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Home My WebLink About0022 KENNEDY CIRCLE - Health 22 KENNEDY CIRCLE, HYANNISP,ORT A=267-057 r 1 i a t Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Fore Not for voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hy p annis ort MA 02647 04/03/1'2. 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, use only the tab 1. Inspector: key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections Company Name PO box 896 Company Address East Dennis MA 02641 Citylrown State Zip Code 508-385-7608 SI 3742 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 .' 04/07/12 Inspector's Signature Date 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_ ****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. L/Q5/ m[gel� I � t5ins•11/10 Title 5 Official Inspection Fo :S U'ce Sewage Disposallystem• of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hy p annis ort MA 02647 04/03/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Fora 51 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hyannisport MA 02647 04/03/12 page. City/Town state Zip Code Date,of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ 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 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 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 mannerwhich 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•11110 Tiffe 5Of ial lnsper ilon Fonw Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hyannisport MA 02647 04/03112' page. Cityrrown 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: 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 ❑ ® Discharge orponding 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hy p annis ort MA 02647 04/03/12. page. City/Town 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 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 fecal coliforrrr 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 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 El ® 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. 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 ❑ ❑ 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 offir.P of the Department. t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hy p annis ort MA 02647 04/03/12 page. Cityrrown 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 ® ❑ 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: ® ❑ 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(5)]; D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hy p annis ort MA 02647 04/03/1.2 page. Cityfrown state Zip Code Date of Inspection D. System Information Description: Number of current.residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings,if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal,System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hyannisport MA 02647 04/03112' page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below) General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes. ® No If yes,volume pumped: gallons. How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records, if any) ❑ Innovative/Altemative 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): t5ins-11110 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hy p annis ort MA 02647 04/03/12 page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 09/28/98 per BOH Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): Depth below grade: 1.4 feet 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.): Septic Tank(locate on site plan): Depth below grade: 0.8 feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ®polyethylene ❑ other(explain) If tank is metal,list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500 gal Sludge depth: 3" t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal.System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hy p annis ort MA 02647 04/03/12 page. Cityfrown 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 30" Scum thickness 3" 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 16" How were dimensions determined? measured Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was sound and fight with tees in place and liquid at outlet invert.The cover on the outlet end should be replaced. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins-11/10 Title 5 Official Inspection Pone:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 22 Kennedy Circle Property Address Patricia Maier Owner Owners Name information is required for every Hy p annis ort MA 02647 04/03/12 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,.structural integrity, liquid,levels as related to outlet invert,evidence of leakage,etc.): 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 per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches,etc.) Attach copy of current pumping contract(required). Is copy attached?' ❑, Yes ❑ No t5ins-11110 Tdie 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hyannisport MA 02647 04/03/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑. Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located,explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hy p annis ort MA 02647 04/03/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ® leaching galleries number: 4 ❑ leaching:trenches number,length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ inn ovative/a Item ative system Type/name of technology Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has 4 infiltrators in a30'xl 1'stone field.There was no sign of ponding or failure. 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 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hyannisport MA 02647 04/03/12 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,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.): t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f . j Commonwealth of Massachusetts -_-- This 5 O icoai Inspection For . ` Subsurface Sewage Disposal System Form-Not for Voluntary Assessments, 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name 4 information is required for every Hyannisport MA 02647 04/03712 page. City/Town State Zip Code' Date of Inspection D. System Information (cont.) i Sketch Of Sewage Disposal System:Provide a view of the sewagejdisposal system,including ties to at leasttwo permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.Check one of the bones below: i hand-sketch in the area below ❑ drawing attached separately #j i aS � a� eu.0 i i I t5ins•11110 Title 5 official Inspection Fo t:Subsurface Sewage Disposal System.Page 15 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hy p annis ort MA 02647 04/03/12 page. Cityrrown State Zip Code Date of Inspection. D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet 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: USGS maps show an elevation of over 20.0 feet. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 f s • Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 22 Kennedy Circle Property Address Patricia Maier Owner Owner's Name information is required for every Hy p annis ort MA 02647 04/03/12 page. Cityrrown 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-1 V10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 �II i� i _ s , �� 161 TOWN OF BARNSTABLE LOCATION G N Me�y��n SEWAGE # /p VILLAGE z,2� ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. (J�S Q t � SEPTIC TANK CAPACITY 1 S LEACHING FACILTry: (type) GCV (size) NO.OF BEDROOMS BUILDER OR OWNER (4- PERMITDATE: - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Private Water Supply Well and Leaching Facility (If any wells exist Feet on site 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 Feet TOWN OF BARNSTABLE LOCATION c ZQL- Y— SEWAGE # 10 4 VI:.LAGE ASSESSOR'S MAP & LOT 2�7- dS 7 INSTALLER'S NAME&PHONE NO. AN, �"C:A'\�'e—S IQ .4 SEPTIC TANK CAPACITY LEACHING FACILITY: (type). Ca Oe-\-A s (size) NO.OF BEDROOMS BUILDER OR OWNER 1/U PERMITDATE: _`k n- 'V COMPLIANCE DATE: -`l ��- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by _ c-6 � 0 ,. No. Fee v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS apphration for Miopool �&pgtem Conotructiou Vermit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System ❑Individual Components Location Address or Lot No. t%a Gf N co-C e Owner's Name,Address and Tel.No. yr ct w et.1S Po rr W Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms_ Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures c, Design Flow gallons per day. Calculated daily flow 1, / gallons. Plan Date Number of sheets Revision Date Title _ Size of Septic Tank !� db Type of S.A.S. rC jQe-f T i Description of Soil Nature of Repairs or/�Iterations(Answer when a licable) I ST �.7 O '�cC--j A ", 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 n to place the system in operation until a Certifi- cate of Compliance has been j8s,0—ed by t is d of Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued 'Y.;.„".�� /. .-;. ..... _ ,. n_ :...F.',: ... �1_iY.,:! ' • .nwn.,a.r*'g4..r yMyt,. 7*3y'i'•_ .::.y,: ..;Yo ,.... « 'f..r'9yy{^y`:.p•!-fr'a+.r"'f"'1.+.r•= .y ...m n« //.�^/F/�I/�.�.-..�. ;,_ No.•. Fee THE'COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes -PUBLIC HEALTH.DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01ppYication for 30i5poear *potem Con.5truction 'Per-mit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon P5Complete System ❑Individual Components Location Address or Lot No. Oa ��11�J �[�' C\+rc Owner's Name,Address and Tel.No. -fct Assessor's Map/Parcel «y Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms_� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow t�? b gallons per day;-Calculated daily flow J gallons. Plan Date Number of sheets f Revision Date Title _ Size of Septic Tank / 0 44t--V Type of S.A.S. C4 Description of Soil S Kl �"IJ , Nature of Repairs or terations(Answer when ap licable) YSaI 4 r� � u T- 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 n to place the system in operation until a Certifi- cate of Compliance has been ' ued by this o r` Signed i _ Date / Application Approved by ( ® U Date 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 1 l Cf �_ TJ C, at &nned U rC a ben constructed in a ordance with the provisions of Tit] id the or Disposal System Construction Permit No. dated Installer CQ � D 1' Designer The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date _ Inspector No. 9 Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mioogai *raem Con!5truction Vermit Permission is hereby granted to Construct( )RepP�r( ) pgrade( )Abandon-( System located at 1- 4 h L.