Loading...
HomeMy WebLinkAbout0198 LINCOLN ROAD - Health 198 LINCOLN RD. HYANNIS' k A = 270 048 ° q C 4 f AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION A a g L` Lc %V, , R-0, SEWAGE# ©t— J,r? VILLAGE_ �--1 ASSESSOR'S MAP&PARCEL nip—05/� INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) -a k Soo (size) 13 r o�S� v NO.OF BEDROOMS 3 OWNER `U.ou�z.. 1M a d �: •�� PERMIT DATE: COMPLIANCE DATE: gr p/p j 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 I j Q UJ !_ W _. _ if Jo, -8 ,= kc' rot 01 � k a A 3= Sri t B3= 31 G '-d 101 �•• �J� J• I� Y\ Lf http://issgl2/intranet/propdata/prebuilt.aspx?mappar=270048&seq=1 10/30/2013 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS °� A-' � DEPARTMENT OF ENVIRONMENTAL PROTECTION 5V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 198 Lincoln Road Hyannis �3 Owner's Name: Dave McBride Owner's Address: Date of Inspection: October 4,2007 Name of Inspector: (please print) Patrick T. Sullivan Company Name: Ready Rooter Mailing Address: P.O.Box 371 Sandwich,MA 02563 Telephone Number: (508)888-6055 CERTIFICATION STATEMENT 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: _ZPasses Conditionally Passes Needs Further Evaluation by the Local Authority Fails Inspector's Signature: Date:j<!3E-%; 'I The system inspector shall submit a copy of this inspection report to the Approving Authority(B azd of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 1:0.: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,aid the approving authority. ' li Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 198 Lincoln Road Hyannis Owner: Dave McBride Date of Inspection: October 4,2007 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: 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 appr ed by the Board of Health,will pass. Answer yes,no or not determined (Y,N,ND)in the for the foll ing statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the se is tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or t ailure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as ap oved by the Board of Health. *A metal septic tank will pass inspection if it is structural sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is avail le. ND explain: Observation of sewage backup or break t or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled uneven distribution box. System will pass inspection if(with approval of Board of Health): roken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required p ping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with appro al of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: I Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 198 Lincoln Road Hyannis Owner: Dave McBride Date of Inspection: October 4,2007 C. Further Evaluation is Required by the Bo/te ealth: Conditions exist which require further evay the Board o Health in order to determine if the system is failing to protect public health,safety or the ennt. 1. System will pass unless Board of Healtines in ccordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner wll pro ct public health,safety and the environment: _Cesspool or privy is within 50 feet ofe terCesspool or privy is within 50 feet ofri g vegetated wetland or a salt marsh 2. System will fail unless the Board of Hd Public Water Supplier,if a )determines that the system is functioning in a manner that protects the public health,safety and envi nment: —The system has aseptic tank and soil absorption system(SAS)and the S S 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 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 f et of a private water supply well. _The system has a septic tank and SAS and the SAS is less th 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 DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well i free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal o or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be ached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 198 Lincoln Road Hyannis Owner: Dave McBride Date of Inspection: October 4,2007 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 _,,Z 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 and overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow �[ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. �[ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. �[ Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] QC—)(Yes/No)The system fails. I have determined that one or more of the above 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 ith a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the followin . (The following criteria apply to large systems in addition to a criteria above) yes no _the system is within 400 feet of a surface d ing water supply the system is within 200 feet of a trib ry to a surface drinking water supply the system is located in a nitroge sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supp well If you have answered"yes"to any estion in Section E the system is considered a significant threat,or answered "yes"in Section D above the lar system has failed.The owner or operator of any large system considered a significant threat under Sectio or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner s uld contact the appropriate regional office of the Department. f Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 198 Lincoln Road Hyannis Owner: Dave McBride Date of Inspection: October 4,2007 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 than owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes No f _ Existing information.For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 198 Lincoln Road Hyannis Owner: Dave McBride Date of Inspection: October 4,2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):33© C. V.k, Number of current residents: -_cr Does residence have a garbage grinder(yes or no):�'� Is laundry on a separate sewage system(yes or no):Qa[if yes separate inspection required] Laundry system inspected(yes or no): < Seasonal use:(yes or no):,1C Water meter readings,if available(last 2 years usage(gpd)): 360 Fr,P•iD �c�6 Sump Pump(yes or no): k _ Last date of occupancy: Gca ti+-x�d.� COMMERCIAL/INDUSTRIAL Type of establishment: _ Design flow(based on 310 CMR 15.203): _gpd Basis of design flow(seats/persons/sq.ft.etc. . Grease trap present(yes or no):_ Industrial waste holding tank present(yes r no):T Non-sanitary waste discharged to the Ti e 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Q 0C)6 Was system pumped as part of the inspection(yes or no): Y=5 If yes,volume pumped: 1 S-o;:�j gallons--How was quantity pumped determined? ezbc� Reason for pumping: TYPE OF SYSTEM Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be ob_tained 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: ���'�-►.._ '�,r.3�'-aS�>~r� 4?�ag/o t - C�rT��,,c�� a� CORM���.�,,.cre Were sewage odors detected when arriving at the site(yes or no):_QO 'Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 198 Lincoln Road Hyannis Owner: Dave McBride Date of Inspection: October 4,2007 BUILDING SEWER(locate on site plan) Depth below grade: %0" Materials of construction:_cast iron t/40 PVC other(ex lain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: V(locate on site plan) Depth below grade: Si I Material of construction:_concrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: // ` x S✓� -� S` 1 TO0 6.As Sludge depth: 3 " Distance from the top of sludge to bottom of outlet tee or baffle: 38`L Scum thickness: 5' " Distance from top of scum to top of outlet tee or baffle: " Distance from bottom of scum to bottom of outlet tee or baffle: p' How were dimensions determined:" TC1SnC Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): �, V, G . �...�� � ©�-�tom'� �Tc c s '�,� .��a.�•c. . G.',d �,� �e,.��,� 0'=T . GREASE TRAP:_(locate on site plan) Depth below grade: Material of construction:_concrete_metal_fibe ass polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee o affle: Distance from bottom of scum to bottom of tlet tee or baffle: Date of last pumping: Comments(on pumping recommendatio s,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of akage,etc.): 'Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 198 Lincoln Road Hyannis Owner: Dave McBride Date of Inspection: October 4,2007 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction:_concrete_met _fiberglass_polyethylene_other(explain): Dimensions: Capacity: gallo s Design Flow: g ons/day Alarm present(yes or no): Alarm level: Alarm ' orking order(yes or no): Date of last pumping: Comments(condition of ala and float switches,etc.): DISTRIBUTION BOX:—JZ(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: n" Comments(not if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): �- Siox $" be�� ���2� - ov.