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Home My WebLink About0197 GREENWOOD AVENUE - Health 1.97 Greenwood Avenue .'.:Hyannis P A 288 066 d k n o i d Town of Barnstable Inspectional Services Department • BA8NSTABM • Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO - March 2021 Karin and Christopher Harvie 197 Greenwood Ave. Hyannis, MA 02601 RE: ,SEWER CONNECTION;DEADLINE EXPIRED . . 197 Greenwood-AVei Hyannis A=288=066 Dear Property Owner, Your sewer connection extension deadline has passed. Please contact the Public Health Division Office to provide an update relative to the status of property's connection to public sewer (i.e. contractor name, DPW sewer connection permit number, anticipated connection date.) If you would like to request an extension, such request must be in writing addressed to the Board of Health (200 Main Street Hyannis, Massachusetts) or e-mail Sharon Crocker at: sharon.crockergtown.Barnstable.ma.us within fourteen(14) days, Sincerely.yours, Karen Malkus-Benjamin Town of Barnstable Health Division Coastal Health Resource Coordinator karen.malkus antown.barnstable.ma.us - ct 6 Town of Barnstable Inspectional Services r + B" MASS, � ' Public Health Division iDifaru,'�s Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 October 11, 2019 Karin L. & Christopher A Harvie 197 Greenwood Avenue Hyannis, MA 02601 IMPORTANT NOTICE Map & Parcel 288-066 RE: 197 Greenwood Avenue, Hyannis,MA Dear Mr. and Ms. Harvie, Your January 301h 2018 sewer connection deadline has passed. Please contact the Public Health Division Office to provide an update relative to the status of property's connection to public sewer (i.e. contractor name, DPW sewer connection permit number, anticipated connection date). If you would like to request an extension, such request must be in writing addressed to the Board of Health(200 Main Street Hyannis Massachusetts) within fourteen (14) days. Sincerely yours, r omas A. McKean, R.S., C.H.O. Director of Public Health Town of Barnstable Q:\WP\SewerConnectDeadlineEXPIRED 197GreenwoodAve 2019.docx Town of Barnstable Inspectional Services MASS.BARNSTABEF. ' Public Health Division � 1639. Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 December 10, 2018 Karin L. & Christopher A Harvie 197 Greenwood Avenue Hyannis, MA 02601 IMPORTANT NOTICE Map & Parcel 288-066 This is a reminder that your property at 197 Greenwood Avenue, Hyannis, MA was due for connection to public sewer on 1/30/2018. The property owner was previously notified of the obligation to connect to sewer and to establish a sewer account with the town. Information on Licensed Sewer Installers is available on our web site at http://www.townofbamstable.us/PublicWorksTech/sewerinstallers.pdf Please note the following two permits are also needed to be in compliance: 1) Septic Abandonment Permits ($ 25) are issued of the Public Health Division, 200 Main Street, Hyannis. The old septic system must be either removed, or filled in, due to future safety concerns. This may be done by the same contractor who connects you to the sewer. 2) Sewer Connection Permit issued by DPW-Water Pollution Control Division, 617 Bearse's Way, Hyannis. Once you choose a contractor/installer have them call Dave Anderson at(508) 790-6244. If you are unable to proceed with a sewer connection you may request a show-cause hearing before the Board of Health. If you would like a hearing, please send, or e-mail,a written petition requesting a hearing to Sharon Crocker at 200 Main Street Hyannis, MA 02601, or sharon.crocker@town.bamstable.ma.us If you have any questions, please call the Health Division at 508-862-4644. Thank you for your prompt attention to this matter. Karen Malkus Town of Barnstable Health Division T Town of Barnstable Barnstable .. : Regulatory Services Department j WcaC j ■ARNSI'ABLE. � 1639, �. Public Health Division 'b,�FDfiAAY A 200 Main Street, Hyannis MA 02601 2Q07 Office: 508-862-4644 Richard Scali,Interim Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 7012 1010 0000 2851 1616 January 13, 2014 ' Karin L. & Christopher A Harvie 197 Greenwood Avenue Hyannis, MA 02601 IMPORTANT NOTIC Map & Parcel 288-1:7-Y d, The Department of Public Works informed us that public sewer lines are now available in your neighborhood. According to our records, your property has a septic system. • This letter directs you to connect your dwelling, at 197 Greenwood Avenue, Hyannis, MA, to public sewer on or before 1/30/2018. The old septic system must be either removed or filled in due to future