� and as described in the above Application for Disposal System Construction Permit.The applicant recog 'zes hi9ler duty to comply with Title 5 and the following local provisions or special conditions. J O � Provided:Cons tru .'on just be cO p eted within three years of the date of t is a It. Date: j Approved by ) ` f'11,' low .. a . t air.Of Failed ,• E is Form Is To Be Used For the Rep lr . Th terns on1Y• Septic Sys : F SKETCH AND APPLICATION FOR A RTIFICATION 0 IT(WITHOUT ' DISPOSAL WORKS CONSTRUCTION PERM D ENGINEERED PLANS? works I, } _i hereby cerfifY U the application for disposal conceming the permit signed by me dated a �G-2 ao( meets all of the located at ctitaie. folloarin6 =. ° kaehMg tiidlhy ` , 11Kte are no wetlands lowed within 100 tbet of tt+e proposed - wells within 150 fleet of the prof° ero no r i �.,• Mete l��e . F �.. There is no h+aease M Elvin►andlordt•ngo in use prgww or needed. I �.I wetlands,the bona^oaf the � � i nen win be Ioested within 230 feet of ern► {{ If the p�P leeching. Will r be 1oc�ated less then fourteen(14)feet above the m,Xlmum adjusted op I prosed leaching f rcilitX w i Om abh elevetlon• `. md m left the Mewl"V pltttse to p or around.ElerNlon( Mg to the Enghreerine pivision 0.1.3.meP) A)Top B)Observed OMWwft T*te Elevation(eacading to Health Divblm well map) DATE: a sIM=• � 4 LICENSED SE C SYSTEM M31'ALER 1N THE TOWN OF BARNSPABLE NUMBER ' F I a�dMd pmt p1M, ! ` j �AttMlr•dtwaA pIM Kdw prolr�M�•AM*IttM IhnMd In0ibt Og1MtiN 1; this plan drould be nbr M04 n -"�- ,�. �� `� 1 � .tt �� z — : Gans s-T—ivv ,a 3-�3id o 09 s-spa-a-air�`=3-yvv�-ln-�]s-a��w is-�-► .�-�- :w n `g• Y �� V ... `� p ` �` r a 4.: II k.. �. ti s` ., No.---- FRs.... D.. ........ THE COMMONWEALTH 00� ASSACHUSETTS _ .r. 41B!0 R® OF HEALTH Appliratilan -for IN-4 uiittl WorkD Totwtrurtiott Prrutit d Application is hereby made for a Permit to Construct (✓) or Repair ( ) an Individual Sewage Disposal �.�. Syst at: L atio Arens r �✓ ..It No. ---=------- ------ --- ..... ---- ller war Addr - --....---- = . =1W Address Type of Building y Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aa4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria Q' Other fixtures --•--- -----•-- ------•--•----- W Design Flow---15 --------------------------------gallons per person per day. Total daily flow-.-------342-6)--------------------gallons. Ra Septic Tank=Liquid capacit 400gallons Length................ Width................ Diameter---------------- Depth_-.:-.--------- W x Disposal Trench—No. .................... Width....______.._ Tot 1 Len th-- -__ Total leaching area-------.------------sq. ft. Seepage Pit No ------ Diameter ._0_010 ow in e ............. . Total leaching area------------------sq. It. � �----- � •-- .P z Other Distribution box ( ) Dosing tank - Y� 7 aPercolation Test Results Performed by.---------_.............................................................. Date------------------------------------ Test Pit No. 1----------------minutes per inch Depth of Test Pit--------:----------- Depth to ground water...-.---------.--.-----. o w Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water..........-. . Description of Soil l/$�- !�' " -. �-------- � -- -------�--` t--- ` Wx -----•---------------------------------- l, ----------d ----------•-----------•--•---------------------------------------•--••`-----------•-----------•------••----•------------------ -----•-------------- --- U r 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 Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been i by he bo rd of he lth. Si ed.:..... `""� __� ..__ —- •---- •----_-- ----- j Application Approved BY ,/ _ .-. � /� &//l / .f.... } _ _ ate Application'Disapproved for the following reasons:. ....---•--------------':-_...............---•-•---------------•-•----------•----------------•---- -------------------------------------------------------- O . 'Date Permit No. /-� - ...•----••-•---------. Issued.. 7-=./a 7 Date 'No......12 FE ............