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HomeMy WebLinkAbout0062 GREENBRIER LANE - Health 62 Greenbrier Lane Hyannis F/R A = 268 078017 e o a TOWN OF BARNSTABLE LOCA'nON 6 a &&z-rz tv OL /—A,'E SEWAGE #Q�Oc'-> VILLA'dCE_l� ASSESSOR'S MAP & LOT20 O°)"�bl INS+JL2T ER'S NAME&PHONE NO.Ae e, s`d r 7 7 d` j 3 6 -7�- SEPTIC TANK CAPACITY �7' BUJ i LEACHING FACILITY: (type)&—) (size) 6-1V NO.OF BEDROOMS `3 BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any weUs 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 � Qz . � b vi C Fo No. 00 - ;U Fee : THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zfppltration for ;Diopooal Opgtem Cott.�truction Permit Application for a Permit to Construct( . j Repair X Upgrade( )Abandon( ) O Complete System individual Components Location Address or Lot No. (Qa Gv,---,,�b6 Qr ug4"& Owner's Name,Address and Tel.No. �yAN r1J I M P) K ae L_ Lpq"G AAs Assessor's Map/Parcel CAB 5A M&- a�-e f oil z-1 T6 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. U'3 Ci" ©i ki,le A R c N fd.v Sf �� ���Y �0�1 U t P—�N M E>S l 141� `mil C.S. 5­O F' 7 7 sr/.7 4-X -P'(). BOX (off_k U-�ov T O i,"A a25 310 Type of Building: Dwelling No.of Bedrooms Lot Size Tsq.ft. Garbage Grinder( ) Other Type of Building N oN E No.of Persons a Showers( ) Cafeteria( ) Other Fixtures LNv PT-T K,,rc,N-EN Slrjt l_Hvn1i" Design.Flow gallons per day. Calculated daily flow r�1 .5 -gallons. Plan Date 3 lam-1 O 5 Number of sheets Revision Date Title 'gym 2� k-ic, V L�GCZ�CSP Size of Septic Tank \U)0 C,o_\ -k;d`--�k Type of S.A.S. - SOU c C3m 5 Description of Soil ma c- A-0 Dion Nature of Repairs or Alterations(Answer when applicable) -7go Date last inspected: Agreement: The undersigned agrees to ensure the construction add 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 til a ertifi- cate of Compliance has been issued by this Bo d of lth. �� Sig Date Application Approve by Date 3 U. Application Disapproved for, ollowing reasons Permit No. 6 _ d Date Issued 3 U S� i Fee TH�OMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application. for Zigpogal *pgtem Congtruction Permit Application'for t Permit to Construct( . )Repair)Upgrade( )Abandon( ) O Complete System Xjndividual Components Location Address or Lot No. (.0a t'82n brP%Qr LP Owge�r's Name,Address andjel.No. ". YANnits � Mt> 1C ELL LAQ70A5 Assessor's Map/Parcela CQ� / 8 Q 1-4 5�M -�9 0_y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 5 3�- U ARC �/ mod... ST �a SN�aY Ervu�R-0NME�J 1Wt_ SVCS. _• S^d 7 s'/ �G� �PD, ZOX (1) �' �tMo�7F►,HA 0753(�o Type of Building: Dwelling No.of.Bedrooms Lot Size I D `�a0 s..ft. Garbage Grinder( ) r- '. Other Type of Bpilding ONE No. o Per Showers( )`Cafeteria( ), Other Fixtures t- v �z�c2Y K rC�IENirJk, l Fl�rlt)P Design Flow _ gallons per day. Calculated daily flow 'S 0 gallons. Plan Date 3 I ��+ Q 5 Number of. heets , Revision Date _ w Title cU o�,e h C c-1 5 4e_r U pclm dee Size of Septic Tank 'iX I ST 000 e �11c Type of S.A.S. v " SOO 0� C hCm S Description of Soil P�Gn 4 Ate AaoLvp Nature of Repairs or Alterations(Answer when applicable) d f r 4 Date last inspected: L 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 operatioq until a Certifi- cate of Compliance has been issued by this Board of Health. _ /�� Signed" /I l Date Application Approved by Date 0 342s-VUS Application Disapproved for following reasons Permit No. Ud 5 0 l� Date Issued 3�� ti • THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (X)Upgraded( ) Abandoned( )by 192` at 4; it>c-2 Z,ra ,E X/,v A 4"V,�5 has been constructed i accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. � O'�`�`Y dated 31 o S' Installer Designer 571 G 4,.CW1-R n�✓ �� 9J The issuance of this e�t shal/not be construed as a guarantee that the Isystem�ill�functio as designed. Date // / J Inspector'I^^- • No. �U d S� /v L/ ---------------=-------- .�` 'Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS 1=igPogaf *P!6tem Construction Permit Permission is hereby granted to Construct( )Repair(Upgrade( )Abandon( ) System located at 0��. 4"' 2 r t A/!7/2 Ie 1 L.-9 1 A _ �7� �� GA.✓Sf9,4 s 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 followingjocal provisions or special conditions. Provided:Construction must be completed within three years of the date of this e i . Date: 3 '� Approved by TOWN OF BARNSTABLE t, /0 9� d p L14 A.,6 SEWAGE#�c� --� LOCATION � �i'lL�F�/y �L 1 r✓�L� VILLAGE IAYAZell'//1? ASSESSOR'S MAP &LOT INSTAL.LER'S NAME.&PHONE NO.