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HomeMy WebLinkAbout0452 LINCOLN ROAD EXTENSION - Health 452 Lincoln Rd' Ext 271-029 Hyannis . !� r e 0 E A31- oa y Commonwealth of Massachusetts Title 5 Official Inspection Form 16, r� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments , J � Property Address r TO v'1 CC4 w,6ci re-fi^/ 3 Owner Owner's Name ��6® S 9 Information is h N s required for every -- t page. Cityfrown State Zip Code Date of Ins ection 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. Inspector I74 )e4e- ation 5 13�29 filling out forms /� on the computer, O Suse only the tab ✓ _/� 1 key to move your Name of Inspector y, cursor-do not use the return Company Name � Q key. O �(� ) X t) Company Address�j 4r. 0 ) /V..)— City/To Jr'D� �9O �/ / O State �/oc/o� Zip Code roam - `�" Tele honCmber License Number P B. Certification ! certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenanc n-site sewage disposal systems.After conducting this inspection I have determined that 7Pas!es 1. 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4.. ❑ Fails , 6pectorature 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable. and the approving authority. Please note: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. t5insp.Coc•rev.7f25/2018 -i5e 5 Cf5dai inspection=orn:s�bsudace Sewage Disposal System•Page t of 18 r Commonwealth of Massachusetts � Title 5 Official Inspection Form . p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L�#IC o/h Property Address Owner Owners Name /A� Q information is I_�06415 A! ig.>601required for every y + page. CitYlTown State Zip Code Date oAnspetzifon C. Inspection Summary Inspection Summary: Complete 1, 2: 3, or 5 and all of 4 and 6. 1) Syst 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: 2) 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): t5insp.tloc•rev.71Z612018 Tine 5 077 Taal inspection=om:Suosurace Sewage asposai System•Page 2 of 18 r Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner C N't 6orre orn Owners Name information is / 67 v1✓II S Aa&O/ 9 required for every / �// page. City[Town State Zip Code Date of Ins ection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 17 broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) 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. a. 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: ?age 3 of 18 t5insp.doc•rev.7/26/2018 -itfe 5 ofai;nspe—=o,m:suosunace sewage Disposal system• f+d Commonwealth of Massachusetts p Title 5 official Inspection Form k'.e,1--4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments / S� �t✓I,C oIv► Property Address Owner Qr fM �CYP/✓%� Owner's Name information is required for everyA-1014141 s 1414 �a page. City/Town State Zip Code Date of In pectin C. Inspection Summary (cont.) ❑ 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 b. 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. c. Other: 4) 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 ogged 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 Title s 03oa1 inspecton corrn:subsurface sewage Disposal System-Page 4 of 18 t5insp.tloc•rev.1262018 Commonwealth of Massachusetts Title 5. Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r-jok L I v!Cv/rl �x Property Address cGrh1,-"✓ewl Owner Owner's Name information is / A 44 f S �,j Qa/ 01 r / required for every ! � � �/ (� J page. City/Town State Zip Code Date of jAspecti& C. Inspection Summary (cost.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ 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 '/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 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 water supply u well. ❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ LK 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.] n e system is a cesspool serving a facility with a design flow of 2000 gpd- - 10,000 gpd. r- 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. 5) 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 CA. 