safety concerns. This may be done by the same contractor who connects you to the sewer. Septic Abandonment Permits ($ 25) are issued at the Public Health Division, 200 Main Street, Hyannis. I Failure to comply with this Board of Health Order may result in a complaint against you, in a court of law. For additional information pertaining.to the sewer connection, please see enclosure. PER ORDER OF THE B RD OF HEALTH Thomas A. McKean, R.S., C.H.O. Agent of the Board of Health Enc. Q:\SEWER connect\Sample order letters for sewer connection\197 Greenwood Ave Hy Jan 2014.doc I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL°AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION pp n F�',RCEL LOT TITLE 5 ._.� OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A :CERTIFICATION Property Address:. Owner's Name: _7i 0160 �Q/}�(d� P� Owner's Address: v3� Date of Inspection. 02 Name of Inspector: lease print) v . (` ICI LAE() d 2003 Company Name: Qd� �j r 6 RNCTABLE Mailing Address: G LTH DEPT. • ,q dace Telephone Number: 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 Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: % ' l4-3 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'Comnients.. ****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 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ,,CERTIFICATION (continued) Property Address: Q Owner Date of Inspection: f��te� rlv Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. S stem Passes: i I have not found an information which indicates ndicates 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 ofscwage backup or break.outor 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 3 ` Page 3 of 1'1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART A CERTIFICATION(continued) Property Address py/yl L�}f9T �Jp Owner: •n v___ o�%�f.F/[1 Date of Inspection: , tJ� 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,fin less°BOard°of°Health determines in acc'o idance with 510 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2., System will fail unless.the Board of Health (and Public,Water Supplier, if any)determines that the-` system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption.system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ 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 tlat'tlie well`is free from pollution from`thaf 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: i .1 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ,. .SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART A CERTIFICATION(continued) Property Address: .' Owner:_ w ' 12w Date of Inspection:mlle/17&" alL�aGo3 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to'each of the following for all inspections: Yes No/ _ t/ 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 Y 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 1V Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number t> 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.] 1V0 (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large�system the system must serve a facility with a-design flow of 10,000 gpd to.15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 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 1.1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: Date of Inspection: I)kP/I'h Check if the following have been done. You must indicate"yes"or"no". as to each of the following;. Yes No Pumping,mformation.was provided by the owner, occupant,or Board of Health Were.any of the system components pumped out in the previous two weeks? c% Has the system received normal flows in the previous two week period? t/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 NA) _ 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. _V11, 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 __Ll'_ Existing information.For example,a plan.at the Board of Health.. V _ 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)] I 5 I Page 6 of 1 I :OFFICIAL INSPECTION,FORM-'NOT FOR VOLUNTARY ASSESSMENTS !SUBSURFACE;SEWAGEDISPOSAL SYSTEIki INSPECTION.FORM PART C 'SYSTEM'INFORMATION- F Property Address:�9 7 Owner: , Date of.Inspection: 0 3 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): -Number of current residents: Does residence,have.a garbage grinder(yes or no),,4*- . Is laundry on a separate sewage system (yes or no)• [if yes separate inspection required] Laundry system inspected( es or no): Seasonal use: (yes or noV� .. ' Water meter readings, if available(last 2 years usage(gpd)): DI OZ- 70Oe11 Sump pump(yes or no V. Last date of occupancy: COMMERCIAL/INDUSTRIA4/1,4' Type of establishment: Design flow.