��C /� �✓�•� �r �'d Y, SEPTIC TANK i CAPACITY �5-X J 5 LEACHING FACILITY: (type)� (size)Z x I za,x NO.OF BEDROOMS `3 BUILDER OR OWNER �Z �C �� IQ AIVA✓4 PERMITDATE: COMPLIANCE DATE: 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 ii lJ�G )q � _ Q ; �q,-S o =41�5:s { - J 06/22/2015 01 :07 FAX [6 002/005 r P 9/16/03 Notice: This Form Is To Be Used For the Repair Of Failed Septic Systems. Only PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM I hereby certify that the engineered plan signed by me dated I 5 concerning the property located at �A neets, all of the following criteria: 0 This failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. a The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. The applicant may use historical data to conclude this fact or,may conduct deep test holes and percolation tests at the site without a health agent present. • There is no increase in flow and/or change in use proposed • There are no variances requested or needed. 0 The.bottom of the proposed leaching facility will be located no less than five feet above the maximum adjusted groundwater table elevation. (Adjust the groundwater table using the. Frimptor method when applicable] PIease complete the following: A) Top of Ground Surface Elevation(using GIS information) 3 B) G.W. Elevation 5 +adjustment for high O.W. DIFFERENCE BETWEEN A SIGnD DATE: s D S 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. gASepeielp9M9Xemp.doe 08/22/2015 01 :07 FAX la 003/005 - Permit Number; Date: Completed by: HIGH GROUNDWATER LEVEL COMPUTATION Site Location: "4&5' S Lot No. Owner: Address: wvg n y� Contractor:_` uimY $;no. _Address: 0. yL 6 l Notes73:)zs San STEP 1 Measure depth to water table tonearest 1/10 ft. .,._............................................. ........................... Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: Mtw ® Appropriate index well,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, OWater•ievel range tone ............. STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................ b mo tf�/yeor STEP a Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 28) determine water-level adjustment ............. STEP 5 Estimate depth to high water by subtracting the water. level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ....... ................................. „ .............................. 1; Figure 13,—Reproducible computation form, 15 Town of Barnstable Regulatory Services Thomas F. Geiler,Director * snRxsraecE. M 9 � Public Health Division Thomas McKean, Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: 5/11/05 Designer: Shay Environmental Services, Inc. Installer: ARCH Construction . Address: P.O. Box 627 East Falmouth Address: PO BOX 914 MA 02536 Hyannis, MA On 5/09/05 ARCH CONSTRUCTION was issued a permit to install a (date) (installer) septic system at 62 Greenbrier Lane, Hyannis, MA`based on a design drawn by (address) Shay Environmental Services, Inc. dated 04/01/05 (designer) I certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in,accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. J VjH OF Mqs �o� CAR111 N tiG (Installer's Signature) � E °A HAY No.IIM CG 7.S T. E (Designer's Signature) (Affix mp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Q:Health/Septic/Designer Certification Form o ' 3 S l Z1�13 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFA RS DEPARTMENT OF ENVIRONMENTAL PROTEC ION cA zi ca �' i FNLED INSPECTION � m ry = n TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASS SSMERTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FO PART A CERTIFICATION Property Address: 62 Greenbrier Lane " p Hyannis. MA kRCF-I.. Owner's Name: Kiell Langaas n Owner's Address: Date of Inspection: February 17, 2005 Name of Inspector: (Please Print) James M. Ford Company Name: James M. Ford Mailing Address: P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508)862-9400 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: Passes Conditionally Passes Needs F rther Evaluation by the Local Approving Authority ✓ Fails Inspector's Signature: � Date: February 21, 2005 The system inspector sha\suba 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 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A .CERTIFICATION (continued) Property Address: 62 Greenbrier Lane Hyannis, MA Owner: Kiell Langaas Date of Inspection: February 17, 2005 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be 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 exfiltration 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 62 Greenbrier Lane Hyannis, MA Owner: Kiell Lanzaas Date of Inspection: February 17, 2005 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 aseptic 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. The system has a septic tank and.SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 62 Greenbrier Lane Hyannis, MA Owner: KZell LanQaas Date of Inspection: February 17, 2005 D. System Failure Criteria applicable to all systems: You must indicate either"yes"or"no"to each of the following for all.inspections: Yes No ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped_. ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation. ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ✓ Any portion of a cesspool or privy is within a Zone 1 of a public well. ✓ 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 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.] Yes (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 System: 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 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 you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 62 Greenbrier Lane Hyannis, MA Owner: jell Langaas Date of Inspection: February 17, 2005 Check if the following have been done: You must indicate"yes"or"no"as to each of the following: Yes No ✓ Pumping information was provided by the owner,occupant,or Board of Health ✓ Were any of the system components pumped out in the previous two weeks? ✓ _ Has the system received normal flows in the previous two week period? ✓ Have large volumes of water been introduced to the system recently or as part of this inspection? ✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ Was the facility or dwelling inspected for signs of sewage back 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? ✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes No ✓ _ Existing information. For example,a plan at the Board of Health. ✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)]. 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 62 Greenbrier Lane Hyannis MA Owner: Kjell LanQaas Date of Inspection: February 17, 2005 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 3 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): 2003- 108,000 gals.:2004- 108.000 gals. Sump Pump(yes or no): No Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): epd Basis of design flow(seats/persons/sqft,etc.): Grease trap present(yes or no): Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped 3 weeks ago for maintenance-per owner Was system pumped as part of the inspection(yes or no): No If yes,volume pumped: _gallons--How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM ✓ Septic tank,distribution box,soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: Installed on 114180-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Greenbrier Lane Hyannis, MA Owner: &ell Lan-aaas Date of Inspection: February 17, 2005 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: _cast iron _40 PVC _other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) Depth below grade: 12" 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: 1000 gal. Sludge depth: 1" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 1" Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): No outlet tee was present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakagge. GREASE TRAP: None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _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.): 7 5 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Greenbrier Lane Hyannis MA Owner: KK,ell Lanrzaas Date of Inspection: February 17, 2005 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: aallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): 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: Even 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.): The D-box was level. PUMP CHAMBER: None (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.): 8 O Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Greenbrier Lane Hyannis, MA Owner: K'el� l Langaas Date of Inspection: February 17, 2005 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type ✓ leaching pits,number: 1 -6'x 6'(1000 gal.) 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.): The liquid level was above the inlet pipe and backing up The leach,lit was in hydraulic failure CESSPOOLS: None (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: None (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.): 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 62 Greenbrier Lane Hyannis AM Owner: Kiell Lang—was Date of Inspection: February 17, 2005 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. A 3 1 30 3a- a So as 3 C/ �8 10 • Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 62 Greenbrier Lane Hyannis,MA Owner: Kell 1 Langaas Date of Inspection: February 17, 2005 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 25+/- 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: topozraphic and water contours maps Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours maps, the maps were showing approximately 25'+1-to ground water at this site. This report has been prepared and the system inspected and failed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees,either expressed, written or implied,relating to the system, the inspection and/or this report. 