HomeMy WebLinkAbout0111 FIFTH AVENUE (HYANNIS) - Health 111 FIFTH AVE.,HYANNIS
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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
Property Address: I I I 1kt3 F,(\L)e—
s ?Dr (`/
Owner's Name: 1 t 0..P P� L )
Owner's Address:
Date of Inspection: 2---O
a - a
Name of Inspector:(please print) W i 7 Liam E_ - Rahi rtson Sr. ye- c�q
Company Name: William E. Robinson Septic Service
MaitingAddress: P O Box 1089
Centerville, MA
Telephone Number:_ ism 77s-8776
CERTIFICATION STATEMENT
I certify that I have personalty 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 15340 of Title 5(310 CNIR 15.000). The system:
-asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Gc.> . Date: l 2;L — o --
The system inspector shalt submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be seat 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.
Title 5 Inspection Form 6/152000 page I
Page 2 of I t
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
. PART A
�— CERTIFICATION(continued)
Property Address:- t C % A ve r\u L
t S �—
Owner: �
Date or Inspection:
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sy
m Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CM
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments: l
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 meta;or not)is structurally
unsound,exhibits substantial infiltration or exfrltration 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 pipes)or due to a broken,senled 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 p'rpe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is rtmovcd
ND explain:
Page 3 of I I
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
rr CERTIFICATION(continued)
Property Address: t 1 t 44\ A 1efk%
W, tO'nI 'Vs CILC+
Owner: .t 1 50,, p
Date of Inspection: 1-X1_
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require fiuther evaluation by the Board of Health in order to determine if the system
is fa ing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(I)(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. S stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
syste is.functioning Ina 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
s rface water supply or tributary to a surface water supply.
The system has a septic-tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more front a
private water supply well** Method used to detenmine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for colifoim
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.
Other:
3
Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 1 l `�� 0-\ A V`_(we
Owner: 11 O '
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You Aug indicate`yes"or"no"to each of the following for all inspections:
Yes o
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 4"below invert or available volume is less than day flow
Required pumping more than 4 times in the last year NOT due to dogged 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 I of public well.
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 f^_ct 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.)
(Yes/No)The system fails.1 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. La ge Systems:
To be c nsidered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You mu t indicate either yes"or"no"to each of the following:
(The foil wing criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public water supply well
If yo ave answered"yes"to any question in Seriio ,E the system is considered a significant threat,nr answered
"yes" n ection D above the large system has failed.The owner or operator of arty large system considered a
signiftcan threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.T e system owner should contact the appropriate regional office of the Department.
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Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
rr CHECKLIST
Property Address: l k
� 1\1kS -�
Owner ^'N C
Date of Inspection:
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
umping information was provided by the owner,occupant,or Board of Health
_ -zWere any of the system components pumped out in the previous two weeks 7
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 NIA)
�— Was the facility or dwelling inspected for signs of sewage back up 7
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 battles 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 n�/ Eo /
xisting 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)]
5
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r SYSTEM INFORMATION
Property Address:
Owner: i 1 JCyL�
Date of Inspection: FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): X. Number of bedrooms(actual):1-3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): _
Number of current residents:L_
Does residence have a garbage grinder(yes or no):ACO
Is laundry on a separate sewage system(yes or no):& [if yes separate inspection required]
Laundry system inspected(yes or no):A--&-
Seasonal use:(yes or no):
Water meter readings,if available(last 2 years usage(gpd)): 0 1--- G a ?S D
Sump pump(yes or no): ti C
Last date of occupancy: 1 Z 3--6 f-
COMMERCIA NDUSTRIAL
Type of establis ent:
Design flow(bas d on 310 CUR 15.203): gpd
Basis of design ow(seatslpersonslsgfl,etc.):
Grease trap pr ent(yes or no):—
Industrial wa a holding tank present(yes or no):
Non-sani waste discharged to the Title 5 system(yes or no):_
Water me readings,if available:
Last date f occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: i R '1
Was system pumped as part of the inspection(yes or no):AO
If yes,volume pumped: gallons-How was quantity pumped determined?
Reason for pumping:
�TY OF SYSTEM
ptic 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:
t�c q 9r
Were sewage odors detected when arriving at the site(yes or no):�o
6
I'agc � ref I 1
OFFICIAL INSPECTION FOIOI—140.1- FOR VOLUNTARY ASSLSSNIM'S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION F010I
PART C
} SYSI' M 1NFORA ATION(contistutd)
Property Address:
Owncr:
Daic of Inspection:,—j.�...
UUILUING SLNV It(lucatc on site plan)
Depth bclow gr c:
Materials of co Structlou:_Cast nun _4U I'VC_Odic[(explain).
