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HomeMy WebLinkAbout0050 KENT LANE - Health 0 rent Lane Hannis A=291 127 4 e it 0 r,. a TOWN OF BARNSTABLE LOCATION N INN SEWAGE# jM/W SP GE o ASSESSOR'S MAP&LOT aZ 4 a 7 ID ?S NAME&PHONE NO. 6 C A N co SEPTIC TANK CAPACITY .S'E/OT L J/y S/°<r C r! a A., LEACHING FACILITY.(type) (size) NO.OF BEDROOMS BUILDER OR OWNER 1✓1.4 A D,40.S F PERMIT DATE: C8*R4d;V?*E DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by I � _ �_ �` M \`� i � _1 X 1 v r a ` w ' e - � ., v ��-�,; _;� •.� , ,�, v J COMMONWEALTH OF SACHU MA ETTS S S d Title 5 official Inspection Form Not for Voluntary Assessments "0y Subsurface Sewage Disposal System Form 7 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information / 1. Property Information: 50 Kent Lane — Hyannis, MA 02601 Map 291 / Par 127 Property Address Morse, Katharina L. Owner's Name 50 Kent Lane Owner's Address Hyannis MA 02601 City/Town State Zip Code June 23, 2006 Date i 2. Inspector: James D. Sears Name of Inspector A & B Canco Company Name 350 Main Street E Company Address izi West Yarmouth MA 02601 City/Town State Zip Code 508-775-2800 Telephone 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 16.000). The System: 7 Passes F 1Conditionally Passes Fails Needs Further Evaluation b the Local Approving Authority az_2�� �e 33O -0 � Ins tor'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. Title 5 Official Inspection Form:Subsurface Selvage Disposal System Page i of 16 f COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection Inspection Summary: Check A, B, C, D or E/always complete all of Section D A) System Passes: E] I have not found any information which indicates that any of the failure criteria described in 310 CM 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: N/A. ® 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: Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection 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 ® 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): inspection if(with approval of Board of Health): ® broken pipe(s)are replaced ® obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: N/A ® 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 environment: ❑ Cesspool or privy is within 50 feet of a surface water� r y ® Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Title i Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 I COMMONWEALTH OF MA ACH ETT SS US S Title 5 official Inspection Fora 9 C Not for Voluntary Assessments see Subsurface Sewage Disposal System Form B. Certification (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection C) Further evaluation is required by the Board of Health (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 DER certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less that 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Title Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 I COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form I 0 Not for Voluntary Assessments I.y �0v Subsurface Sewage Disposal System Form B. Certification (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ® E 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 leaching is less than 6" below invert or available volume is less than '/2 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 surface water elevation. ® n/a Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ® n/a Any portion of a cesspool or privy is within a Zone 1 of a public well. ® n/a Any portion of a cesspool or privy is within 50 feet of a private water supply well. ® n/a 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 and chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000 gpd— 10,000 gpd. 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. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 r COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form d Not for Voluntary Assessments 9� Subsurface Sewage Disposal System Form B. Certification (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection 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. N/A 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 office of the Department. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Fora i1 5V0�� Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. Checklist 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection 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? F41 ® Was the site inspected for signs of break out? E] ® Were all system components; including the SAS, located on site? ® Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition ofthe 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)]. Title 5 Official Inspection Form:Subsurface Sewage Disposal System' Page 7 of 16 COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form d ` Not for Voluntary Assessments 41 y0� Subsurface Sewage Disposal System Form D. System Information 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection Residential Flow Conditions: 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 0 No Is laundry on a separate sewage system?