11 ANTLANTIC ENVIRONMENTAL P.O.BOX 2384 %A i MASBPEE,MA 02649 9 Pro; f MAR 2 0 1996 ,% 9 Attn: Commonwealth of Massachusetts Date: 03/16/96 Town of Barnstable Board of Health 367 Main Street Hyannis MA 02601 From : Mr Michael DeDecko Po Box 2384 Mashpee MA 02649 Dear Board of Health Official; I certify that I have personnally inspected the sewage disposal system at the following address : 62 Greerrier Lane, West-Hyannisport Ma. The information reported is true, accurate and complete as of the time of the inspection. I have not found any information which indicates that the system fails to adequately protect the public health or the Environment. If you have any questions regarding this inspection, please contact me at this number: (508)477-14-20. Thank you. S' cerely, Michael DeDecko phone 508 477-1420 v Commonwealth of Massachusetts Executive of Environmental Affairs DEP Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Ga fo�otR,C,4N� Property Address: 62 Green Brier Lane -West-Hyannisport Ma. Address of 0 wner: M r E dward R ozanski (if different) 23 Rotman Street, Windsor, CT. Date of Inspection: 03/14/96 Name of Inspector: Michael DeDecko Company Name, Address and Telephone number: Atlantic Environmental P.o Box 2384 - M ashpee Ma 02649. Tel : (508) 4771420 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 inspection . The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. The system --X-- Passes ---- Conditionally Passes ---- Needs further evaluation by the local Approving Authority ---- Fail L Inspector ' s SignatureJ- '��w lDate: 03/18/96 The system Inspector shal submit a copy of this inspection report to the Approving Authority within thirty (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 or the Department of Environmental Protection. The original should be sent to the system owner and copy sent to the buyer, if applicable and the approving authority. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 62 G reen B rier Lane- West-Hyannisport Ma. Owners : Mr Edward Rozanski Date of Inspection : 03/14/96 INSPECTION SUMMARY: Check A, B, C, or D A) SYSTEM PASSES: -X-- I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CM 15.303. Any failure criteria not evaluated are indicated below B)SYSTEM CONDITIONALLY PASSES: ---- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes,no, or not determinate (Y,N, or N D). Describe basis of determination in all instances. If "not determinated", explain why not. ---- The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration , or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. ---- Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of H ealth). ----- broken pipe(s) are replaced ----- obstruction is removed ----- distribution box is levelled or replaced ---- The system required pumping more than four 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 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address : 62 G reen B rier Lane - West-Hyannisport M a. 0 wner : M r E dward R ozanski Date of Inspection : 03/14/96 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ---- Conditions exist which require further evaluation by the Board of Health in order to de- termine if the system is failing to protect the public health , safety and the environ- ment. 1 j SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: ---- Cesspool or privy is within 50 feet of a surface of water ---- Cesspool or privy is within 50 feet of a bordering vegetated wetland or a small marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNC- TIONING INAMANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. ---- The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. ---- The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. ---- The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. ---- The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analy- sis 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 notrogen is equal to or less than 5 ppm. D)SYSTEM FAILS: --- I have determined that the.pystem violates one or more of the following failure criteria as defined in 310 CM 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to cor- rect the failure. -- Backup of sewage into facility or system component due to an overloaded or or clogged SAS or cesspool. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 62 Green Brier Lane - West-Hyannispoit, M a Owner: Edward Rozanski Date of Inspection : 03114/96 D) SYSTEM FAILS (continued) -- 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 over- loaded or clogged SAS or cesspool. -- Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. --- Any portion of cesspool or privy is within 100 feet of a surface water supply ortributary to a surface water supply. ---Any portion of a cesspool or privy is within a Zone I of a 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 feet from a private water supply well with no acceptable water quality ana- lysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds,ammonia nitrogen and nitrate nitrogen. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 62 Green Brier Lane -West-Hyannisport M a. Owner: Edward R ozanski Date of Inspection: 03/14/96 E) LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above : The design flow of system is 10,000 gpd or greater Large System and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist : --- 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 The owner or operator of any such system shall bring the system and facility into full compli- ance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please, consult the local regional office of the Department for further information. i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 62 Green Brier Lane - West-Hyannisport, M a. Owner: Edward R ozanski Date of Inspection: 03/14/96 Check if the following have been done : -x Pumping information was requested of the owner , occupant and Board of Health. --x None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during the period. Large volumes of water have not been introduced into the system recently or as part of this inspection. --x As built plans have been obtained and examined. Note if they are not available with N/A. --x The facility or dwelling was inspected for signs of sewage back-up. --x The system does not receive non-sanitary or industrial waste flow. --x The site was inspected for signs of breakout. --x All system components, excluding the Soil Absorption System, have been located on the site. --x The septic tank manholes were uncovered, opened and the interior of the sep- tic tank was inspected for conditions of baffles or tees, material of construc- tion, dimensions, depth of liquid, depth of sludge, depth of scum. ---x The size and location of the Soil Absorption System on the site has been deter- mined based on existing information or approximated by non-intrusive methods ---x The facility owners and occupants if different from owner were provided with information on the proper maintenance of Subsurface Disposal System. r i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 62 Green Brier Lane - West-Hyannisport, M a. Owner: Edward Rozanski Date of Inspection: 03/14/96 RESIDENTIAL: Design flow : `2 30 gallons Number of bedrooms : o ?;� Number of current residents: O Garbage grinder (yes or no) : rho Laundry connected to system (yes or no): \�e_S Seasonal use (yes or no) : K)o Water meter readings, if available: uI P. Last date of occupancy : l°t5 y' COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow : gallons/day 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 : Other: (Describe) ............................................................................................................ Last date of occupancy: GENERAL INFORMATION PUMPING RE O R D S nd source of information ...Mo..O.Mnp gWN.f P11A_ .................... System pumpeJ as part of inspection (yes or no):....N 6............ if yes,volume pomped: .................... gallons Reasonfor pumping:............................................................................................................ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 62 Green Brier Lane -West-Hannisport, Ma Owner: Edward Rozanski Dale of inspection: 11111//1 TYPE OF SYSTEM .I5, Septic tank/distribution boxlsoil absorption system --- Single cesspool -- Overflow cesspool ... Privy --- Shared system (yes or no) (if yes, attach previous inspection records, if any) --- Other (explain)........................................................................................... APPROXIMATE AGE t of all components, date installed (if known) and source of information .!�C)k j% .o .Ca�nr4` .b-'k) ip : l....l'i�I..y.. u�LS.�.A.L.1 o� n .................................. ................................ Sewage odors detected when arriving at the site : (yes or no)...t-C.O .. SEPTIC TANK : .... (locate on site plan) Depth below grade: ...,`.... Material of construction: ....K concrete ......... metal ........ FRP ........ other (explain) ................................................................................................................................................ Dimensions: S. 4�.. :. Sludge depth :....C>........ Distance from top of sludge to bottom of outlet tee or baffle:....... `.�................ Scum thickness :....,0............. Distance from top of scum to top of outlet tee or baffle: ..........1 ......................... Distance from bottom of scum to bottom of outlet tee or baffle :.....1.`.-l'l............. Comments : (recommendation for pumping , condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity, evidence of leaka e, tc.)