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..... .... ..... ...........OF...................._1.............. ....I.............................................. Appliration -for Dhipatial Marks Towitrurtion Vrrmit Application is hereby made for a Permit to Construct (e<or Repair an Individual Sewage Disposal System at: ... V ------------------- ....2 ,- ... ----------- - ---------- Lo t4iQo"nw Wacrd ik ess e. A..t N o. ....... . -- ---- ... — 4 - 4V #.ddr Installer ------------------ ................o..w.... .......... -------- Address Type Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms_________________ ---------------Exp�nsion Attic Garb age Grinder-A - -pi ��VdA ypi�--d�B --tdlding --- ---------- No of Showers a t-- a de e- ria Otherfixtures -----------------------------------------------------------------------------------------------------I------------------------------------------------ Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------...........gallons. P4 Septic Tank—Liquid capacity-------------gallons Length________________ Width..........._... Diameter__:._....._.---_ Depth.-_.--.--_.----. r x Disposal Trench—No_ ____________________ Width____________.__-;__- Total Length,.........___.__._._ Total leaching area--------------------sq. ft.- Seepage Pit No-_----_----------- Diameter;;.._,__.____.__.._.. Depth below inle,t_.................Total leaching are.a --------------sq. it. Other Distribution box Dosing tank Percolation Test Results Performed by------------------- ...... ----------------- -----------------m�-77...... .. Date------------------------------------ Test Pit No. I----------------minutes per inch, Depth of 'Test Pit.................... Depth to ground water.--._---:.--.--.--.-.--. 44 Test Pit No. 2................minutes per inch Depth of Test Pit...._..._._____..___ Depth to ground water__.--.---_---_"----_.--. 9 ............................................................................................................................................................. 0 Description of Soil--------------------------------.............................................m.........................................------------------------------------------------- U ..........................................................................................................................................................---------------------------------T------- ------------- ----------------------------------------------- ------------------------------------------------------------------------------------------------- 7----------------------------------- 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been 1Wffj by he bo of e,1th. Signed------------------ ... ... ............ ------------------- - ................................ Date ApplicationApproved By----- ...........................................................--------------------------------- - ------------------------------------------ 11__�- Date— .Application Disappro4d'joi the.following reasons:-------------------------------- ................................................................ ................ . ......................................................................................................................................................................................................... Permit No..............k�....................... Issued.................. Date ate THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ —ONO OF............00,�L ................................ j Tutifirate Of Tompliaurr THIS IS TO-CERTIFY That the I i1vid I Sewqaispo/,?—Lstem constructed (P�or Repaired by---------------------------7;�_ ----- ....................... ................................. 7ns V . . ..... . Article ----------- at...... .......... ------- ---- ............ ... ..... ----------...................... has been installed in accordance wi the provisions of ArtiZeXI of Th State nitary (CodVes d * e in the application for Disposal Works Construction Permit No---- escrV . . ................ dated........... ......... ................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE TWAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------......... f 74.................................... Inspector--.. ................................................. .5.................. OF-MASSAC-HUSETTS BOARD OF HEALTH ..... .............................. No......../4472- ...... ............. OF ... FEE...... ... Bi-XI:r0fial rk,q Tantitr ti prr it d-------------------- I -- -- -------------------------------------- Permission is hereby grante ,to Con�tructj �r Repair an Individual Sew Di ystem /0----- .",.......... ........... --- ----------------------------------------------- at N o,. as shown on th a 1* ion for Di osal'Works Construction Permi N I... Dated_...... ��,2 lio pp ic4 D,pp ic ..... ................... -----------...... -------- ... ............................................. oard of ealth DATE............... .. ..................................................... FORM 1255. HOBBS & W RREN. I.NC.. PUBLISHERS RS l r . ;� r' . t V •.i 4 4 i�I. ` } � i 0 • rY' a ... _ �r r