HomeMy WebLinkAbout0079 HOMEPORT DRIVE - Health 79 HOMEPORT DRIVE, HYANNISPORT
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
. Property Address: 79 Homgport Drive
Hyannis, MA 02601
Owner's Name: Tom and Keeley Rigo
Owner's Address:
Date of Inspection: January 26, 2006
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 a
CERTIFICATION STATEMENT p
I certify that I have personally inspected the sewage disposal system at this address and that the. tformation report
below is true,accurate and complete as of the.time of the inspection. The inspection was perfo=- ed basedmn my
training and experience in the proper function and maintenance of on site sewage disposal systeffis. I am ar]PEP ..
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sys in: ZE ',
✓ Passes N '
r-
Conditionally Passes a m
Needs 7er Evaluation by the Local Approving A thority
Fails
Inspector's Signature: % Date: February 3, 2006
The system inspector shall sub i 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 1
Page 2 of 11
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 79 Homeport Drive
Hyannis, MA
Owner: Tom&Keeley Riko
Date of Inspection: January 26. 2006
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:
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Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 79.Homeport Drive
Hyannis, MA
Owner: Tom &Keeley Rigo
Date of Inspection: January 26, 2006
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
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:
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Page 4 of 11 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 79 Homenort Drive
Hyannis, MA
Owner: Tom&Keeley Riso
Date of Inspection: January 26, 2006
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 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.]
No (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 Y
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.
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 79 Homeport Drive
Hyannis, MA
Owner: Tom&Keeley RiQo
Date of Inspection: January 26, 2006
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
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Page 6 of 11 ry
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 79 Homeport Drive
Hyannis, MA
Owner: Tom&Keeley Rigo
Date of Inspection: January 26, 2006
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: 2
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)): Unavailable
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): gpd
Basis of design flow(seats/persons/sgft,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 4 months ago-per owner
Was system pumped.as part of the inspection(yes or no): Yes
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 March 13198-per as built card.
Were sewage odors detected when arriving at the site(yes or no): No
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Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 79 Homenort Drive
Hyannis, MA
Owner: Tom&Keele�Rivo
Date of Inspection: January 26,.2006
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: 2'
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: 1500 Qal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 2"
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: Measuriniz 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.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage
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
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Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 79 Homeport Drive
Hyannis, MA
Owner: Tom &Keeley Rigo
Date of Inspection: January 26, 2006
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: 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: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Commments(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. There were no signs ofsolids
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
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 79 Homeport Drive
Hyannis, MA
Owner: Tom&Keeley Rigo
Date of Inspection: January 26, 2006
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: 4 high capacity infiltrators-30'x 11'x 2'(per as built card)
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.):
There did not appear to be any signs of failure. The bottom to grade was approximately 5'
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: 79 Homenort Drive
Hvannis. MA
Owner: Tom&Keelev RiQo
Date of Inspection:, January 26, 2006
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.
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Page 11 of I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 160 Crystal Lake Road
Osterville, MA.
Owner: Carl Thut
Date of Inspection: January 26, 2006
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 30+/- 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: topographic 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 inaps were showing approximately 30'+1-to ground water at this
site.
This report has been prepared.and the system inspected and passed 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
TOWN OF BARNSTABLE Z6 $ C
LOCATION SEWAGE # o
`4/ILLAGE �D'� ASSESSOR'S MAP & LOT --I
INSTALLER'S NAME&PHONE NO.
SEPTIC"TANK CAPACITY L
LEACHING FACMI TY:.(type) 1ft G fib �L (size)
NO.OF BEDROOMS
BUILDER OR OWNER t,
PERMIT DATE: -�. �I g COMPLIANCE DATE: L Jy
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
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No. / I/� a Fee 5-0 q
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Rpplication for aigosW 6pgtem Construction Permit
Application for a Permit to Construct( )Repair(Xpgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 9 y!vr p� r(j" 0 riv-e. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel r o L`/PVTO Z:S 0�W50K)
Installer's Name,Address,and Tel.Nw.� 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 7Z 3 gallons per day. Calculated daily flow 3'ACI gallons.
Plan Date Number of sheets Revision Date
Title h
Size of Septic Tank / 0'v o Type of S.A.S. t G
Description of Soil /1'1 g*A4�2
Nature of Re airs or Alterations(Answer w en a plicable)
d
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been d b thi
Signed Date r q—?