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 El ❑ 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 t5irssp.tloc.my.712612018 'itle 5 Offcal Inspection Form:Subsurface Sewage oisoosal system•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments (� �IkiCoIn l Property Address Owner Owner's Name /� information is A���f OAP 01 required for every State Zip Code Date of Inspec on page. City/Town C. Inspection Summary (cont.) If you have answered"yes' to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" for each of the following for all inspections: Yes ❑ umping information was provided by the owner, occupant, or Board of Health ❑ ere any of the system components pumped out in the previous two weeks? ❑ as 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) r— 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)] ?iUe 5 D.Sdai inspection rom:SuCscrace Sewage Disposal System•?age 6 of 18 15insp.doc rev.7/262018 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments l Z, Property Address CG� Gre✓�� Owner Owner's Name information is P�j ci &14 required for every Ci 1� page_ Town State Zip Code Date of In"pe!Z D. System Information A&114- 44-- 9�- /%; .1. Residential Flow Conditions: 2 Number of bedrooms (design): 'Number of bedrooms (actual): 330 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: / /OC)O a. yew Gies 36 x C;z yc� le4 C, 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes f No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes F<No information in this report.) 1 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: Date Page 7 of 18 t5insp.doc•rev.7126,2018 Tive 5 `cat nspecoon=cm.s csu`ace Sewage Disposai System• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments oleo/4-1 0429 Property Address �j , Owner COP4 `'' a re'KID Owner's Name information is /�4 required for every ✓�N( page. City/Town State Zip Code Date of lifspectiV D. System Information (cont.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpdj Basis of design flow (seats/persons/sq.ft., etc.).- Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No t Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? �YesNo If yes; volume pumped: ldno gallons How was quantity pumped determined? Reason for pumping: -kp/ #ice— t5insp.00c•rev.7128/201-8 -itte 8 Offiaa nsoemon roan:Subsurface Sewage Disposal System•?age 8 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form s ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments •� (mil /�✓��0��'1 /�� QX� Property Address A C G #A4L a e-e-wl Owner Owner's Name information is 4011 required for every � page. City/Town State Zip Code Date of I pectin D. System nformation (cont.) 4. Type of tem: 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)and a copy of latest inspection of the l/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): 9 7- /yd Approximate e of all components; date installed (if known)and source of information: ata��/ 0�t ►?a L- - AT le ayGka Were sewage odors detected when arriving at the site? ❑ Yes iO 5. Building Sewer(locate on site plan): Depth below grade: 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_): I S;Ue 3 `oai inspection=om.Suosurface sewage Disposal System•Page 9 of 18 t5insp.doc•rev.7/26/2018 i Commonwealth of Massachusetts Title 5 Official Inspection Form r' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C� /vt Coln ted 40— -4 Property Address Owner Owner's Name information is 0.) 601 ef I� required for every page. City/Town State Zip Code Date of I specti D. System Information (cont.) 6. Septic Tank (locate on site plan): 30 // Depth below grade: feet Materi f 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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle — How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): TG COr► c�i770� /'✓ v Q��f. -ine 5oai InspeGIIcn Form:suosurface Sewage Disposes System•Page 10 of 18 t5i,p.doc.rev.726/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form P l,. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address C".O#--I Owner Owner's Name % /yj information is Q N K�S /i (0 O/ / q required for every ,1 page. Cityfrown State Zip Code Date of In ectio D. System Information (cost.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 i❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7126i2018 -i9e 5 of5aa:Inspection Form:Subsurface Sewage Disposai system•?age 11 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form �01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address cis aee ✓n Owner Owner's Name Q l information is Q�h!f ��/t Oc 60� required for every P page. City/Town State Zip Code Date of Insp ction D. System Tnformation (cons.) S. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 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.): 7;te 5 Of aa.nspacaon Fo gin.Suo&j face sewage Disposai System-?age 12 of 18 t5msp.doc•rev.7125/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Form -Not for Voluntary Subsurface Sewage Disposal System Assessments 4r Lj A Property Address 0 Q P111 / �{ Owner Owner's Name ` nn T information is required for eve A✓�K�! re G every City/Town State Zip Code Date of Insp ct'on page. D. System Information (coot.) 10. 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.): * If pumps or alarms are not in working order, system is a conditional pass. 11. 