� ....\•aT' - o��. ovi�'. �o Sol:-Qs G o t J��.l a�+'�r - � 5�.� p� ��,a, w.b-C�a J� �•A t y.,:y.� o e�¢,r PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump cham er,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 198 Lincoln Road Hyannis Owner: Dave McBride Date of Inspection: October 4,2007 SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: leaching chambers,number: 9 w/ q` �;o,.-c 3 x Q S leaching galleries,number: leaching trenches,number, length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): ��5<J- o.,,� G 1ti+e,�.•�te-e,r- �"�C..;.� 6°t a� �r�.�LrG. L�o c,'�Q.Sl Lam.e�.e.,`. �u Ka�ec.�, l�s� o� 5..C1_S. C1�v., s�ov.•c cf�5�1�s ��� �.�Jb�r �'�.+ro�-�cJl� �,:49.,•e.. cl�,..t 1.S o� GVvsw.1e•o✓"• �� 5'+Sw a� �.►aSi CESSPOOLS: (cesspool must be pumped as part of inspe ion)(locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of h draulic 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 draulic failure,level of ponding,condition of vegetation,etc.): I Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 198 Lincoln Road Hyannis Owner: Dave McBride Date of Inspection: October 4,2007 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. { r-'. c e►�� 1 w"T e.r' LIJ I I 10 3 n r , Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 198 Lincohi Road Hyannis Owner: Dave McBride Date of Inspection: October 4,2007 SITE EXAM Slope Surface water Check cellar✓ Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: btained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with the local Board of Health-explain: Checked with local excavators, installers-(attach documentation) y"Accessed USGS database-explain: '��1,n..S'crv`ea., vSA. Gorv� You must describe how you established the high ground water elevation: -•,Jo � oe�v.. c�'�.J� '���rv�.:�+., tiro G¢\\�.T Pr — Q 5,�. 3. 5` zc�c o r�acQe. `trs � � .t�•c. -rc ST a c Q i' ����. II Y�GG�.SS+e. Gea` c�POe...^� c�sd'�@.f� C oev�:Tdt�•r"' d..� �7-o.�'e fVrAO�O��S � Town of Barnstable �p 1HE Tp� Regulatory Services ST"LE ; Thomas F. Geiler, Director L MASK. 9`vArED6►9. �p`0� Public Health .Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-8624644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. TOWN OF BARNSTABLE LOCATION (aQ q L R0, SEWAGE# 0 t— VILLAGE {�-Ib.A;�,,�,s� ASSESSOR'S MAP&PARCEL a7O�QYS INSTALLERS NAME&PHONE SEPTIC TANK CAPACITY LEACHING FACILITY:(type) C"Y•..b-e y%S•a Soc (size) Y NO.OF BEDROOMS 3 OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching;Facility 1;i 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 BYVZ 6-N. ` r 4. ILI N ' h L 0 Ol d a _t w 4j 16 o�+ 4.4 • O Q TOWN OF BARNSTABLE 97 LOCATION /�� Li����..i ' /� SEWAGE# VILLAGE ASSESSOR'S MAP & LOT v171f 09 INSTALLERS NAME&PHONE NO.Lei j&�AA SEPTIC TANK CAPACITY �r®� C dL 'r LEACHING FACILITY: (type) r61-0 GAL 44xS NO. OF BEDROOMS 3 BUILDER O OWNER t PERMIT DATE: COMPLIANCE DATE`. Separation Dis?ance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leachitg.Facility '(If any wells exist f " on site or within 200 feet of leaching facility) r Feet Edge of We and Leaching Facility (If any wetl.ands''exist within 300 feet of.leaching facility) 'Feet Furnished by /���% ,E _\ Y ' 4 �► o � No. _'^-° -i- Fee�� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01pprication for Migooar *p5tem Cou5truction Permit Application for a Permit to Construct( )Repair( )Upgrade(v/ Abandon( ) P"Complete System ❑Individual Components Location Address or Lot No. �CO Owner's Vame, Addres�and Tel.No Assessor's Map/Parcel `5 r' eo r/ C /� Installer's Name,Address,and Tel.Nno. Designer's Name,Address and Tel.No. 1✓ Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of BuildingO.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow /f® gallons per day. Calculated daily flow �Em gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank w��101 Type of S.A.S. Z �L7d O' i r Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by thi o d eal Signed Date "�, -_-g/o Application Approved by tV Date Application Disapproved for the following reasons Permit No. Date Issued 1 No. ffSS�� J 1 / � .