Application Approved by a Date—?o 7-S= 9�
Application Disapproved for the following reasons 10,
Permit No. Date Issued
TOWN OF BARNSTABLE ! ..LOCATION SEWAGE#. IL�/.
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VII UAGE i�-•l �pp�'r""' ASSESSOR'S MAP&LOT 6101-�hC�
�T cr i i
� INS'TALLER'S NAME&PHONE N0.
SEi T)V:TANK CAPACITY
L8ACtUNG FACILITY: (type) aS `�y,�Z�f- tl`�L (size)
NO OF:BEDROOMS 3
BUIiD1R OR OWNER
PEIZMI7':DATE: �. - 4 8 COMPLIANCE DATE:_
Sep iv' 6n Distance Between the:
Maximum Adjusted Groundwater Table and.Bottom of Leaching Facility Feet
Ptiyatt Water Supply Well and Leaching Facility (If any wells east Feet
oriaite or within 200 feet of leaching facility)
Edge,of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
; .
Furnished by .
.. _ `.
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No. Q '"II fD ,�. Fee 50, /
THE COMMONWEALTH.OF`M HUSETTS--___.i Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF"BARNSTABLE, MASSACHUSETTS
Application fort,Mitpogar *pgtem Construction Permit
Application for a Permit to Construct( )Repair(X grade( )Abadon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.-t Cl kAornr_PtiNT 0hv-9 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel Y Y - -1-ib o_►w So►'J
Installer's Name,Address,and Tel.N�n ( Designer's Name,Address and Tel.No.
ON' AS
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons.;i7 1 i1 fl Showers( ) Cafeteria( )
Other Fixtures
Design Flow —93 o gallons per day. Calculated daily flow ? 3�� gallons.
Plan Date Number of sheets Revision Date
Title t -.�
Size of Septic Tank ij Type of S.A.S.�� I 1`�%K�I=��T✓�*?U/1s
V T
Description of Soil
a i
Nature of Repairs or Alterations(Answer when a plicable)= v� 57�� /.� 9 a! Olti
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Date last inspected:
Agreement:
The utZersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this alt pp
Signed Date y'!/C?
Application Approved by _ Date 2- 2S= 9,
Application Disapproved for the following reasons
Permit No. /�6 Date Issued Z —
d.N ♦ �. -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTI that the On-s' a e Disposal System Constructed ( )Repaired( )Upgraded
Abandoned( )by r
at r has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. l 41—//6 dated
Installer Designer
The issuance of this permit shall of be co strued as a guarantee that the system mill function as designed.
Date �_% Inspector 1�
————————————————————————————————— ———
No. �^ Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migpogal *pgtem Construction Permit
Permission is hereby granted to Construct( )Repair( grade( )Abandon( )
System located at
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:Construction must be completed within three years of the date of this permit.
Date: / Approved by t'.
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Q� TOWN OF BARNSTABLE
LOCATION ` Hot^tporr Z�( SEWAGE #
v7,1=LAGE NYMI) S ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY �00 l , CAP
LEACHING FACILITY: (type)
►,I �Aw/eCJ (size) 30X !1 X a
NO.OF BEDROOMS 3 ,]
BUILDER OR OWNER R 1 q b
PERMTTDATE: 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 leachi g facility) Feet
Furnished by V/l tAt�"A" 's FDA l
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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)
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hereby certify that the application for disposal works {
9 , !
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construction permit signed by me dated C�'-� -k ,concerning the
property located at `7Ci
meets all of the
fo lowing criteria:
LX• ere are no wetlands located within 1o0 feet of the proposed leaching facility
s
• There are no private wells within 150 feet of the proposed septic system i
• ere is no increase in Flow and/or change in use proposed
• There are no variances request
ed or needed.
(,am" the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility,will 114ii be located less than`fourteen(14)feet above the maximum adjusted
elevation.
groundwater table e r
i
Please complete the following: u
A)Top of around Elevation(according to the Engineering Division G.I.S.map)
3
B Observed Groundwater Table Elevation(according to Health Division well map)
DATE:
SIGNED: ;
f
LICENSED SEPTI YSTEM INSTALLER IN THE TOWN OF BARNSTA13LE NUMBER
- i
[Attach a sketch plan of the proposed system.Also if the licensed Installer posesses a certified plot plan,
>• this plan should be submitted].
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