Distance (tort private teak" supply'%cell Of SULtiun line:_
Cun►ments( iscondition of joints,venting,evidence of i akage,Etc.):
SEPTIC TANK:_(localc on silt plan)
Depth below grade: / �
Material of eonstruetiun: /conctek metal ftbergiass lwl)-ethylene
_uthcr(cxplain)
_ —
If tank is metal list age:` I
ccrlificatc) s age cunfnmed-by a Certificate of tvntpiiance Gcs or uu)..—(attach a copy of
Dimensions: G °e G $,L
Sludgc dcp1h: p /
Distance from Iup of sludge to bunum of uutltt tcc ut bafllc�y
Sctun thickness: O—/
Distance from tup of slum to►up of outlet tee or bafllc: FJL
Distance born bullutn of scum to bunum of uutict%cc or balllc:
l lo%v acre dimensions dctcnttincd: C> —
Cotnmcnts(utt pumping rccuumtcnJatiotts,utict and outict Ice or Unit cunJitiwn,structut al intcgtity, Iiyold Icy cis
as seialcd to oulici inve(t,cvidcncc of leakage,etc.):
— �[a•o u c�►L y,...�G rt;�s i•.- �/wok' -
CREASE TRAP:_(beat un site plan)
Dcpth below grade:_
Malerial of eonswetiun: tuucrcte metal libciglass_pulycdiylene _other
(explain): — —
Dimensions:
Scum thickrtcss:
Distance front ictp scum to iup of owlet Ice or ba(Ile: _
Uisiance Gout bo ont of scum to bunum of uutict ice or bafllc:
talc o!last pun in&-
Cununcnts(ot pumping lcconunatdatiuns,adct anti uutict tcc yr bafllc cuitdtttca,shuiluiai intcbtil),liquid lctcls
as fclalcd lu o [let ince(l, to
of lcaka£e,etc.):
7
Page S of i I
OFFICIAL INSPECTION FOKM—NOT FOR VOLUN'I'AI(Y ASSUNSIIILM-S
SULISUIWAC•: SENVAGI; DISPOSAL SYSTEA1 INSPE-CTION FOItNI
PART C
r �SYSTEM INFORMATION(continued)
Property Address:
0►rncr C``� tS� r(k
Date of Iospcctlon:l--��.0
TlGllT or HOLDING TANK. _(tank must be punqud at bole of iuspec(ion)(lucate on site Flan)
DCpttt below ade:
hiaterial of co struetion: cuncrNe_ttretal_fiberglass_ _Jrulyethyle►re olher(explain):
Dimensions;
Capacitp; alluns
Ucsign 1=10 gallunslJa}•
Alarm pros nt(yes or no):
Alum Icv I; Alann in svurking urdcr (ycs ur nu):
Uale of I t pumping: —
Cunurrc, s(condition of alarm and nuat switches,etc.):
DISTKIUUTION BOX:__�/(if lrrescn(must be opcncd)(locate on site plan)
Dcp9l of liquid level above uullcl invert:_O_
Conuneiits(Holt if box is level and Jistributiun to oullcts equal,any evidence of solids ca�rpoVer,any evidence of
leakage into or out of box,etc.): ,
2dcr
(locate on silt plan)
Pumps in working (yes or no):
Alanns in workirl�ordcr()cs or no):
Cutnments(no condition of pump chamber•conditiun of mumps and ahpurtatauces,e(c.):
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
Owner:
Date of Inspection: —v 2r /
SOIL ABSORPTION SYSTEM(SAS): Y (locate on site plan,excavatiodnot required)
If SAS not located explain why:
Type
lynching pits,number:_
t/(eaching chambers,number: c�
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.): �j "�
S 5 '&a�'li .;l
CESSPOOLS: (ce spool must be pumped as part of inspection)(locate on site plan)
Number and config lion:
Depth—top of liqui to inlet invert:
Depth of solids lay r:
Depth of scum la er:
Dimensions of sspool:
Materials of c struction:
Indication of oundwater inflow(yes or no):
Comments ote condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (lo ate on site plan)
Materials of c struction:
Dimensions:
Depth of s ids:
Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of]l „
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: l I i ! -+�4) A
Owner:
Date of Inspection: /-1 2_ djq '
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.
t�t
galk
s-D
f
A'AY
10
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Page I I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
r— ��_ ^
Property Address: 1 rt( -X t �l
Owner. 13111
Date.of Inspection: / 2-—p V
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
s�
Estimated depth to ground water rl 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 ISO feet of SAS_)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
11
TOWN OF BARNSTABLE G
LOCATION / JLZ rT�J V SEWAGE # / O
VILLAGE �� ��'� ! ASSESSOR'S MAP & LOT ° fJ�
INSTALLER'S NAME&PHONE NO. JqO
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) �'"I�d�c� (::�-s l k*X (size;) '" 416
NO.OF BEDROOMS
I
BUILDER OR OWNER 10 s J-v
PERMITDATE: l 7 " 2 COMPLIANCE DATE: " ®�'! `l
Separation Distance',Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any well Kist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands a st
within 300 feet of leaching facility). Feet
Furnished by
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N. �. � � Fee $50
\THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
- PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Mgogar *p6tem Construction Permit
Application for a Permit to Construct( )Repair )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
111 Fifth Ave . , W. Hyannisport, MA William Jappe
Assessor'sMap/Parcel —$K. 487, W. Hyannisport
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
-g 61089, Centerville, MA
Type of Building:
Dwelling No.of Bedrooms 2 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 Sand
Nature of Repairs or Alterations(Answer when applicable) New D-box and 5 precast leach
chambers . .