[if yes separate inspection is required] ® Yes No Laundry system inspected? Yes ® No Seasonal use? ® Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): N/A Sump pump? ® Yes F41 No Last date of occupancy: Present Commercial/Industrial Flow Conditions: N/A 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: Last date of occupancy/use: Date Other(describe): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 COMMONWEALTH OF MASSACHUSETTS N Title 5 Official Inspection Form 0 r Not for Voluntary Assessments p, V8 V Subsurface Sewage Disposal System Form D. System Information (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection General Information Pumping Records: Source of Information: 2001 and 2004 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: E] 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: 1995—Permit#1768 Were sewage odors detected when arriving at the site? ® Yes El No Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Form Not for Voluntary Assessments Vey`e� Subsurface Sewage Disposal System Form D. System Information (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection Building Sewer(locate on site plan): Depth below grade: 1' feet Material of construction: ® cast iron 13 40 PVC ® other(explain) Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Good Septic Tank(locate on site plan): Depth below grade: 9" feet Material of construction: Elconcrete ® 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: 1,500 gallon pre cast Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle 28" Scum Thickness 1" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt and Tape Title i Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Main tank at working level. Inlet tee, outlet tee. No sign of leakage or overloading. Grease Trap (locate on site plan): N/A 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 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): N/A Depth below grade: Material of construction: ® concrete ® metal ® fiberglass ® polyethylene ® other(explain) Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 COMMONWEALTH OF MASSACHUSETTS w Title 5 Official Inspection Form d Not for Voluntary Assessments 5� o Subsurface Sewage Disposal System Form D. System Information (cont.). 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection Tight or Holding Tank (cont.) 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 a copy of current pumping contract(required). Is copy attached? ® Yes ® No 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.): Distribution box is 16"x16", 20" below grade. One line in, two lines out. Box is clean and solid. No sign of overloading or solid carryover. Pump Chamber(locate on site plan): N/A Pumps in working order: ® Yes ® No Alarms in working order: ® Yes ® No ,I i Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 COMMONWEALTH OF MASSACHUSETTS r Title 5 Official Inspection Form d Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection 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: Type: ® leaching pits number: ® leaching chambers number: ® leaching galleries number: El leaching trenches number, length: Two at 30'x4'x2' ® 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.): Probe and test hole. leachingwet. No sign of overloading, working good. 9 9, 9 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 COMMONWEALTH OF MASSACHUSETTS Title 5 Official Inspection Fora e� Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NIA 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 Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Privy (locate on site plan): N/A Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding;damp soil, condition of vegetation, etc.): Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 4 COMMONWEALTH OF MASSACHUSETTS d Title 5 Official Inspection Form !� Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection Sketch of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. IIi I I � i I i R ha 4 "D 6 � D r C G 3 r • S_ , D C Tnie otlicwl Inspection Fern: Suh uri'aoe See uge Lisp sal Scstert Pave I". -,I Io COMMONWEALTH OF MASSACHUSETTS 4 Title 5 Official Inspection Form tl Not for Voluntary Assessments O, VBv` Subsurface Sewage Disposal System Form D. System Information cont. Y (cont.) 50 Kent Lane Property Address Hyannis MA 02601 City/Town State Zip Code Morse, Katharina L. Owner's Name June 23, 2006 Date of inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to no ground water: 8' 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 E] 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: Test hole 8' no water. Test hole 5' below bottom of leaching. Bottom of leaching at 3' below grade. Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 TOWN OF BARNSTABLE L( CATION S O K d-✓f gl'/?Jz�� SEWAGE # /p u—/ 941b� Vii LAGS 14 ASSESSOR'S MAP & LOT e INSTALLER'S NAME & PHONE NO.RO131d'ipt l9Cll4wo SEPTIC TANK CAPACITYcz- LEACHING FACILITY:(type) L " r �c�size)Z 3,0jx�/X NO. OF BEDROOMS Z PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER &)RS DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i a O A 'c ' J �- l✓ a� N0..../. ��7�� Fxs..... ®........:.. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Uinpuml lVorkii .Tvatitrurtion Urrmit Application is hereby made for a Permit to CcMs -uct ( 1,00<or Repair ( ) an Individual Sewage Disposal System at: i (� ems• . 1..... ----- �-..C��.�a ....................... ....�:......K.......1-....L ,�,.. - ..._.. e Location-Address or Lot No. �... �. +..t� ti ------------=------------------•----- .... � � �n . . ,... ......................................... Owt er Address e. � �(r�.v�.v��S-r-- 5. o 2 6.a\................. Installer Address Type of Building Size Lot............................Sq. feet Dwelling— No.,`of Bedrooms--------------------------------------- ----Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of 'Building ---------------------------- No. of persons_-_-_---__------___-__.-:- Showers (. ) — Cafeteria ( ) p' Other fixtures ...........____________________ _ _ W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. R; Septic Tank—Liquid capacity-------__..gallons Length---------------- Width---------------- Diameter-----.---------- Depth............. Disposal Trench—No. =----------------- Width.................... Total Length-------------------- Total leaching area............_.......sq. ft. Seepage Pit No____________ ____ Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box O Dosing tank ( ) Percolation Test Results Performed by----------- ----------------------------------........................... Date........................................ Test Pit No. I________________minutes per inch Depth of Test Pit...__--_____-__-__ Depth to ground water-.--__.-_.-__-_------_-- (i, Test Pit No. 2................minutes per inch Depth of Test Pit_---_-----______ Depth to ground water........................ ----------------------------------------------------------------------------------------------------......................................................... ODescription of Soil........................................................................................................................................................................ x W ----•---------------------- -------------------------------------------------------------------------- ---------- ------------------------------------------ -----------•---- .......................... Z Nature of Repairs or Alterations Answer when applicable.__-S_14C>-V-t. n!�--_....t�....__ -e i�_�5 .�... .._.___. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees no t place the system in operation until a Certificate of Compliance has been issued by the board h alt . Signed . --------- - ----- ------- `�..Jfo Application.Approved By - - ------------------------------------------------------------ -------------- D ..-------------- ate Application Disapproved for the following rearons- ------------__----------------..-..---------------..-...-......----..._.-..------------------------------------------------ ---------- --------------------- -- -----------...q------ ----------- ----- ---------..._.-..._---------------------------------------------------------------------._..._.......... -------------------------------------- Permit No. --------- / fv Issued --------------ll�-. -- � -------- Date k THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY, That t e Individual,Sewage Disposal System constructed ( ) or Repaired y /N� �. - _ 4-b � .. p-vL�•/ �� - Y. ! ......._....Insrdlc 5!� /,/�` 1 �IGI has been installed in accordance with the provisions of TITI,E 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ..-...-.5..... .._ dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....._........... � ............... ------------ ---- ... Inspect -------- THE,COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN O F BARNSTABLE v O 9 - 6 v No.---=�---•/•�•--� r''• FEE....:? ............... �i��r,a��1 Dr�� �Ilit�#P1UQri �Prntit o rf Gam /I ,n n Permission is hereby granted------.UAW--kut -------- to Construct ( ) oy Repair QC an Individual Sewage Disposal System t7G�.h l!17.j -------•..............•.-...---------------------•------•- . atNo..------�--------------------�----. �--- -•� - Street a� _��.� as shown on the application for Disposal Whorls Construction Permi No.. ._----�C ...............ated..__.-.��. - 6..._.............. ............ ------------------------------- 5................................. Board of Health DATE.--------.. /----------------•---�--- ' FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS �f . �J C.7 No. .. _.. r Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS"" If BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Dhrip ial Worlui Tomitrurtion- Vamit Application is hereby made for a Permit to Coi>`struct ( ✓) or Repair ( ) an Individual Sewage Disposal System-at: ....................... ------ r -----....... . .Qz---•-•-•----- ............ --------------------------- Location-Address ' or Lot No. In __._ �h4! - �± Q!C e�- S b ��r �� �.C. .. ..---------•-------------------------------- `` Owncrl Address ............................. -- ....0 6.0.................... Installer Address UType of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms............`. _--_.---. .-.-_._--Expansion Attic ( ) Garbage Grinder ( ) -.-_-__- No. of ersons---------------------_._.__ Showers — Cafeteria Pk Other—Type of Building __________________ p ( ) ( ) Otherfixtures •u-----------------•---••---------------------------..----•------------- ---••--•-------•- n .......-•--gallons, W Deslgn Flow......................................... ..gallIn�per person per day. Total daily flow........___........._.......... . gal R: Septic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter_-- ----------- Depth------------- - Disposal Trench Nio q ......... Width.............. ..... Total Lak.th........._._........ Total leaching area....................sq. ft. Seepage Pit No ----L. ......... Diameter.---.--.--_--.----- Depth 16'dvw inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank O Percolation Test Results Pel�orm b�,Q . =- Date Ic Test Pit No. 1..--------_-.-minutes per 1fn Depth of Test Pit-------------------- Depth to ground water...-_.-..------_----.-_. Gi, Test Pit No. 2.............1: gtes,peer;4nch Depth of Test Pit.................... Depth to ground water........................ ------------=----------------------•-----------------------------................................................................................... ODescription of Soil---------•-------------•-------......--••-•--••--•--••--•-----•-•-•-•••-••--._....-•--------•----•-•-------•-----••---••----•--------•-••----•-•--•-••---••-•--••.-•-•- x W U Nature of Repairs or Alterations—Answer when applicable.-_- -.-_-_-- 4��.r._.ouec�'........ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees no t place the system in o eration�until a Certificate of Compliance.has been issued by_the.board, h alt Signed ., - _�. r-." ---- ----- ------ ...................,�-- Application Approved B e � —�... Date Application Disapproved for the following reasons: -------------------------------------------._-------------------------------------------------- .---- --------------------------- ---- -----------------(p---------------------------- y----------_...- -------------------_------------------------------------------------ -- --------- ---------------------------------------- __. O D Permit No. ...- ------------ ------------------ Issued �------------------------------------------------------- Due SOIL E4:�ST Lo6 MAN^ � 4 AW Z �o xdL TEST 4 DATE of TwtiT: t�. 1 PL LA-T lor.l QAT�: L_ASS TJ4A 0 KEY MAP �,AoD Mitv.�'ril,. 1�J �'4uS; SAV'.)p T-r- --- f, ��arE_zE Iti (c., ) LAyE-ram I Erg E..E) CoQTou� sA C� -r K-----W-A_T _' -jl Z _ ) P r 1 Lr GLASS ! `NIr 4 I��% t��``;r`, M/N�M�4c.. C$,�D?PJ6� LRQco, ; fFRC . PATc ©F LE S TAAr..) l` r~ '1 LCLk II e EX16T iti1G � l� Lam,r / (� GAL F�L FLOW : 2 SE 2f)ot4S x ! 10 Gpp `L Z o ��D ! TA ra v- l " + Z(3oxL) + z(4xZ)] x .7� GPI/�F - l5"i.� urii �� �, �a,., '� ✓6i�!5 '� LAN S/-ALE: LD r 446TA-L,. 0,LIE S�� GAL . SFPT1 G T�IK _._. - - N" Y GAA E (1) - 1�lSTR,) e,CT10Q BOx -1 ' 1 Z:.�rl t WO rLl - � x `t x ? -EACttIUC -72FLICU �/ _ >7�.,=} ;P� > Z?l� 6P1� // V_ �� z3y rowu w4T �, L ) T r U►=1F /" pttK TEST _ gin _oWE� � U c x�SrJnJ� �E; ��Ch�LS TD 2,C PUM EP fILL.F0 I "F Pr,'+, TA,JV_ I-D- BO J ~C 5E ; A fvl •G_ i A)E (f,n t Ae-rEL F3AS E GI'-) A, (r' L-/LYE Cr_ 1 v S - ;SAD �` X� 410 1 ' jVAE OF I LE ........... 0 iir a r W of FoWL AMad To Wt FEtwl L E-Ac P --Tz o'Lc- _ � 1 J ` _ 4 t-o" OF FI U I,%} e50AV :: - - - i LAyiEk of 3' Poor I�d' ro /i SrDvjk wjE PROJECT �7 4� _t7 r oil r l TITLE D,A• . 4D EJFF -3 r, rU ! /zr �W � ��JT PAfr:;f _ Dkg�>FOo:�ALEI'� a -� ' L..�1. Gj x I TI►,I� V-50?C T''t�T ✓C. �!rC l-� �1"O N E l i nI�4 F• l PYc. �EMAnJ tEV�L � Z'-o" Wioe o. oos /Fr. Mc�UMur� ?!TCN j - _C-!1ti16 1�tr�lr.l To t_t (c�.1G B E N N ETT �'R E I L LY Inc. -.. , Engineering & Environmental Services W h M -I 84 Underpay, Road I Z' ✓m- �i Z l �' 1� wz FJ�l I'.O. Box 1667 2 - 508-896-6630 Office Brewster, MA 02631 508-896-4687 Fax W Jl� DATE: SCALE: BY: CHECK: JOB NUMBER: A, W SrA L LA77«M_� < . C1>r,. .� -rD �� rr"L F- !� ,..,�,