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HomeMy WebLinkAbout0009 FRESH HOLES ROAD - Health Fresh<<Hoies1,9�O'k , ------- Hyannis MP - - 202 155`. 0 0 i. ' COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ASSESSORS TITLE 5 PARC4N0 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION I �' a Property Address: l CL Owner's Name:Owner's Address: RECEIVED Date of Inspection:- -�� JUL 14 2004 Name of Inspector: pl se print) TOWN OF BARNSTABLE Company Name: HEALTH DEPT. Mailing Address: Telephone Number:. D2 b(� 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 pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: JPasses Conditionally Passes Needs Furt Evaluation by the Local Approving Authority s Inspector's Sig re: 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 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time:This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 -• page I 1< Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR INSPE VOLUNTAY ASSESSMENTS CTION FORM SUBSURFACE SEWAGE DIS POART A SYSTEM CERTIFICATION (continued) Property Address: e " Owner;, 1 k Date of Inspect Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D i A. yytem Passes.: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or a 3n CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: PUMP. b System Conditionally Passes: ; or e or more system components as described in the"Conditional Pass" section b the Board of replaced 1l pass. repaired. a system,upon completion of the replacement or repair,as app Y (Y,N,ND)in the for the following statements.If"not de rmined"please Answer yes,no or n determined explain. The septic tank is meta d over 20 years old;or the septic tank(whether met or not)is structurally unsound,exhibits substantial in lion or exfiltration or tank failure is imminent. stem will pass inspection if the existing tank is replaced with a co lying septic tank as approved by the Board Health. •A metal septic tank will pass ins 0 e if it isold rs avcturally ailable,sound,not leaki and if a Certificate of Compliance indicating that the tank is less Y ND explain: Observation of sewage backup or break out hi static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneve 'stribution box.System will pass inspection if(with- approval of Board of Health): broken pip s)are repla d obstruc. n is removed distri tion box is leveled or re aced ND explain: The system required pum ng more than 4 times a year due to broken or o tructed pipe(s).The system will pass inspection if(with approv of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 a Page 3 of I I .i OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.A CERTIFICATION(continued) Property Address: L d. Owner. er Date of Inspection: 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 fail to protect public health,safety or the environment. 1. Sys will pass unless Board of Health determines in accordance with 310 CMR 15.303 system is not functioning in a manner which will protect public health,safety and thee ironmtent:the — Cesspo or privy is within 50 feet of a surface water _ Cesspool privy is within 50 feet of a bordering vegetated wetland or a salt m 2. System will fail unless the Boa of Health(and Public.Water Su lier,if any)determines that the system is functioning in a'manner th rotects the public health,s ty and environment: _ The system has a septic tank and so bsorption system( S)and the SAS is within 100 feet of surface water supply or tributary to a surfac water supply. _ The system has a septic tank and SAS and t SAS s within a Zone I of a public water supply. The system has a septic tank and SAS and the A s within 50 feet of a private water supply well. _ The system has a septic tank and SAS an he SAS is le than I00 feet but 50 feet or more from a private water supply well".Method used t etermine distanc "This system passes if the well water alysis,performed at a DEP rtified laboratory, for coliform bacteria and volatile organic compo ds indicates that the well is free the presence of ammonia nitrogen d nitrate nitrogen is equal to or less th p 5 Ppm from that facility and failure criteria are triggered.A py of the analysis must be attached to this fo pm'provided that no other 3_ Other. s 3 page 4 of 11 OF FICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASS ESSMEN FORM TS SUBSURFACE SEWAGE DISPPA T ASYSTEM INSPECTION CERTIFICATION(continued) PO",Property Address: 1w1�s Owner. y Date of Inspection: D. System Failure Criteria applicable to all systems: inspections: You must indicate"yes"or"no"to each of the following.for all I Yes No component due to r cesspool Backup of sewage into fie iliffluent to thersurface of the ground or so e s AS o urfa a waters d eto an overloaded or t� Discharge or pondmg o clogged SAS or cesspool _ above outlet invert due to an overloaded or clogged SA or Yid Static liquid level in the distribution box cesspool Liquid depth in cesspool is le unans Vie°ast year NOT dwe available t clogged or less obshtructed pipe(s)•Number 1� Required pumping more than of times pumped po P ground water