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued byth' B and of Health.
Signed
Date r j
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
04
No. 010
Fee $50
- THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
- PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Tippricatton for Dtgozar *pfstem Con.5tructton Verna
Application for a Permit to Construct( )Repair )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
111 Fifth Ave . , W. Hyannisport, MA William Jappe
Assessor'sMap/Parcel —$� 487, W. Hyannisport
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
-ggf61081, Centerville, MA
Type of Building:
Dwelling No.of Bedrooms 2 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 Sand
Nature of Repairs or Alterations(Answer when applicable) New D—box and. precast leach
_._. chambers.
Date"last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by th' B and of Hea h.
Signed Date _l g"
Application Approved by _ Date 41Y
Application Disapproved for the following reasons
` Permit No. 'r Date Issued
t
——————————————————————————THE COMMONWEALTH OF MASSACHUSETTS
5Jappe_>i.. BARNSTABLE, MASSACHUSETTS
(fertifivate of Comphauce
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (X )Upgraded( )
Abandoned( )by Wm. E. Robinson Septic Service,
at 111 Fifth Ave . ,_W_.,�Hyannispor , MA. hasjleqn constructed in accordance
with the ovisio of 141,e�'andtthe fo is osal S stem Construction Permit No. ated
Installer m. "lnson`" R y Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date -, ClQ Inspector
No.—---�— ------------------------Fee $---
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Ja ppe
Dt5po5al *pgtetX ComAruution Vermtt
Permission is hereby r to toc stn�ct )Repay U rade( Aba don
System located at f� It V Ave, W. ri�a n gs poY't; 10 ( )
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 Jnust be ompl ed within three years of the date of eimit. (p C
Date: Approved by
pV ,
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
ENGINEERED PLANS)
I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated . / �' �7 , concerning the
property located at I II Fifth Ave.,W. Hyannisport, MA meets all of the
following criteria:
* There are no wetlands 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 with 250 feet of any 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 Elevation(according to the Engineering Division G.I.S. map)
B)Observed Groundwater Table Evaluation(according to Health Division well map) 3 r
SIGNED: DATE S'/gr 9
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
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TOWN OF BARNSTABLE
LO#ATION �`J SEWAGE # �— d 7 c-y
VILLAGE ���, �ys�a ASSESSOR'S MAP & LOT)ye OCio�
INSTALLER'S NAME & PHONE NO. G ��(_ y�/yJ Spy t-V
i
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) QQ-e C06 (size) (Q v-jk
NO. OF BEDROOMS- PRIVATE WELL OR BLIC AT
BUILDER OR OWNER
DATE PERMIT ISSUED: -49�4 —
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No �'
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No.... .:. Fmi_..��
THE COMMONWEALTH OF MASSACHUSETTS
'BOARD OF HEALTH
�.............OF......1�► fv�-S .--------------..-----------..-----
Appl ratilin for Disposal 18orks Tonstrudiun ramd
Application is hereby made for a Permit to Construct ( ) or Repair (aa%dn Individual• Sewage Disposal
System at: _
----....�Ca..l._.._.. ':�.:.. .. ....................... +��v`:�1- .. - '` ,r�w:� . ...........................° ................
w^ `^»-.----M-M. Location-Address c� - or Lot No.
W .......•..-�^-- yql ......
Owner '' Address
a ...................... �- ... --.�.----.............. ....... Q...0�'k� ?1�-. .. .... --.....-----.....-:.........-----
Installer, Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.... .Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building ......_ No. of persons............................ Showers
W YP g -------------•-•----• P ( ) — Cafeteria ( )
at Other fixtures ..--•...............................•--.....•--••_---' =
W Design Flow..... -....................gallons per person per day. Total daily flow.... _ _..._...._...........gallons.
WSeptic Tank—Liquid capacity.J.M.gallons Length.: ......: Width,__.4....... Diameter................ Depth.................
xDisposal Trench—No..................:.. Width.......:............ Total Length.................... Total leaching area....................sq. ft.
.._... Diameter......La�....... Depth inlet_....L0......... Total leaching area..................s ft.