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: number; length: leaching trenches p� !eaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovativeiaitemative system Type/name of technology: -me s otfioal;nsoe.:tior,=0-c:SUDSLRaGe Sewage Dlsposai System•?age 13 aP 18 tsinsp.dor•rev.726/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address , Ga v�Zee sr 4e tYv� Q Owner Owners Name �- oa 6 0/ S / information is LA N�f required for every page. City/Town State Zip Code Date off pectin D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): J 0 QP4 ' S� s cl Gti. � e 7'�,114er. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): 5me 3 OY`�aai Inspe,�on=onn sucsudace sewage oisposai system•?age 14 0;78 t5insp.doc•rev.7262078 Commonwealth of Massachusetts Title- 5 Official Inspection Form ry Assessments � Subsurface Sewage Disposal System Form - Not for Voluntary% s ents 12J Property Address el Owner Owners Name information is �� D required for every Al a page. City/Town State Zip Code Date of Vlfnec4tio — D. System Information (cont.) 13. 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.): t5insp.doc•rev.7f2612018 Twe 5 Ot Qai mspecoon:orrn.suosur`ace Sewage Disposal System-?age 15 of 18 Commonwealth of Massachusetts -. P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments e is — 9 ii)�: Z/ 01 n ad Property Address Owner Owner's Name information is required for every Gi t�✓�� page. City/Town State Zip Code Date orffispe4n D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks o "nchmarks. Locate all wells within 100 feet. Locate where public water supply enters the buil g. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately I I i I I i I I 1 141 4-4_ So 43- 3z? ! -7e >Z I t5insp.tloc•rev.7/26,2018 Title 5 Of`cal lnspe=on Form:Sunsrf ce Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Zt 4L �► �� 2� Property Address orer� Owner Owner's Name information is Q s4 4 f j 0.)6 O '(S 9 required for every 14c,) page. City/Town State Zip Code Date of specti D. System information (cons.) 15. Site Exam: L1 Check Slope 60 ❑ Surface water C ,� ❑ Check cellar o 4o%"' ❑ Shallow wells Estimated depth to high ground water: 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 descriibb how you est blished`the nigh ground water elevation., q 47iT 1/0 S, / /Je 4 c,/ 4- Before filing this Inspection Report, please see Report Completeness Checklist on next page. i -itle 5 o tlaal.nspecaon=or:Sut,-`ace Sewage Disposal system•Page 17 of 58 t5insp.doo•rev.7282018 c\ Commonwealth of Massachusetts P Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address // r CG�bo,�2vri Owner Owners Name • �jJ 0 J /� information is required for every page. City/Town State Zip Code Date of In ection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. inspector Information: Complete all fields in this section. certification: Signed & Dated and 1, 4 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 F re Criteria) and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 15 or attached For 15: Explanation of estimated depth to high groundwater included 'Itle 5 ot`aa;Inspection Foy Suosurtace Savage Disposal System•?age IS of 16 t5insp.00c•rev.7/26/2018 `G TOWN OF BARNSTABLE �] / LCACATION `Y'S-� L.J,v e,,ok SEWAGE # VILLAGE � ASSESSOR'S MAP &LOT INSTALLER'S NAME&.`PHONE NO. h, SEPTIC TANK CAPACITY / LEACHING FACILITY: (type) /©®b -- —(size _ NO.OF BEDROOMS A Lj BUILDER OR OWNER Cal ell reel? f PERMTTDATE( `-17 q1 COMPLIANCE DATE: '? .. Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility -`Feet j 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 � i � !� � --� � ��i -. � �' � ' Q - � � � � � � i .., �._ .._� -� i � W � :, �� �- .. ,_ No.9 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for ]Digogar *pgtetn Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot o. a Owner's Name,Address and Tel.No. Assessor's Ma /Pazcel A fT Installer'se, 1ddress,andT 1.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 330 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature o epairs o Alter tions(Ans er when applica le) — X �— Date last inspected: Agreement: The undersigned agrees to ens a the onstruction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions oflb itle 5 f th Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issuedthis o d of h. Signed Date Application Approved by Date-5�n Application Disapproved for the following reasons Permit No. Date Issued ` G TOWN OF BARNSTABLE ` LOCAON Z �-l RJ /'V �of � SEWAGE # ! TI VILLAGE ri�'l/f �`Jl ASSESSOR'S MAP& LOT �'d INSTALLER'S NAME&PHONE NO. —J Q M v SEPTIC TANK CAPACITY 140 � 11 LEACHING FACILITY: (type) /OpC' L- / t (size)a- bx NO.OF BEDROOMS 3 �Gvcili ly `Ti«d BUILDER OR OWNER en •2 I'Z t PERMITDATE: 3 —17 ^ q 1 COMPLIANCE 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 II ► � a z� � � - q 1 oil 9 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for Migogal *pttem Contruction Permit x :b Application for a Permit to Construct( )Repair( )Upgrade(. )Abandon( ) ❑Complete System ❑.Individual Components Location Address or Lot o. o Owner's Name,Address and Tel.No. _ Assessor's Ma /Parcel Installer's Nam ee ddress,and Tel.No. Designer's Name,Address and Tel.No. �.J�'I��fy�CZGeaL� •�.. .r i �. .. 