elevation. Any portion of the SAS,cess of or privy is below high gr to a surface 11L1 Any portion of cesspool or privy is within_1 DO feet of a surface water supply or tributary water supply. )J O Any portion of a cesspool or privy is within a Zone 1 of a public well. j3�D Any portion of a cesspool or privy is within 50 feet of a private water supply well. A� Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water terqual�foralysis rmhbacteria and volatile orgais system passes if the lnic compoundsl water s� performed at a DEP certified laboratory, the presence of indicates that the well is free from pollution from that facility and that no other failure riteria nitrogen and nitrate nitrogen is equal to or less than 5 pprn.provided are triggered.A copy of the analysis must be attached to this form.] ve failure criteria exist as (Yes/No)The system fails.I have determined dtlte s st m fa one or ilsre of the The systemoowner should contact the Board of described in 310 CMR 15.303,therefor t correct the failure. Health to determine what will be necessary Large Systems: d to 15,000 To considered a large system the system must serve a facility with a design flow of 10,000 gp gPd• You must t cate either"yes"or"no"to each of the following (The following •eria apply to large systems in addition to the criteria above) yes no supply _ _ the system is within 0 feet of a surface drinking water , the system is within 200 feet tributary to a surface water supply the system is located in a nitrogen Sens • e area(I rim Wellhead Protection Area—1 WPA)or a mapped Zone II of a public water supply well question in ion E the sys is considered a significant threat,or answered If you have answered"yes"to any"yes"in Section D above the large system undertSectione ownerD hall upgrade tor of stem in accordance with 310 CMR significant threat under Section E or f 15.304.The system owner shou ontact the appropriate regional office of the artment. 4 i Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 9 ' Owner: Date of Inspection: t✓ Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No \JAS_ Pumping information was provided by the owner,occupant,or Board of Health 1JD Were any of the system components pumped out in the previous two weeks? _ Has the system received normal flows in the previous two week period? V_ f0 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? t _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _ Was the facility owner(and occupants if different from owner)provided with information on the proper tiSaintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part.0 is at issue approximation of distance 9 unacceptable)[310 CMR 15.302(3)(b)j 5 r Page 6 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address• owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): qi4 Number of current residents:I_ Does residence have a garbage grinder(yes or no)'. Is laundry on a separate sewage system(yes or no):1_Q[if yes separate inspection required] Laundry system inspected(yes or no)r Seasonal use:(yes or no)V2�,0 Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):fA 0 Last date of occupancy: v. OMMERCIAL(INDUSTRIAL Typ establishment: Design flo sed on 310 CMR 15.203): gpd Basis of design flo ats/persons/sgft,etc.)! Grease trap present(yesor Industrial waste holding tank presen or no)-- Non-sanitary waste discharged to the Title (ye o): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records `` Source of information: ��OS1n yo- Was system pumped as part of the inspection(yes or no): S 1, 1, If yes,volume pumped: ��allons--How was quantit�umped determin d? L 4L Reason for pumping n J 4Jpj' t^eC O 1(�Gle ITY E 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/Altemative 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): 71 Approximate age of all components,date installed if known)and source of information: t Were sewage odors detected when arriving at the site(yes or no): 6 Page-7 of I 1 OFFICIAL INSPECTION FORM.—NOT FOR VLTAECTION FOR ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM j SYSTEM INFORMATION(continued) I Property Address: i Owner: t' _, Date of Inspection: f_! / (�1�1+— BUILDING SEWER(locate on site plan) Zr �� Depth below grad r e: Materials of construction: cast iron �40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of jo' ts, ting,evidence of leakage,et SEPTIC TANK:_(locate on site plan) tr II Depth below grade: 32— Material of construction: oncrete metal_fiberglass__polyethylene _other(explain) f Compliance(yes or no): If tank is metal list age:_ Is age confirmed by a Certificate o —(attach a copy o certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: _ L Distance from top of scum to top of out tee or baffle:_]�Q�r t2 r f Distance from bottom of scum to bottom of outlet tee or ba e:--y-- How were dimensions determined: in et and outlet tee or baffle condition,structural integrity,liquid levels Comments(on pumping recommendations, as related to outlet invert,evidence of leakage,etc. v EASE TRAP:_(locate on site plan) Depth be ade:y Material of cons n: concrete