3 Seepage Pit No:.._..1..------ p g q.
• 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................:.......
x -----------------------------------------------•-----------------------••.....•--------------...--------------:................•••..................----•-••--
ODescription of Soil.........................................................................................................................................................................
--•--•• ----- ---
W --•-------- --------------•---------_-••-•-•--••----------------------•----------.._...........------------------------------- ----------- ----------•-......--••--------•-•---•---_.
U Nature of Repairs or Alterations—Answer when applicable____-- ---------y_4-P.7T...... -4jWi.l.i..t...............
-------•------••--------------------------•--••----•------------------•------- -------------------••------------------------- -•----- _ --------•--.-.--------
.._......
Agreement: '.
The undersigned agrees to install the aforedescribed Individual Sewage Disposal.System in accordance with
the provisions of'I' L 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 t e bopKd
Signed.... ........ ---------
Date
Application Approved By........... --. L..,.... ....y.................................. -•--------Lt'
Date
Application Disapproved for the following reasons:............................................................................................................-
..-•--•-•-•-•-•-•---••----•---•-•------------•----•----•-•-------•------------------------•--.......-•---...-•---.....................................-------------•--------•---....- •-•--••--•-•-
Date
Permit No g?i=..�7..`l
' -•----------------•-------- Issued..........................=•-.............................
Date
-01
No.....A,12?
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. .......................................
Appliration for Disposal Works Tons.trurtion rrrmit
Application is hereby made for a Permit to Construct or Repair Individual Sewage Disposal
System at:
..................... . .............. .O
• .... Krr:n........................................
Location-Address or Lot No.
..........VNJ%, V,,Ctopl-e
................................................ ............... ............................................................
Owner Addres;Q_0
............
..................... ....... .........LAt-:a................t...........................................
Installer .Address
Type of Building -A Size Lot............................Sq. feet
Dwelling—No. of Bedrooms........................... .......Expansion Attic Garbage Grinder ( )
P4 Other—Type of Building ..................;!�....... No. of persons............................ Showers Cafeteria ( )
Other fixtures -------------------.............................................................................
..............."---------- -------
Design Flow.....:.'-K----------------------gallons
----------*.........gallons per person per day. Total daily flow-?.?�......................gallons.
Septic Tank—Liquid capacity4177gallons LengthK....... Width._..q....... Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.....A------------- Diameter...._?:74 Depth below inlet.....q-1......... Total leaching area..................sq. f t.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit._.................. Depth to ground water_.__......_._.........__.
44 Test Pit No. 2................minutes per inch Depth of Test Pit..._................ Depth to ground water.._.........._..........
9 .............................................................................................................................................................
0 -Description of Soil........................................................................................................................................................................
W
----------------------*-----------------------"---------------------------------------"--------------------------------------------------------*----------------------------------- ------------
.................................................................................................................................. .....................................................................
U Nature of Repairs or Alterations—Answer when applicable..--`--j., _._.T-A(j---------I
..................�- , L.(" ..................
........................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TAIT11 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
.operation until a Certificate of Compliance has been issued by the board of-health
Signed.._.
........... ;.................... .......;.......... ............
Date
Application Approved By----------
--------------------- -------------- ..........
Date
Application Disapproved for the following reasons:.............................................................................................................
.........................................................................................................................................................................................................
Date
PermitNo......2..a.....1-1.2........................... Issued......................................................
Date
----------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................................
(9rdifirate of Tnutpltanrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired
by..................... ...........................
........ ..........................................................................
� k ............ Installer r
at...............k......... .. . .. ................4.. pa= .........................................................................................
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No..........KJK.::_/..7.�.... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..........................1-/-)A - N
..;-------------------*.....*..."------------------ Inspector................. --------------------------------------------------*------
-—————————————————————---—————————————
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............................................9. ..........................V................ ....................................... FEE........................
N
Disposal Works TOnstrurtion "prrutit
Permission is hereby granted------. -S� -Oft..
- D-Oft.(......................................................................
......
to Construct or Repair _anIndividual Sewage Disposal System
atNo.:--- ......pe� . ................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No.f Dated..........................................
............................ ....................................................
--------------- Board of Health
DATE ................................................
TOWN OF BARNSTABLE G r G
LOCATION /% 1 I LIP V SEWAGE #
VILLAGE_ ASSESSOR'S MAP& LOT D
INSTALLER'S NAME&PHONE NO. i
SEPTIC TANK CAPACITY /C?
LEACHING FACILITY: (type) (size) 416—�--
NO.OF BEDROOMS
BUILDER OR OWNER Y5 ,0 t,.
PERMITDATE: 7 Z`'i COMPLIANCE DATE: , > e 7 �y
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom o/weU
cility Feet
Private Water Supply Well and Leaching Facility (If t
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlan
within 300 feet of leaching facility) Feet
Furnished by
I
f'