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 3 3 0 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title i. Size of Septic Tank Type of S.A.S. Description of Soil Nature o Repairs o Alterations(Answer when applica le) idtY t Date last inspected: Agreement: The undersigned agrees to ensude"the clonstruction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of�itle 5 gf th Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b this Bo d of Signed Date Application Approvd by Date 7f 0� Application Disapproved for the following reasons ; b j { 'Permit No. Date Issued qt •---------------- THE COMMONWEALTH..OF`MASSACHUSETTS i BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site,Sewage Disposal System Constructed( )Repaired YUpgraded( ) Aband ned( )by at �640W/. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit o. dated � �-�' 1 Installer Designer The issuance of this permit shall not be construed as a guarantee that the system will funnet�ion as designed. 7 Date - �"�, l I Inspector [`h` V ---- ------------------------------- 1 No. I ^< /ia Fee � lot= THE COMMONWEALTH OF MASSACHUSETTS j PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Migogar *pgtem Cori.5truction Permit Permission is hereby granted to.Construct(�)Rep ( grade( ),Abandon( ,) System located at L^(Al b i and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this it. a Date: �%�.— Zc. �� Approved v • e. F 7 .f NOTICE: This Form is to be used for the Repair of Failed Septic Systems Only CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I ""ht , hereby certify that the application for disposal works construction permit signed by me dated 3-27—� '/- concerning the property located at S x t meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility C There is no increase in flow and/or change in use proposed ` • There are no variances requested or needed. SIGNED : DATE: —'227 —7 / LICENSED SEPT[ SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. jxcrt Y7� VID � Q '4 ' V _ 1 � --� T D3n x 1 ' v' No 07� Fxs.... v.............. THE COMMONWEAL.TWOF MASSACHUSETTS BOARD OF HEALTH -� r. ........OF............. ------------_. Appliratiou for Uiipla.5a1 Workfi Tomitrurtiou Vamit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: , ..YS.. �_t lil y oLN... �d-�� /�N... ! --------- .........................................................� .4---------------...............--- Location-Address or 1- o - ...._ ,5e 1---------- 0 Owner Address Insta er Address Type of Building �� Size Lot_je-P.. 100'_.._..Sq. feet U Dwelling—No. of Bedrooms................, •---__._____.______--__Expansion Attic ( ) Garbage Grinder ( ) �1PL4 Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures W Design Flow.............____��__.___._._.___._gallons per person per day. Total daily flow__._._....................._s�3.�__.._._.___.__..gallons. WSeptic Tank—Liquid capacity./O..O.gallons Length....... Width------57>_ Diameter................ Depth........`.-. x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------I----------- Diameter.......1.d.°...... Depth,below inlet__- Total leaching area._ "...sq. ft. z Other Distribution box (K) Dosing tank (. ) '—' Percolation Test Results Performed by------��. = _--__--•-�-�--'_____�___�'_ Date....��""_1_�_.a��____.. Test Pit No. L_�.�.minutes per inch Depth of Test Pit...... �.__ Depth to ground wat�erAAr. (s, Test Pit No. 2................minutes per inch Depth of Test Pit Depth to ground wat�r-j ----- -'--(-----"----------------1- ----------- - a --•---.....----••-----••------�-------------........................................................-----.... O Description of Soil 1_'_ a- Wei4� ----------/ t'L1 € ........ t-------------=---------------------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------....................... U Nature of-Repairs or Alterations—Answer when applicable.............._________________________________•---------------_-•-_-_______-___•_•--_•--_-•___. Agreement: The tmdersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'T T p ' > 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 of health. d..... ............... Date Application Approved By...Alllul� Date Application Disapproved for the following reasons----------------------------------------------------•------------------------------------------------......