metal_fiberglass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or Distance from bottom of scum to bottom of outlet tee o Date of last pumping: gr q Comments(on pumping recommen ns,inlet and outlet tee or battle c ition,structural integrity, li uid levels as related to outlet invert,ev' ce of leakage,etc.): V- Page S of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner: � 1 Date of Inspection: c) 7HT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth belo de: terial of cons on: concrete metal fiberglass_pol a other(expiain): Dimensions: Capacity. as illbnk Design Flow- ns/ a Alarm present(yes or n Alarm level: Alarm in working order(yes or no Date of 1 pumping: C ents(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: t 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 a n PUMP CHAMBER: (locate on site plan) PumEZr or no): Alaror n Com pump chamb umps and appurtenances,etc.): R Jr ' 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: ` ho1�Sv Owner. Date of Inspection: na SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,.excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number. 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.): ESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Num and configuration: Depth—to liquid to inlet invert: Depth of solids IS Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or Comments(note condition of soil,signs of by is failure,level of ponding ion of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solid Comme note condition of soil,signs of hydraulic failure,level of ponding,condition of vege ,etc.): i 9 `C Page 10 of I 1 7 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ` IeE R� ; Owner: Date of Inspection: Lo (�(� 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. L 1 ' Li �/ D 'V 2-7 d o ^ 4 e ° J`e�-� 10 tI Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMEN FORM TS SUBSURFACE SEWAGE DISPPOSR CYSTEM IN SYSTEM INFORMATION(continued) Property Address. • ! Owner• W %` 2'" ns Date of Ipection: 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 15o feet of SAS) Checked with local Board of Health-explain: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain; W must describe how you establish the hi h round wat r elevation: `^ You m l' �0\x� f Town of Barnstable e '^ y Fyn r Regulatory Services Thomas F. Geiler, Director Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 August 12, 2002 Mr. Eric Winer Winer Realty Trust P.O. Box 434 Harwichport, MA 02646 NOTICE TO ABATE VIOLATIONS OF 105 CMR' 410.00 STATE SANITARY CODE II - MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION The property owned by you located at 9 Fresh Holes Rd. was inspected on August 9, 2002 by Lee McConnell, RS, Town of Barnstable Health Inspector, and Sam White, Town of Barnstable Health Inspector, because of a complaint. The following violations of 105 CMR 410.00 State Sanitary Code II - Minimum Standards of Fitness for Human Habitation were observed at 9 Fresh Holes: REGULATION 105 CMR 410.504(B): Rotted and deteriorated wall at base of tub. The walls around base of tub not a nonabsorbent surface and waterproof covering. REGULATION 105 CMR 410.280(B): Mechanical venting system in bathroom not in proper working order. You are directed to correct the violations listed within seven (7) days of receipt of this letter. You may request a hearing before the Board of Health if written petition requesting same is received within seven (7) days after the date the order is served. Non-compliance could result in a fine of up to $500.00. Each day's failure to comply with an order shall co stitute a separate violation. PER ORDER OF T BOARD OF HEALTH omas A. McKean, R. . Director of Public Health Town of Barnstable cc: Gwen Williams W a,'_ _ .:Ik t y4 L�•,x3�t, �N" 'A � '�' b .`fi 'rP' � ' S .. yP i f > i x • S. V ." � • £�C • � G �� � { To fi �. 'a;2' r tog ah• , ^nt .+^'fix ' . FFF IP t^Im A,ek�' v..c. r ♦[_ f°�7�'� i4'iY, ,n. w �';y.r,' ,sa.> lt .� I - r n s '� � -4"�.�6� ��. �.�t+ •me iJ mr �. ��'�,n:a� r.yi;Y '`� b �� .t`�Y ��"'�C:,�• (lk °. , Sa S d ? 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'.per, x" � � !x'�'� ,+«�. {+�,.��'� .w�� �= •" � �'",�a ' t*n`ii; ..^ro,>, 'a, r� .au .r e 4°{ ,,. r.,;r' 's.. •M a ' • �m ..� � .,� ,��..:..-n �''. .:•^,. � ,�. ..f S,.,a$'° �` 'd� ' .Sy" r.�y ..x r's. � �f�i. _. i �, �`S"`' k`ei.+.# "'?• .�.,. lw .s t w:Z *k -54 4, w At -0 t� `. • =. p e aiaT 'g+ x '?+•nws:A' F 4. ` �" ,fi � *'�*� . �' -,� "*r a s ,.�'• a �5w ,,,, .�^ram., �' S ro is� " 0r 54 a - m a �` aq:� *-,. s rc^^'; ;^�"r-' 41 s .ram t� w��a "s ° . c `..may ixf uP py .� �.'.��'4°r z ed rfis.• � rc...�!z. .rs $«P w w''iC a ^4 $� ! i`x - �� ��'1 vF, y r s �84 ,�y, w& tr " rd a er a yam.. waa a �t -gas by wfp i • a •. yes, g - ' .- <f �& 3aa s"° tea,^ "` .`,, 'Z�a., loll ^` rs_�:,^y^r,^'' spa •::' m -' ✓ ".: ,: g'a arr a tw ' y r w Aug 20 02 09: 39a Eric J Winer (508) 430-4308 P. J. WINER REALTY TRUST #14 Eric J. Winer P.O.Box 566 Harwich Port, MA 02646 Phone/Fax 508 430-4308 S/20/02 Town of Barnstable Public Health Division 200 Main Street Hyannis, MA 02601 Dear Lee McConnell and Sain White, 1 am in receipt of your letter of 8/14/02 with photos included. In order to fix the dainage caused by the tenants not closing the shower curtain it is necessary to replace the walls with Durarock. 