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HomeMy WebLinkAbout1441 IYANNOUGH ROAD/RTE 28 - Health 1441Iyannough Hyannis A= 274-029 1 f e Apr-ly 1512:u1p p 1 Commonwealth of Massachusetts VU Title ,5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner information is Owners Name required for every Hyannis MA 02601 4-14-15 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form-Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important When A. General Information filling out forms on the computer. / �/1/ ````�� IH OF jygS����i use only the tab 1. Inspector. did A key to move your cursor-do not James D.Sears 3��:' JAMES '•N use the return key_ Name of Inspector c); ;y CapewideEnterprises LLC �y Company Name Ice 153 Commercial Street ' ;'amll��G� . � Company Address _.... — Mashpee _ MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification 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 ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I 4-14-15 jptpector's Signature Date I 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. i "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. t5ins 3/13 Title 5 official hupection Form:Subsurface Sewage Disposal System-Page of 17 I i Apr191512:01p p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner Owner's Name - information is required for every Hyannis MA 02601 4-14-15 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) tnspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 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: The system is a 1000 Gal.Tank D Box and pit 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. Check the box for°yes", "no"or"not determined"(Y, N, ND) 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. ❑ Y ❑ N ❑ ND(Explain below): i i i i it t51ns•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 2 of 17 Apr l y l b o 2:u1 p p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments C-' 1441 Iyannough Road Property Address Tom McNulty Jr. Owner Owner's Name — information is required for every Hyannis MA 02601 4-14-15 page. Citylrown Slate Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumpslalarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditional) Passes Y y (cunt.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 limes 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): i I I - - i C) Further Evaluation is Required by the Board of Health: i ❑ 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 t5ins•3113 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 3 of 17 i Apr 19 1 b 12:02p p 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner Owner's Name -—` information is Hyannis MA 02601 4-14-15 _required for every _ y _ page. City/Town state Zip Code Date of Inspection B. Certification (cont.) 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 fecal coliform bacteria indicates absent 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: ail D) System Failure Criteria Applicable to All Systems: You must indicate"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 El ® 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 is less than 6" below invert or available volume is less than Y2 day flow /Ar-r l5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 4 of 77 I li Apr 19 1512:02p p.5 Commonwealth of Massachusetts Title 5 Official Inspection Form �I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1441 lyannough Road Property Address —�- — Tom McNulty Jr, Owner Owner's Name information is required for every Hyannis MA 02601 4-14-15 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 j ® 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. i i ❑ ® 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 fecal coliform bacteria indicates absent 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 i and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® 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 j 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. I For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No i ❑ ❑ 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. 15ins•3113 Tile 5 oflida!Inspection Farm:Suttairface Sewage Disposal System•Page 5 0117 I Apr 19 1512:02p p.6 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner Owner's Name information is Hyannis MA 02601 4-14-15 required for every y _ page. Citylrown State Zip Code Date of Inspection C. Checklist Check if the following have been done_You must indicate"yes"or"no"as to each of the following: Yes No ❑ IR 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? 0 ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ ® this inspection? ❑ ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) j ® ❑ Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ Was the site inspected for signs of break out? i ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank j 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: ❑ ® 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 approArnation of distance is unacceptable)(310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): I i 15ins•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Hpr-I& -1 b i-z:usp p y Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner Owner's Name information is required for every Hyannis MA 02601 4-14-15 page. CityrrDwn State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.Tank D Box and pit. I I Number of current residents: — Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? (Include laundry system inspection El Yes ❑ No information in this report) I Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ❑ No i Water meter readings, if available(last 2 years usage(gpd)): Detail: I Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment Office Building i Design flow(based on 310 CMR 15.203): 391.5 Gallons per day(gpd) Basis of design flow(seatsipersons/sq_ft., etc.): 391.5 i Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No I I Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No i Water meter readings, if available: 151ns•3113 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System•Page 7 of 17 I Apr 19 1512:03p p.g Commonwealth of Massachusetts I t Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 1441 lyannough Road Property Address To McNulty Jr. I Owner Owner's Name information is required for every Hyannis MA 02601 4-14-15 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: I Date Other(describe below): �I i I General Information j I Pumping Records: Source of information: NA II i Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons I How was quantity pumped determined? j I Reason for pumping: i Type of System: ® Septic tank, distribution box,soil absorption system ❑ Single cesspool I ❑ Overflow cesspool I ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) i ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the UA system by system operator under contract j ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Oiraal inspeN—Ion Form:Suosurraae Sewage Disposer System-Page 8 of 17 i I Apr 19 1 b 1 L:u:ip p.9 Commonwealth of Massachusetts -^ Title 5 Official Inspection Form d Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner Owner's Name information is Hyannis MA 02601 4-14-15 required for every page_ Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1977 Permit #77-466. 2015-New D Box. I Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): 4' Depth below grade: fear Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeng BLDG to tank cast iron. PVC SCH 40, I I Septic Tank(locate on site plan): 3' � Depth below grade: feet __._._....—.. __.. _.. I Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) I If tank is metal, list age: years l Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast Ii I Sludge depth: 1„ I !Sins-3113 Tile 5 Official Inspection Form.Subsurface Sewage Disposal S+sfem-Page g of 17 Apr 19 15 12:04p p.10 I Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner Owner's Name information is required for every Hyannis MA 02601 4-14-16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness 011 j Distance from top of scum to top of outlet tee or baffle $ j 18" i Distance from bottom of scum to bottom of outlet tee or baffle j i How were dimensions determined? Tape-Sludge-Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level. Tank at 3' below grade w/both covers-2'steel at grade,in and out let tee's. No sign of leakage or over loading. i i i i Grease Trap (locate on site plan): I Depth below grade: feet Material of construction: I i Q concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain): i Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: II Date 15ins•3V13 True 5 omdal In specGon Forth:Subsurface Sewage Olsposal System•Page 10�7T Apr 19 15 12:04p p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface D'Sewage g Disposal System Form Not for Voluntary Assessments 1441 lyannough Road Property Address — Tom McNulty Jr. Owner Owne1's Name information is required for every Hyannis MA 02601 4-14-15 page. Cityffown State Zip Code Date of Inspection j D. System Information (cont.) i Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): l i I i i Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: -- I Material of construction: ❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: I Capacity: — -- gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No i Alarm level: Alarm in working order: ❑ Yes ❑ No I Date of last pumping: Date i' I Comments(condition of alarm and float switches, etc.): l �I Attach copy of current pumping contract(required)- Is copy attached? ❑ Yes ❑ No !Sins•3113 Tille 5 official Insaaden Form:Subsurface Sewage Disposal System-Page 11 of 17 I Apr 19 15 12:04p p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I 1441 lyannough Road Property Address r Tom McNulty Jr. i Owner Owners Name information is required for every Hyannis MA 02601 4-14-15 page. City/town State Zip Code Date of Inspection i D. System Information (cant.) t Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): D Box is New 2015 45" Below Grade w/one line out Steel cover at grade Pump Chamber(locate on site plan): Pumps in working order: Yes El Alarms in working order. ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i i *If pumps or alarms are not in working order, system is a conditional pass. i Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: i 1 [Sins-3113 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 1T. i I i Apr 19 1512:05p p•"13 I Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner Owner's Name information is required for every Hyannis MA 02601 4-14-15 page. City/fown slate Zip Code Date of Inspection D. System Information (cont,) Type. ® leaching pits number. ❑ leaching chambers number ❑ leaching galleries number ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,etc.): Leaching is a 1000 Gal. Precast Pit. Pit at 45"below grade. Pit is dry w/steel cover at grade. No sign of over loading or solid carry over. 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 ❑ No tSins-3113 Tille 5 Official Inspedlan Form:Subsurface Sewage Disposal System•Page 13 or 17 Apr-I a -I o-I t:uop p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner Owner's Name information is required for every Hyannis MA 02601 4-14-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i i i Privy(locate on site plan): Materials of construction: I Dimensions i Depth of solids -- - I Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, i etc.): j I I I Ii r i I I i i t5ins•3,13 Tells 5 Official Inspection Form:Sutrsurfaoe Sewage Disposal System•Page 14 011; � i Apr 19 15 12:05p p.1 5 Commonwealth of Massachusetts Title 5 Official Inspection Form ;l Subsurface Sewage Disposal)System Form-Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner Owner's Name information is Y required for every Hyannis MA 02601 4-14-15 page. Cilyffown State Zip Code Date of Inspection D. System Information (cont.) I Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately I I o I G G I i I i I I t5ins•aft Title 5 OfTlclat Inspection Form:Subsurtace Sewage Disposal System•Page 15 or 17 i Apr 19 1512:06p p.16 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner Ownef's Name information is required for every Hyannis MA 02601 4-14-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells NC Estimated depth to high ground water: 2 feet t Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ® 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: Area High Before filing this Inspection Report,please see Report Completeness Checklist on,next page. 151ns-Y13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Apr 191512:06p p.17 Commonwealth of Massachusetts U/� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1441 lyannough Road Property Address Tom McNulty Jr. Owner Owner's Name information is required for every Hyannis. AAA 02601 4-14-15 page. City/rown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3113 T111e 5 Olfidal Inspection form:Subsurface Searaga Disposer system•Page 17 of 17 No. ®v Fee tZo-a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2ipfication for Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑Complete System ,Individual Components Location Address or Lot No. (qq( _TyA 1VUI)UEs{I V;�> Owner's Name,Address,and Tel.No. (k'T 133) H`AN05 -r14C:t 4C A <N v L;r4 Assessor's Map/Parcel 4-j o f 0 a 1441 i A L)- N A0?J I Installer's Name,Address,and Tel.No. .702-1 71—F 8 77 Designer's Name,Address,and Tel.No. ux- 1:53 u its /A Type of Building: ,�Q Dwelling No.of Bedrooms /li►I Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures y� Design Flow(min.required) �� gpd Design flow provided A gpd 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) �-�{/\L � (,�/ /�`0✓�� {}�►����/'' R LL4 `jam pir 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 Certificate of Compliance has been issued by this Board of He� . Signed Date "F — 8'a©`s Application Approved by Date 8 AO/ Application Disapproved by Date for the following reasons Permit No. Date Issued �� ;,1 f --"----No.(/Y/�� � 0 ( Fee CG - THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. ./ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS RppYication for Bisposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair()o Upgrade( ) Abandon( ) ❑Complete System ,0 Individual Components Location Address or Lot No. p4q I =yA NUOU" Ri> Owner's Name,Address,and Tel.No. 64�r13,;) H14ANN15 -ri4OW.¢S U-00u GYy • Assessor's Map/Parcel ':Jq/o A 9 1441 I h V N RD WAOMIS Installer's Name,Address,and Tel.No. 50t-14T1-8 877 Designer's Name,Address,and Tel.No. GAP6ZutDG ls�M15FT L4,r► Type of Building: Dwelling No.of Bedrooms `t. /U►I Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures y� Design Flow(min.required) �tJ Cf gpd Design flow provided NM gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil i Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this Board of Health. , L Signed Date Application Approved by Date Application Disapproved by Date for the following reasons z Permit No. Date Issued q 8 OO1 --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Re_naired(4 Upgraded( ) Abandoned( )by CAPewli* wiumiSrS L(iG- at- I Y 41 S YA Nu0U al-4 M HV4 JAI I S has been constructed in accordan-e ` with the provisions of Title 5 and the for Disposal System Construction Permit NoA(y-0y I dated Installer QAVGWt*be SQTG2 KjSLC L(iL Designer U #bedrooms 40 Approved design flow J\ gpd The issuance of is peInf it shall not be construed as a guarantee that the system wil unction as designed l nn Date ( < Inspector ------------------------------------------------------------------------------------` No (/ 09( m.. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( ) System located at 1441 Z VA N jd()6N Al.� t��yC4ou I s and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 perm'.. Date�� GY S Approved by \ rl y L"O�CATION �� ` SEWAGE PERMI �z 3,4 a - . VILLAGE 7W A AlA- s1v1-s y INST LLER'S NAME & ADDRESS B UtLDE R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED , a 77 r � ' C i No............. .1,�. ...............� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �_0 / .. �J . 3 .. s _.._...-_._.._.._.-..._.. fratiun for Uiu uttl Works Tanrurtiun.. rprutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Sy tern at: Locatio re .or Lot-No. ------�T./�/Au/lt .. �. 1 �.-•-•--•-•- -•--•-------------------------------- Owner -------------------------•-...• Address. Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedroo Expansion Att c ( ) Garbage Grinder ( ) aOther—Type of Building vSi n/e=3 --- No. of persons S ?'�__�_.___...__ Showers ( ) — Cafeteria ( ) Othfixtures _....-•---•--•--------•----•------.-.-..••-..--•----_..-•--•-------•--•-•-----------------------•----••---------------------•-...._._.._..__......--•- Design Flow_._..__. _���__5 __._ .____ _g P P P Y Y W gallons per person per day. Total dail flow____________________________________________gallons. WSeptic Tank—Liquid*capacity.1_0.4?__gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------I......... Diameter.__-_g........... Depth below •nlet___� ______.._. tal leaching area..... �....sq. ft. i3oO'6 / Z Other Distribution box (>6 Dosing tail, an PC_— c'`3"7 7 p /V S S y rf, C,b c ~' Percolation Test Results Performed by.......... d_____ a1_4 , S!_._ rat______________ Date__—_:T_�3-7/7:_____..__-. Test Pit No. 130 e-.rKiixnt�s per inch Depth of Test Pit......... _______ Depth to ground water..../'_°i __- Gr4 Test Pit No. 2................minutes per inch Depth of Test Pit____1�__________ Depth to ground water____ d'1°......... O Description of Soil........... .....................�­- x U ------•--•-•--•--•---------------•--------•------------------•---••-•••--••-.._...------•-...-•------._...------------------------------------•••---•--•-------•-••---------------•------•------•---• W 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 iITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board o he lth. Signed._�.._...-•- ----- -----------•-•- --f k1J,,,4.2-7 ate Application Approved BY--fi-C,- d -------------------------------- -•--•---- --�--7��T 1&t�'�K 0 K Application Disapproved for the following real ns:_____ ____ _.._ -- k. -------------------- - Date PermitNo......................................................... Issued-....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD—OF HEALTH._. . .-. . .--....oF � J / r 7 4; .........................••---- Appliration for MipaiiFal Workii Tunotrnrtion Vamit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal L cat rey t�I► or Lot No. 11" x �Oer` Address a ... .......... f... .. �"'. _ ..............._........______.. -••--......._............................ --•................._...^^._...._.- Installer Address 4 Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedroo ......................................Expansion Att ( ) Garbage Grinder ( ) p�, Other—Type of Building �'�EM $... No. of persons".�'�'!.' --------- Showers ( ) — Cafeteria ( ) 114 Oth femur d �x -----------------------------•----•--•----------------------------------------------- ............................................................. W Design Flow...................!.._.._.___......:-----__gallons per person per day. Total daily flow......................._....................gallons. WSeptic Tank—Liquid capacity.) ...gallons Length................ Width................ Diameter---------------- Depth............... x Disposal Trench—N . ................... Widt Total Length Total'�leaching area....................sq. ft. Seepage Pit No.........[---------- Diameter --- ----- Depth below inle .._. tal leaching area.. 10. ....sq. ft. t+1 b i ib i Other Distribution box ( Dosing t Z i o F -- `'' Percolation Test Result Performed by. .._._.___ ..�_.__., _ ' _ a Test Pit No. 1 .� per inch Depth of Test Pit_____ _._____. Depth to ground water ' `,, _. k- Test Pit No. 2................minutes per inch Depth of Test Pit ............... Depth'to ground water " •-- .-• -----•---- D Description of Soil.......... ....4 . f!! .. rr._.. ................................ --- .- U -•-------•-----------------------------------------------------•--•-------------------------------..._._...... ......--••--...............--- -------------------------------------------------------------------------------------------------------•------------------------------------------ UNature of Repairs or Alterations Answer when applicable.........................p;__-____.____:_-_:---.___.----____-•--•-•--:_.:_.-.- •--•------__. Agreement The undersigned agrees to install the aforedescribed Individual 'Sewage Disposal System in accordance with the provisions of TIT1Z- 5 of the.State Sanitary Code— The undersigned further agrees not to.place the:system in operation until a Certificate of Compliance has been issued y the boar �o ,i lth, ,Signed yy ..�+.. - . ........................................................ ... --- . -�--- APPlication APProved By. �Date Application Disapproved for the following re "ons:................................................................................................................ ---•--••-----------------------•-•-•••---••--------------•--------•-------------------....---•--•--•••--••••---•---•-•---------••-----------•--•----•-•--•-•--•---------------••--••••-•----•-•••-••---- Date Permit-No.........................: .....•----•------......__ Issued............................................ Date THE COMMONWEALTH OF MASSACHUSETTS.. BOARD _0A HEALTH y* ....;.OF........... ........ .. ................. �r�ifirtt�r of f�ont�rli�anr�e T . I TO/ ERVFY, T the Indivldual Sewage Disposal System constructed ( or Repaired ( ) by er ....... .`* - ---------------- - -- .---•-_------- has been installed in accordance with the provi ions of T "' ` f The State Sanitary ode as described in the application for Disposal Works Construction Permit No._- ......_ +............. dated.--.-.-. � " 1�_:___..._..__..._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYASTTEE WILLr A ISFACTORY. (�- . . ......................• Inspector.D THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEA TH ` ............ ........ .: .OF..... .... .. ..... ........: ..... ` No......................... FEE.--<-..--................ io�roo rko oat igt permit Permission is hereby granted .. y g .......................................... - to Constr t o Repa Indio d Sewag is osal System atNo.. .-� 1 ........ . ..... --- ----------- ------------------------•--•- Street as shown on the application for Disposal Works Constructio rmit o._ ____:_::._______ Dated-----l ....................... ......... - r ................................. Y...................................................7 7 ;, Board of H DATE............ --,• FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - - r� THE Tp No i -- 1r OFFICE OF THE BOARD OF HEALTH S BAHHSTABL% : OF THE MA88. 0Mp9. TOWN OF BARNSTABLE, M SS. # '- ---------- 19 � SiEWAGE DISPOSAL PERMIT Permission is, ra Ito - " -° f g n - _ - to construct Upon they Premises of �� e _✓ % z r ----1 1-------- ------------------------------ In the vil ge of ' f'09Aor�more feet from any source of water-supply 20 feet from building r 10 feet from property line -- �.�_ -----�-- Health O i �r." -