(based on 310 CM11.15.20.3): gpd Basis of design flow(Seats/persons/sgft,eic.): . .. „ Grease trap present(yes or no): Industrial waste holding tank present(yes orno):— - Non-sanitary waste discharged to the Title`5 system(yes or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the in pecti (yes orno : If yes, volume pumped: _gallons--How was quantity pumped determined? , Reason for pumping: TYPOF 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'(des crib e): T A.,pproxiinate ge of all components,date installed(if known)and source of information: Were sewage odors detected when arriving.at the site(yes or no ) 9 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: 197 C ? Owner: Date ofTnspection: 62M/1�9P _ goo BUILDING SEWER(locate on site plan)v/ktQ— Depth below grade: Materials of construction:_cast iron _40 PVC other(explain): ,. Distance from private water supply well or suction line ` tr Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: !/(locate on site plan) Depth below grade: Material of construction:—Vc<6'ncrete_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:j W, X s ` Sludge depth: / =t _ Al Distance from top of sludge to bottom of outlet tee or baffle: ` Scum thickness: Distance from top of scum to top of outlet tee or baffle: 7— Distance from bottom of scum to bottom of outlet tee or baffle' 7 How were dimensions determined: Comments(on pumping recommend tions, ifilet and outlet tee or baffle condition,structural integrity, liquid levels as laced to outlet invert,evidence of leakage,etc l ,� �i GREASE TRAP./J�k(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 Page 8 of l 1 OFFICIAL-INSPECTION'FORM=NOT FOR VOLUNTARY ASSESSMENTS 'SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: Owner• C1/LLP /�,P/Zp1 Date of Inspection: 000 TIGHT or HOLDING TANK(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons 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: y if resent must=be'o ened locate on site lan ( P P )( P ) , • Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlet equal,any evidence of solids carryover, any evidence of 'age 'ntoY out of box, etc. : r a , PUMP CHAMBER(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): _ e .- Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): 8 ` b Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM PART C SYSTEM INFORMATION,(continued) i + Property Address: Owner: b Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits, number:_ leaching chambers,number: . eaching 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.): CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or'no): Comments(note condition of soil,signs of hydraulic failure,level of poriding, condition of vegetation,etc.): PRIVY&_(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 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: q/ Owner: -1 Date of Inspection: � �_�%� 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. 10 Page I I of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM°INFORMATION-(continued) Property Address: r Owner: Date of Inspection: �zo_— �� SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water d 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: Checked with local excavators, installers-(attach documentation) Accessed USGS database:-explain: You must describe how you established the high ground water elevation: ®o' 31 f 11 Permit Number: Date' Completed by: HIG'H•GROUND-WATER LEVEL COMPUTATION Site Location % > �'/ Pd�1%L��D� /TJI��?J S . got No. Owner: nP/^� - Address: Contractor: 44ar Address: Notes.- STEP 1 Measure depth to water'table to nearest 1/10 ft. ........ :._.. .Dale G'y0,�; month/day/year STEEP 2 Using Water-Level Range Zone and.1ndex WQH'Map locate site and determine: A 'Appropriate index well........ 0 Waterdevel ranae zone :....._.. EI. 3 Using monthly report "Current f Water Resources Conditions" i determine current depth to l water level.for index well ...:...::.......... !� ®� I 1 . month/year STEP i Using Table of lMatzr-Izvzl Adjustments_ for index well (STEP 2A), curnent depth to water level for index.well ('STEP 3), and water-level'zone (STEP 2B) determine water-level adjustment .......... :................................... STEP 5 • -L-stimate depth to high'water by subtracting the water- -level adjustment (STEP 4) from measured'depth to water level at site (STEP I)'.' ...................:.............................:............. .. ....................................... /,7 Figure 13.--Reproducible co,,lputation Term. . :ti ��4' 5�- �( � ,\ {. ,� � n � � - � � a z' 9 • f— �� i-- + } � t � ; C/�, R g d1 . t`.;� i R� x f _ 7 � � S ' j i� 'f''A � i � - fi '( iii7D _ _ "'—'s� i fi . ;it ij.jI i1 li F I }. Q� t- . 3i f 5 1S f n .. 9 .�S �: Si i s� z . � I �� E I y�. '�� :i —�,; ;,'_ _`� � N � � ,� ; N { � � 3 .. �. � � �, F OWNr'O I.s .BL_ SaY r .d7�P'iiON f cl �� E-V•sve� �V/£- SEWAGE# `l7 9 F� VILLAGE ��'��! ' 3 _ASSESSOR'S MAP&LOT 2 INSTALLER'S NAME&PHONE NO.A24f -vy SEPTIC TANK CAPACITY /S d o Cr 11d ,✓� r/2 A%d4 S f y X LEACHING FACILITY: (type) y /� (size) NO.OF BEDROOMS BUILDER OR OWNER PERMTTDATE: I Z - ( 1`7 COMPLIANCE DATE: I Z- 7- 2 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 ' A A f� `rs c, r No. �W !i' Y Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for �Digpooal *p5t m ComAruction 3permit 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. Assessor's Map/Parcel � � 0 _ �^ Installer's Name,Address,and Tel.No. L wi,IflQ_IQ( 1�1-6eyyi' Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) T e° Z I S`D O 5'C D a OJ( 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 t to place the system in operation until a Certifi- cate of Compliance has been isstffld b azd o ealt Sign Date �° S Application Approved by f Date Application Disapproved for the following reasons Permit No. Date Issued Fee --�✓ - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN.OF BARNSTABLE, MASSACHUSETTS ZIpprication for Migpooal *p5tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System El Individual Componen&- t _ Location Address or Lot No. Owner's Name,Address and Tel.No. y G� �w0 !� Ayti ,s �,�A.✓ �v v Assessor's Map/Parcel Installer's Name,Address,and Tel.No. (,,,�,.lgagv,l 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 11; 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 Nature of Repairs or Alterations(Answer when��,ap�plicable) /r TIe' !/ / S—D O S% L)43,0)( �,✓Fi/7-�A r0AJ" ,3 's�"o VE Aavw.v4 '6e/W 4P E/I - _ ^ti 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 t to place the system in operation until a Certifi- cate of Compliance has been issu d b card o ealt 557 Sign _ Date Application Approved by Date �1 Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS- Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded( ) Abandoned( )by A 2 c.14- �--c- S'7- at 5 ? G 2 ' r moo '4' has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. �7`G r�U dated Installer ��C-G Designer The issuance of this permit shall not be construed as a guarantee that the syste ill functio as designed. Date Z- O 3-9 7 Inspector ---- --------------------------Fe ---- - No. THE COMMONWEALTH OF MASSACHUSETTS --� PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS xigpozaf *pgtem Construction Permit Permission is hereby granted to Construct( )Repair( )Upgrade( Abandon System located at / 1 7 �� cc 'v p o� �c� �-�/�a.�✓z✓' 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 following local provisions or special conditions. Provided: Constructio must be completed within three years of the date o -s-pg it. j Date: Ti Approved by G \ Yt. 10/9/97 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) k 4ae o4li,.�re�y��hereby certify that the application for disposal works construction permit signed.by me dated concerning the property located at A� w wo-OS meets all of the following.criteria: � There are no wetlands located 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. .•l If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will Do 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 Elevation(according to Health Division well map) a , SIGNE DATE: L l LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. q:health folder:cert J ,t � , ��Fi�6I�s7a�e .S r �Q� vc= /,3��,0 ,:_. ��''�'y' U'.'o •► Y 1 =� �^ .wT �GI D �T -- fit/ � O � � � � �� TOWN OF BARNSTABLEv LOCATION 4 v� c SEWAGE# ASSESSOR'S MAP &LOT 1-1 0 INS TALLER'S NAME&PHONE NO. �' �'+�s T SEPTIC:TANK CAPACITY 1500 ,✓F i//1 A r M s (size) /O x 3 LEACHING FACILITY: (type) y NO bF,BEDROOMS BUIDER OR OWNER FA A PER DATE: 1 Z - 1- R 1 COMPLIANCE DATE: 1 Z— 7- 9 7; Separation Distance Between the: Mai hilt t-Adjusted Groundwater Table and Bottom of Leaching Facility Feet Priyii Vater Supply Well and Leaching Facility (If any wells exist I orisite or within 200 feet of leaching facility) Feet ! Edge:of Wetland and Leaching Facility(If any wetlands exist w tl.100 feet of leaching facility) Feet Furnished by I -N 7v00el — i ' i l 0S, OR 0 D w � I