plans are to b used, t '`DJ3A JOHN LTRACY DEBIG.
3/4 T9 G ..,. � -
'� \' n'
P fY•+ '� �.p., 3/:qpT. ..:;I .. v 4� P'T 4'. g' - ..
PFy^d -r;• "se al¢_t < Footing Sizes shown are for ideal,:` - B 'dp:7y� .i;f. _ 2uPPorHA.MNan;Road.
:— ... In Ia. Conditions.and*are t ; oil _ .. _ 'MOnyono MAO10o7-873a
o be incgeased itlG
_ I. :Size and/or reinforcin °Pere-me tC -�- r 'i 4,13 267,.0 p
Floor :)01•ot - -, & -=Zx4-L6oc �" Foundation Contractor;. and actual So'Tld •D ra n^, '-1�•/ �
conditions_warrant.
:tiL S ^4 ` min
All foundation Walls are •o have #,.
r r IRebarS installed as the G C4,,' _
/ Note .All Sub F.l eig t•ln,a do d�0 r. _ - n Cd F _ -
U n dd e f"ka m e t c;. 44 Ad' nip �.�yy �p
.� dnd ,Nailed nto JolS o8ju pe r'€SGP. :,� /D .- _�� �"� - U9 —. NY` .. .. ends, u a NIMODUCE $J D1Y G9tfS lido,
,b.l)bw.i t. Be
�tio �C-.tractor reccom
. el ibP. �T
0
Ns
/f f� if 1 I :IO L 17RACY e}�rE�IGN
3 ..
_....- --
i-_ ;` i r,.` c d 1. t a n n L 'YIIAQI
f
f
qp ry� Sip r
4 i i :pl,�ty PC•n;47ir'�Yr �:4,l.)i 1 .. ... - .. ..
• Is: