HomeMy WebLinkAbout0112 LINDA LANE - Health 112 LindaLane
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
+ d DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
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OCT 1 9 2004
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
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Property Address: 112 LINDA LANE ` `--- �-^�
HYANNIS,MA 02601 IPtiRCEI.
Owner's Name: JOSEPH&LINDA MURPHY
Owner's Address: 29 BUTTERNUT DR. LQ ® -"
SUTTON,MA 01590
Date of Inspection: 09/17/04
i
Name of Inspector: (please print) George McGuirk
Company Name: the CHASE/harris Corp.
Mailing Address: 108 North Main Street
North Grafton,MA 01536
Telephone Number: (508)839-6500
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 (310 CMR 15.000). The system:
Passes
Conditionally P s es _
Needs Further v luatio b t 1 Approving Authority
Fails
Inspector's Signature: Date: 10/6/.04
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.
Notes and Comments
TANK OK, D-BOX OK,WATER LEVEL IS I' BELOW THE PIPE IN THE CHAMBER.
THIS IS A VACATION HOME. THE WATER USAGE IS HIGHER THAN EXPECTED
DUE TO A SPRINKLER SYSTEM.
****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 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 112 LINDA LANE
HYANNIS,MA 02601
Owner: JOSEPH&LINDA MURPHY
Date of Inspection: 09/17/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
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:
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):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 112 LINDA LANE
HYANNIS,MA 02601
Owner: JOSEPH&LINDA MURPHY
Date of Inspection: 09/17/04
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for 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.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A _
CERTIFICATION(continued)
Property Address: 112 LINDA LANE
HYANNIS, MA 02601
Owner:JOSEPH&LINDA MURPHY
Date of Inspection:09/17/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X_ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X_ Any portion of the SAS,cesspool or privy is below high ground water elevation.
X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X_ 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.]
NO (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.
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•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 112 LINDA LANE
HYANNIS,MA 02601
Owner: JOSEPH&LINDA MURPHY
Date of Inspection: 09/17/04
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X_ _ Pumping information was provided by the owner,occupant,or Board of Health
X_'Were any of the system components pumped out in the previous two weeks?
X_ Has the system received normal flows in the previous two week period?
X_ Have large volumes of water been introduced to the system recently or as part of this inspection?
X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X_ _ Was the facility or dwelling inspected for signs of sewage back up?
X_ _ Was the site inspected for signs of break out?
X_ _ Were all system components,excluding the SAS,located on site'?
X _ 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?
X_ 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:
Yes no
X_ _ Existing information.For example,a plan at the Board of Health.
X_ _ 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)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:112 LINDA LANE
HYANNIS,MA 02601
Owner:JOSEPH&LINDA MURPHY
Date of Inspection: 09/17/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents: NONE-VACATION HOME
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO_ [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): YES
Water meter readings,if available(last 2 years usage(gpd)): 174 GPD
Sump pump(yes or no): NO_
Last date of occupancy: VARIES
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: HOMEOWNER
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X 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:
5/00 PER RECORDS AT THE BOARD OF HEALTH
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 112 LINDA LANE
HYANNIS,MA 02601
Owner: JOSEPH&LINDA MURPHY
Date of Inspection: 09/17/04
BUILDING SEWER(locate on site plan)
Depth below grade: 54"
Materials of construction:_cast iron X 40 PVC_other(explain):
Distance from private water supply well or suction line: TOWN WATER
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: X locate on site plan)
—( P )
Depth below grade: 48"
Material of construction: X_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: 5X10X5
Sludge depth: 10"
Distance from top of sludge to bottom of outlet tee or baffle: 229
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 1899
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: 112 LINDA LANE
HYANNIS,MA 02601
Owner: JOSEPH&LINDA MURPHY
Date of Inspection: 09/17/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X_(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.):
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 chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 112 LINDA LANE
HYANNIS MA 02601
Owner:JOSEPH&LINDA MURPHY
Date of Inspection: 09/17/04
SOIL ABSORPTION SYSTEM(SAS): X_(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:_
X_leaching chambers,number: 1
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.): WATER IS 12"BELOW PIPE
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Title 5 Inspection Form 6/15/2000 9
Page 10 of i l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 112 LINDA LANE
HYANNIS,MA 02601
Owner:JOSEPH&LINDA MURPHY
Date of Inspection: 09/17/04
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.
B
BACK
E
A
T D
T: SEPTIC TANK
D:D-BOX
E:LEACHING CHAMBER
AT: 17'
BT: 24'
Ali: 27.5'
BD: 20'
AE:46'
BE: 31'
Title 5 Inspection Form 6/15/2000 10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 112 LINDA LANE
HYANNIS,MA 02601
Owner:JOSEPH&LINDA MURPHY
Date of Inspection: 09/17/04
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_29_feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
X_Checked with local Board of Health-explain: PER OWNER'S CONVERSATION WITH BOH
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Title 5 Inspection Form 6/15/2000 11
r _ _ TOWN Or BARNSTABLE
LOCATION/Zc1 G:,,,& SEWAGE #
o n
VILLAGE , 6/ Azz C ASSESSOR'S MAP & LOT 01d
INSTALLER'S NAME&PHONE NO. Xe,(0 fi cZ 27,r--p6 j K
SEPTIC TANK CAPACITY I-rc O
,a r,
LEACHING FACILITY: (ty ) 14i WTOXJ (size)_ V J
NO.OF BEDROOMS
BUILDER OR OWNE
PERMITDATE: e®O COMPLIANCE DATE: O
Separation Distance Between the: ;
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
4 ; 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
G
1
,
0
1
o
5
d
. r
I ,
No. °I Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
s
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0[ppYication for Digaar *pztem Congtruction 3permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Womplete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 'D / V Y`to�A,LQ
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
i ) k�� 5 � 4
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 `�y� gallons per day. Calculated daily flow tJ gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ids? �;�5�kcf_-,K_ Type of S.A.S.
Description of Soil P6 a COv-&-c-
Nature of Re airs 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 be r
Signed Date
Application Approved b ,. 157 _ Date-t� s
Application Disapproved for the following reasons
Permit No. r Date Issued ti -" �
j TOWN OF BARNSTABLE - -j-�/-�--- ----
LOCATION�Io1 C,,,,/,� L� SEWAGE # r ol.�V
VILLAGE ��yq.v o q r,
—.-7---� ASSESSOR'S MAP & LOT� 0
INSTALLER'S NAME&PHONE NO. /?7jih .ITer,��
SEPTIC TANK CAPACITY /-rd'O
LEACHING FACILITY: (ty ) _/y�j7—a f71o1:p (size) _ .$� //J,r J�
NO.OF BEDROOMS
r
BUILDER OR OWNSFV-
j PERMITDATE
COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within.300 feet of leaching facility) Feet
Furnished by
COE
I
9 i
Fee
4 _ _- -THE COMMON EALTH OF MASSACHUSETTS Entered in computer: �
u . J YES `
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplicatio,n for ;h6po$af *p$tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) 10fComplete System ❑Individual Components
Location Address or Lot No. '`�., ��y� �l Owner's Name,Address and Tel.No.
'Assessor's Map/Parcel ��g O 7 ' v'C oU d,_"Lf
Installer's Name,Address,and Tel.No., Designer's Name,Address and Tel.No.
I��G(A� S•P��1Cr '
V-)
Type of Building: t�
Dwelling No.of Bedrooms t Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow `��� gallons per day. Calculated daily flow "1 9_y gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1 s7) CAP `t Aw Type of S.A.S.
Descripiion of Soil C CNV?,�L-
Nature of Re airs or Alterations(Answer when applicable) r s rb Z��l
L' �_k\ ST O SiOP.S
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 provi�Tlidlenvironmental Code and not to place the system in operation until a Certifi-
cate of Compliance has bean TiealChSigned Date �-
Application Approved b Date
Application Disapproved for the following reasons
Permit No. W Date Issued r '
--------------------------------------- -
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Dis sal System Constructed( ) Repaired( )Upgraded
Abandoned( )b
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit DW490 2 dated 1P- -7a9T:D
Installer Designer The issuance of this pe shfall notbe cons ed as a guarantee that the syste'm wyllunc/tiara as designed r `j r'
t, ( Inspector
Date ') � � � N p
No.---------------------------------------
Fee
i
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwigozaf 6potem Construction Permit
Permission is hereby granted to Construct( )Repair(V'` Upgrade(�b radon( )
System located at �`' �-
Y Z
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
ix>s
4t comply with Title 5 and the following local provisions or special conditions.
V,i,tlk, Provided:Cons tiara must be completed within three years of the date of t e it.
Date: Approved
r -
Y 1/6/99
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)
C�f hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at "C' l aa=c j{y meets all of the
following criteria:
The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
& There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
here is no increase in flow and/or change in use proposed
d/There are no variances requested or needed.
-/ The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. (Adjust the groundwater table using the Frimptor
method when applicable]
VIf the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following: �
A) Top of Ground Surface Elevation(using GIS information) 67;~ , 3
B) G.W. Elevation �1 +the MAX. High G.W. Adjustment .J•� _ 5 t &
DIFTERENCE BETWEEN A and B
SIGNED : DATE:
(Sketch proposed plan of system on back].
q:health folder:cert
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