-w Fee (/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes P6BLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 0(pprication for Mizpogar *p!5tem Construction Permit �- Application for a Permit to Construct( )Repair( )Upgrade(V�Abandon( ) PI/Complete System O Individual Components/ Location Ad"df'ess or Lot No. ' Owner's Name,Address and Tel No. /qf- Z-,�re�1� Assessor's Map/Parcel h111"11 f-5 Installer's Name,Address,and Tel.No. Designer's?Name,Address and Tel.No. Bo��a�a t�� �oys>` Type of Building: i Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder Other Type of Building Ae r C2No.of Persons Showers( ) Cafeteria( ) Other Fixtures L l Design Flow &11�1 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title �'< t ;.. . t. :--i Type of S.A.S. Z Size of Septic Tank /,,,��0< �_' -:r YP Description of Soil 13/YZc� A Z —. ic.•� Nature of Repairs or Alterations(Answer when applicable) ` Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system i in accordance with the provisions of Title 5 of the Environmental Code and not to place the system iii;;,operation until a Certifi- cate of Compliance has been issued b thi , o d P Signed Y .�" # _ '' Date Application Approved by ,k ` `t i` "': `. ' Date Application Disapproved for the following reasons Permit No. 4' Daie Issued( r > THE COMMONWEALTH-OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERT Y,that the gn-site S wage D•sposal System Constructed( )Repaired( )Upgraded(� Abandoned( )by �f 7®G O (s l9 S at 1N d �/' fJ� S has bye; onstructe in accordance _with the provisions of Title 5 and the for Disposal System Construction Permit No � —�d ted �� l:�ts- C1_ Installer Designer The issuance of this shall not be construed as a guarantee that the sy to ill funct on a design d. Date 2permit k)l Inspector ( G• 11�t� .v No-Qm) Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Mi!6po0af *pgtem Construction Permit Permission is hereby granted to Co struct( ) epair( )Upgrade(✓)Abandon( ) System located at 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:Cons truc�nh� m le,ed within three years of the date of p Date: Approved b PP Y NOTICE: This Form Is To Be'Used For the Repair Of wiled Septic Systems. Only. - C-VR=CATION OF SKETCH A_ND APPLICATION FOR A DISPOSAL WORKS CONSTRUC EON PERMIT fFYrI'HO'LTI'DESIGNED PLANS) �����✓ ��� �%l y czrff7 that the anolication for disoosal works cor,suuction permit sued by me dated concenin� the property located:,at G�fl � y . . Me= all.of the I�IlO�r'I17E CaZterla:. (/ ae'ai e::Srsi to S C ZLn�ted to.a resin; i2i Q r1ei mg on v. .t e:e n 21 J'Liln—v o comIn1e:m. or _'ses 25so`.ate`1'wtzh the ciwe t_..L^_Q. soLs c.2szia,._2s C-1 A.-,- i andf�_.—_-�:arion ate is .^s ,n^'L Jr ..:iL:! :0... �" - "�:ZLa71L:`.; �C... ne:_are no we`iands .>'i-in. 100 --.of�Ze:,rJnes-szvric:.sem ;.,e no p.:.Yare wet wi- .1:0 _-__o,.the aroMsed Septic u .s-:g is no mc.°;-s P-in flow 2nd/or.c :e ;n se oroxs--d. ae._ —z no v-arances.Z=Used or nm,4e✓ /7,zz bottom.of the pro?osed i c Q acidity w*:h not be i=--md l-- _ n 4:ran Eve L_:2.cve the =—=- mum adj=,ed,,—mmd-A-ate:tabie elaarion. fAdjus the round ate:.table.using the'=, ptor ethod when applicable]. if the S. S.-%U be locamd with_10 feet of 2:iY.veQerate,we the boom of ne t7r000sed leaching nriiiry-ivzll not be ted Iess than fourt=(14) feet above the sz:u-num aditsed groundwater table ei—Mli , Pie=se complete the foilomnb A) Top of Ground Surface Elc:adon I 'ng GIS imh=,aion) 3). G.W.s:madon �S —th:.MAX-nL;i G.W.A4jugmeat. 3.v _ ��✓ ` DL--F= -_TIC 3EFWHEN A and 3 1 J ` SIGMED DA=-: xh el [S'r=(t proposed pl-n.of sysz=on back]. i d O N - I � i Q vJ I L b D 2 _.v.x.�wj L^r 4S' .s l.L .� .�- +^ .i�Fq Or MIN Y„ 1 ' E E ..:t - 4.. S Fft a TOWN- OF BARNSTABLE .. LOCATION SEWAGE yS`� VII.I AGE hfn�,cr ASSESSOR'S MAP & LOT a27O INSTALLER'S NAME&''PHONE,NO.'' a SEPTIC TANK CAPACITY /Slid el LEACHING FACILITY: (type). ✓a-4 L�(. l,• i C/�.�. 1 /� x�f X� ' (size) � NO OF BEDROOMS 3 BUII DER O OWNER ry r PERMrrDATE: 8 �/ COMPLIANCE'DATE: Segaration Distance Between the Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility57 Feet„ Pnvate Water Supply Well and Leaching Facility (If any wells exist f on site or within 200 feet of leaching facility) Feet'. Edge:of Wedand and1eaching Facility(If any wetlands"exist within 300'feetof leaching"facility) Feet Furnished by ip y£ tf : .j 5h } oy �Md, 1 c ® .Y . - --. - _ a