1 have hired a contractor to remove the walls around the tub as well as the tub surround. This job will be started this week but may take a few more than seven days from the receipt of your letter to coiTlplete. I will notify you as soon as it is completed for reinspection. Thank You, - Eric J. Winer TOWN OF BARNSTABLE LOC TIO14 f —/. / f/C�S L�ol� 2 _ SEWAGE # 00 r VIL11AGE���.viA�� C' ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /.-o d • �..:. rr1 LEACHING FACILITY: (type) ��/7 �'�? �O �_ (size) S NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: 0L COMPLIANCE DATE: a Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 AN i � ' 77 .{r I ti w j Y 1) i No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ZIPPItratton for Zt!6pooal *pgtem Conztrurtton Vertu Application for a Pernut to Construct( . )Repair( )Upgrade(-VI/Abaridon( ) '!Complete System El Individual Components' Location Address or Lot No. (1._1 t ���5�, .. Owner's Name,Address and Tel.No. r• Assessor's Map/Parcel %�/J� ci�c"1e " V V\�}SQ 1(� 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 ��0 gallons per day. Calculated daily flow 1S7? gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 5�D A Type of S.A.S. c f Description of Soil S 4M o i Nature of Repairs or Alterations(Answer when applicable) �'STKI ji— S o 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 accordance with the provisions of Title 5 of the En ironmental Code and not to place the system in operation until a Certifi- cate of Compliance has be4.n ihTued+ L Board o _ alth. _ Signed �� Date /© 00, Application Approved by 9►e,.,..... Date_10 00 Application Disapproved for the following reasons Permit No. Moio, -- 'L Date Issued TOWN OF BARNSTABLE LOCATION cl _l/ lcgeC I 2 d SEWAGE # VII.LAGET�,1,,i�/r ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. t SEPTIC TANK CAPACITY T LEACHING FACII:TTY: � 12'70 7 S (size) S (type) ) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: D DU COMPLIANCE DATE: 00 Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 ------------- _Ic L > 9 L Z � j No. ,.._ Fee i� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes -PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2 pplication for Mi!5 pooa1 *pgtem Construction Permit ` Application for a Permit4o-Construct( )Repair(, )Upgrade(V�`Abandon( ) WComplete System O Individual Components f Location Address or Lot No. —' l /Z r; ` U —�_ Owner's Name,Address and Tel.No. Assessor's Map/Parcel ��� ����}-C 5 {� SU Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. vs lo��s �• �.•�vt,'�S. 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 ``d gallons per day. Calculated daily flow u 1 s7 gallons. Plan Date Number of sheets Revision Date Title (. Size of Septic Tank .,0-b. n Type of S.A.S. j!�s,/LC..c Description of Soil Nature of Repairs or Iterations(Answer w en applicable) ��''CT a' I.J n /�° k J''n/Z !, C� a _.�C-T✓ ,To CIS u Y Tom_ Date last inspected:_ Agreement: 1 The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposalr [em in accordance with the provisions of Title 5 of the EnklxQnmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee isti"s-utrd'by-t ' oard al�,h -00 Signed �' - Date /0 Application Approved by Date Application Disapproved for the following reasons i . Permit No. 6t 00c, Date Issued --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS l. (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed(,' )Repaired( )Upgraded Abandoned )b t �—G >� S — C_ at y has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.;2&V 16, dated Installer Designer r The issuange of 2�" f be construed as a guarantee that the sy to 1' uin/c Date Inspector V f - -------------------------------------- No. Feer� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS &!5pooal *p0tem Conotructian- ertttit Permission is hereby granted to Construct( )Repair( )Upgrade( r._ ndon( ) System located at P/�-2 r. 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. k y Provided:Construction must be completed within three years of the date of this permit. ''� a��� Approved by Date: 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) 1,� S , hereby certify that the application for disposal works construction permit signed by me dated "!d-OV , concerning the property located at nJ -/� mil/ `j GJdI� /y y, meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. I The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system 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. 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 6?alo+the MAX.High G.W.Adjustment. 37= ^d -� , 7 j DIFFERENCE BETWEEN A and B SIGNED : DATE: [Please Sketc roposed plan o system 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 a . f_ Y _ 1 ✓' � w. r� 1 .. '� i� - 'I. c40 ,f • f ^1-„���. � I .� f � 1 _.. . ..' "...� ��. 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