_..... ................................................................................................................ . . . ----•---•--................................................ Date Permit No. :_. / Issued..5�`p o9'.7— e Date Fxs... .....�..�........ THE COMMONWEALTH'OF MASSACHUSETTS BOARD OF HEALTH "Gw .....--.....OF............ - -. ............. Appliratiou for Uiipna�ai Works (foutitrurtion rrrmit Application is hereby made for a Permit to Construct (XO or Repair (%; ) an Individual Sewage Disposal System at: .�� . N Art.._&-. - ..._ _ N. ...................................................... ... ............... Location-Address or I o No. t�.i.1`� ._.. t 4PAA$.Qr` _.�•h± ............ ......�_!_N __._.,1. ! ..1..`........... ......---••...................••---...-•---... Owner Address Installer Address QType of Building Size LotZ ....0 ------Sq. feet V Dwelling—No. of Bedrooms................,.......................Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P., Other fixture _____ W Design Flow.................�`�---._............._-----gallons per person p r day. Total daily flow............3✓�_Q.................gallons. WSeptic Tank—Liquid capacity/ .0--gallons Length_... ........ Width------ Diameter________________ Depth___-__ �_.. x Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area--------------------sq. ft. Seepage Pit No-------/............ Diameter......40......... Depth below inlet__ t�..... Total leaching area_/.4�...sq. ft. Z Other Distribution box (lK) Dosing tank ( ) '-' Percolation Test Results Performed by-----GC=�A,-6.de-.___._.�'`.,"'._.._ .._Cu �" �'� �79 -- Date- d •--•-t p e7'.— 2 D Test Pit No. 1._..�''.._Z'.minutes per inch Depth of Test Pit-----C�....... Depth to ground wat�r/.�:�__... 4� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground wate ..................... Ix •-•-•-•••-••-•--•-------•------•-••-•-•---•--•••-••----------- -••---•••---••-••••-----••---------•......................................................... O Description of 9 z,4/0 0/L G �� ~� t.... ...... W x •----•-----••-- --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•---•--- 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 TITLE p 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 of health. fined ------------------- Date Application Approved By. ` ------ . •--••- Date Application Disapproved for the following reasons:............................................................................................................... .__ -----------------------------•-----•--------•--••--•--••----••-_••--•----••-•----------------•----•••-••--•---•--------------•-•--••------•---------------•---•--•-•--•--- ............................. Date PermitNo..........................:.............................. Issued.-----•--••---•-----------•--•-..:..................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH .....OF....... .. -:.. '�^' Trrtifiratr of (fir mptiattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) ------- ---------- ........................... ------6;XF�) nst ler has been installed in accordance with the provisions f ,T I.The State Sanitary Code as described in the application for Deposal Works Construction Permit o_•. _. /.. ................. dated... �__.__._.____.._ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT.BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL FUNCTION SATISFACTORY. /O DATE .......... ;K7-f� ---•---------------------------•---. Inspector ................... .--- �� 3 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF UEALTH / OF.. l.. No. .l�>I :' FEE.... ................. �i��u��t1 �rk� ��atta�#r�.�Uan rruti� Permission •s hereby granted....................................................-•........................................................................................ to Constru or Repair ) �n dividu S .wag is os ,System at ..... I-�et ­�-/ as shown on the application for Disposal Works Construction Per No. /_�.__..'� ___ Dated.._11_-_1—.77:,...... Board of Health d DATE....=---•-•--•-•--••--•-•-•-•----...--••••......--•••-•---••-•-•--_. :.. FORM 1255 HOBBS & WARREN, INC., PUBLISHERS L 0 C A.T ION pp SEWAGE PERMIT NO. i � '-,a-4 -7 9- 6 6�e _ VILLAGE INS A LLER'S NAME i ADDRESS a BUILDER OR /OWNER� DATE PERMIT ISSUED to -lei _ ?a DATE COMPLIANCE ISSUED gl�o '� � -z �, ',ice E`� 6> �` 0`� a S cs_ u�"a x� i�F�3' f �s ��� / e •J�/ fir , � � `� Lod'` ZS 7 t i r i ,. .t AJ 4 140, UO /421 ,-7' 10, soot . 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