...1.......,.. c�.�...R?....Q�.. �1N �Ct �.�1: ��!. ..�(l�le.�. SIC�IR:........14....I......NTF�<. .... �.l�uc.l..na.�l�'.t�r:�..�:�..:��:i�1�.r.....�►.N....:'4.�..r�,�....,r��c.�.`1- ......................... t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 62 Green Brier Lane -West-Hannisport, Ma. Owner: Edward R ozanski Date of inspection: 03/14/96 GREASE TRAP : .....100....... (locate on site plan) Depth below grade: ............... Material of construction: ........concrete.........metal........FR P........other(explain).... ............................................................................................................................. Dimensions:................................ Scum thickness:........................ Distance from top of scum to top of outlet tee or baffle:....................................... Distance from bottom scum to bottom of outlet tee or baffle:............................... Comments: (Recommendation for pumping condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.)........................ ................................................................................................................................................ ................................................................................................................................................ TIGHT OR HOLDING TANKS:..00....... (locate on site plan) Depth below grade:................ Material of construction:........concrete........metal.........FR P..........other (explain).......... ................................................................................................................................................. Dimensions:............................ Capacity:....................gallons Design flow:...............gallons/day Alarm level:............................. Comments: (condition of inlet tee, condition of alarm and float switches, etc.) ................................................................................................................................................ lie SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 62 Green Brier Lane -West-Hyannisport, Ma Owner: Edward R ozanski Date of inspection: 03/14/96 DISTRIBUTION BOX:...k� (locate on site plan) Depth of liquid level above outlet invert:...0S..D.qTie1—ZNlKd Comment: (note if level and distribution equal evidence of solids carryover, evidence of leakage into or out of box, etc.).. ........... ................................................................................................................................................ ................................................................................................................................................. PUMP CHAMBER:....���.... (locate on the site) Pumps in working order: (yes or no)............... Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.).................... ................................................................................................................................................ ................................................................................................................................................. SOIL ABSORPTION SYSTEM (SAS):... ........ (locate on site plan, if possible; excavation not required, but may be approximated by non- intrusive methods) if not determined to be present, explain: ................................................................................................................................................ ................................................................................................................................................. Type: leaching pits, number: ...!.. ..1 K.(o.:PT- leaching chambers, number:........ leaching galleries, number:........... leaching trenches, number , length:..................... leaching fields,number,dimensions:................... overflow cesspool, number:.......... Comments: (note ondition of soil , si ns of hydraulic failure, level of pondin , condition of,vegetation, .yn ..................... �d t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property address: 62 Green Brier Lane -Vilest-Hyannisport, M a. Owner: Edward R ozanski Date of inspection: 03/14/96 CESSPOOLS:....�.�... (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: ..................... Indicator of ground water: .................... inflow (cesspool must be pumped as part of inspection) . ................................................................................................. ................................................................ ............................... Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ................................................................................................................................................. ................................................................................................................................................ PRIVY: ....NCB.... (locate on the site) Material of construction: ................................... Dimensions: ...................... Depth of solids: ................ Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) . ✓l 4 Y s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address : 62 Green Brier Lane - West-Hyannisport, Ma. Owner: Edward R ozanski Date of inspection: 03/14/96 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate at wells within 100'. 1 o r �z a� 35 0 3 El y DEPTH TO GROUNDWATER: Depth to groundwater: <<--�rfeet Method of determination or approximative: U. f.2....Ka.IZ ..la.'... .lug..l1.✓.f. ESAµ!..Pr.!...r. ? vAdu .. �1Cscww,al': ��� ................................................................................................................................................ ................................................................................................................................................ �!2 t \ ' Lb CAT10 SEWAGE PERMIT NO. VIL -J'AGE INSTALLER' NAME i ADDRESS 2�1 BUILDER OR OWNER DATE PERMIT I S S U E D DATE COMPLIANCE ISSUED /, �� r __. � � `1 N -�._. III LA1 �� ,; i 6� 7 i -i � � Fuse. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEA T `Zl�g , ..�'1,U/ ..........oF.........//� 11 .. --------------------=--aCEL Apptiration for Disposal Works (foutitrurtinn .rrmtt-J2 Application is hereby made for a Permit to Construct A l or Repair ( ) an Individual Sewage Disposal W .S.yst , Z ^.... ...on- ta 4I� d - ccLoc io -Addr � or .Z:.0 Lot. .. .................................� : ...... nerr ddress � � � / Installer Address Type of Building Size Lot.�.3�_......Sq. feet V Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria dOther fixtures -------------------------------------------------------•-•--••-----•-••--••••••---•-•------------•-••-•••.....••............-•••-•-•-............_... W Design Flow............................................gallons per person per day. Total daily flow...........3_30..................gallons. WSeptic Tank—Liquid capacity/40.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No. ................... Width......7........... Total Length._............__. Total leaching area............._._. sq. ft. Seepage Pit No---------Z....... Diameter..../6-------- Depth below inlet......6......... Total leaching area..��sq. ft. Z Other Distribution box Dosing tank '-' Percolation Test Results Performed by.._._...... ' C/!r� _ f ::.__....... Date...... Imo._y. '__ . Test Pit No. 1.....�...minutes per inch Depth of Test Pit- o_ ........... Depth to ground water.._.......90.4... (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •---••••........ -- ------------------------•-------------------...............--------•--••---------...-•----•-•-------......._-•---•--......----.•••-- Descriptionof Soil - -•---------------------------------•--------------------._.----.•.-.------..---•---••-•--•-------•----- ` =�" V .... .----•----------------------------••------•-------------•--..............._......--••-••-••••......... U Nature of Repairs or Alterations—Ariswer when applicable............................................................................................... ...............•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT I.;::. 5 of the State Sanitary Code he undersigned r her agrees not to place the system in operation until a Certificate of Compliance has been is d by oa d health. S S n . ...... ............ . ....... � �..� �D 7 ApplicationApproved BY . -- •• • ... . ........................ •-• .. ................---.---------- Date Application Disapproved for the following reasons: ----------- ................•---•---••---------------------------------....-----------------..•...------------.........----------------------•-•-------------•---......---------------------------------------------- Date __��, Permit No. Issued- ----• •--•--------------------- Date No..........................! Fps d. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TLJ aA----------------_------------ ..OF........./,,Z� . ApplirFation for BiipooFal Works Tonstratr#ion ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal S s at: .. 'kevo Xkoe... A -•---------------. _ .. ........................................ /dip Lo •ion�-/Addy s .!;.-........'P!�-j �!._+r.�f__.. l-S -- .r„. . ....... ................. ./.'��. or It r ner %� Address .........- a ..p-' - ' "----------------:_.....----- -........------------- 4i -' >..J -_............... Installer Address U Type of Building Size Lot: _______Sq. feet Dwelling=No. of Bedrooms_________________________-------------------Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of ersons____________________________ Showers YP g ---------------•--...__.._.. p ( ) — Cafeteria ( ) Other fixtures -----------•------------------------ ---- - -------- Design Flow...........................,................gallons per person per day: Total daily flow........... ',I' ...................gallons. WSeptic Tank—Liquid capacit}Ahm__gallons Length................ Width................ Diameter....... ____ Depth................. Disposal Trench—No Width_. Total Length � Total leaching area__._ sq. ft. Seepage Pit No......... Diameter.../1 ......... Depth below inlet......6.......... Total leaching area__A -sq. ft. z Other Distribution box.(y" Dosing tank '-' Percolation Test Results Performed by...........;_171 �f_._ 4 1'____•__._.._ Date._ I?!'+': ,f f Oa- � Test Pit No. L__._ ____minutes per inch Depth of Test Pit./ _____________ Depth to groundrater........Test Pit No. 2................minutes per inch Depth of Test Pit__..__...._________. Depth to ground ater_..___._.__.____._.:_:_- x ------ >� 1, O Description of Soil____.____a __....__.... _.__.....---•---------------•--••-•---------...-----•---.:_..__...--•--------•----•----•-•---•---•-- - -- --- ----------- U Nature of Repairs or Alterations Answer when applicable............................................................................................... .._...--•--•-••------------------------------....................................•----------------_____-----•--••--- 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 undersignedifrrther agrees not to place the system in operation until a Certificate of Compliance has been iss ed by /o�4ad if ieal' th. gn ,±Ld!1 ` " f---•----------------- ---�.-'- r`' ..... � Date_ Application Approved B ------ ._ Date Application Disapproved for the following reasons------------------ ..................................................................................... ..........................................................•••-•-----•--..:...-•-----...•••••-------••-•--•-•-•--•--.--..._...••----••••••-•-----------•---------------•--••-------•-------•••-•----•-- Date PermitNo.......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS - BOARD OF HEA`-LL H ' ............. f - h2.......'OF....... .. ! "!,7, r'.............................. f9rdifirate of ToanpliFanrr THIS IS TO CERTIF'?That the WInivillual Sewage Disposal System constructed ) or Repaired ( ) by------------------------ ... = --- •--------- f /�. r Installer F ,ice m� I�v Lam' at..................... .� : ±"" t - i+�! -43 c� ---------- p � J has been installed in accordance with tife provisions of TITLE 5 of The Stat000ee Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated_-_-//-.j44 7 f4_.._.________. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. ....................•-•-•-•-•--••-•-•-••-_.... Inspector................................................................................. THE,COMMONWEALTH OF MASSACHUSETTS BOARD R HE �L.T pnp r , . ...........f�. ...........OF.....- --1' i.' 4.r----•............................. No 1..-.. FEE. . ........... Disposal,* orks Tonstrurtion ramit Perm'ssio is hereby granted............C ?'?!"... ?1'YI?((` ' to Construct ) or Repair ( ) an Indio ual/Sewa Disposal Sy '' x.,...., • tree as shown on the application for Disposal Works Construction Pe 't No. ____._ k._._.__. � ated- �.i© -....._.. W.......................... Board of He alth DATE....1 '_3D_._ FORM 1255 HOBBS & WARREN, INC., PUBLISHERS TOWN OF BARNSTABLE LOC,6,110N lea G« �DIU,/ /�� SEWAGE # Vi..L.. JE N�/-AAA C ASSESSOR'S MAP & LOT' INSTALLER'S NAME&PHONE NO. SEPTIC TANK.CAPACITY r LEACHING FACILITY: (type) +'�' ` n r' �` (size) NO.OF BEDROOMS / BUILDER OR OWNER ��/1S'+d Ss.� . �.. .� �P►�ro�-►tit 17JAFLCU 11Qr- 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 ff ility) Feet Furnished by SAC.y.Fpn Fof� c W e V r V.-44 Aw t%1"T 60va, P/r�loot've -Z, 7OW, Qt _Ak 04W 1.0, w *4 Rje, ..... .... .. .... ...... co fww 9/!ID LZY LAYER CA" D/_ 4 ^A ARON C �A ­ ­ 41 M' & ' A NEV MjV. AVK.rf v -' WA5NFP__ 41V .Apr 0 0 SLA o AWeCAS r SEAM446Z­� jP/T,OR �,iMlll At IAP,&A-r &AevArlows: R7 A7 ,&41j 40 pr c 45" 7, All 0 61-� '41%,K,� 404/74"=.7-SZP77C rA 4-0,4 NA< ZAALE,: QRO�A(DNQ4TER- 0 1Af4lFr4&157RA&&T10lV BOX—.=7 -rLZ7- M SECT�'ON OF' 0 A013 RID' ON A6LY :9 A7. �W4A M/4:_=7--&EA CH Na ��.*-7- 3 9.4 F -rA p/r JL 1APAWS1 0 C%A-qaA4GlEAt71SA705AJ_ZINIr— S 49rlSr 014 7 46ST 101. 7-0 7A 4 Ar371AlA7_.-AD Ar4OAl S-41-./PA 40A CAMMG j ff — i014 7'0& 0. $OIL, ,V41148ER oow. .40 . &ACjq1,VC, .40_-A P/7- $41 Z ae— rrolw L44 CNINCP Ar Ac r MA EP'# 'A4 2-b b Sq. INCH RESERVE LEA rMIM 9 ZA FT 7 A i;K�F& 9. ­_. - C- .4C-IIV 7 Fj F X ... .. C.e W. �W I s-,:I)A 0 41 K jamot��-W_ fi il I i l! 77s#q O4y Y 7 _7 J! x