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HomeMy WebLinkAbout0260 LONGVIEW DRIVE - Health 260 LongviewDrive Hyannis CP/R A = 251 129 "" a s TOWN OF BARNSTABLE LC'"Nf10N SEWAGE # VILLAUE 1�f ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. ' SEPTIC TANK CAPACITY Aojoa LEACHING FACILITY: (type) (size) NO.-OF BEDROOMS 572aC-ld c�- 4'AMTe BUILDER OR OWNER PERMITDATE:_l�` COMPLIANCE DATE:. 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 . 3 Furnished by-- IT 1 1 1i1 � t J COMMONWEALTH OF MASSACHUSETTS . EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION pASS FSS0RSM y� F *04 No APNO. S� s TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: a b o L o vIVA) D2 a n 4?4 s, A it 0 ��a ! Owner's Name: -�! � pp"w�/e f Owner's Address: 'C..- a Date of Inspection: Name of Inspector:(please print) Joseph M.Martins t o Company Name: Accu Sepcheck - Mailing Address- 17 Northside Dr., S.Dennis,MA 02660 Telephone Number: 5W385-5891 CD p � CERTIFICATION STATEMENT �a I certify that I have personally inspected the sewage disposal system at this address and that the info ation i0ortet below is true,accurate and complete as of the time of the inspection.The inspection was performed ased only rrn training and experience in the proper function and maintenance of on site sewage disposal systems. am a DEP approved system inspector pursuant to Section 15340 of Title 5(M 0 CMR 15.000). The cyst Passes Conditionally Passes Needs luaiion by the Local Approk,%uuju,-ty Fails 4&� Inspector's Signature:9- m Date: The system inspector shall sa 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 sent the system owner and pies sent to the buyer, 'f ap iicable,and the approving DEP.The original should be ys • W mo e �e /;Wg ,authority.. �-c,�'°� 9 f9 e2ds C �. .f�► Notes and Comments: fed S �C �U ' ©✓f��'� j►eA Co✓,,odeA A P Q PU M p 1 Ae,e ol M r" ""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 I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: d "view _ �. Owner.' ICOGf ten le r- Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete an of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Syste Conditionally Passes: �(n ! v /q ! re a Wet �� "" V ✓ .One or more system components as described in tfie"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 t explain. The septic tank is metal and over 20 years old*a`r°°the septic tank(whether metal or not)is structurally unsound,exhibits substantial'infiltration or efiltration 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 pipes)or due to a b okeft,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: 1 ' Page 34 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Z-o V R4� dJ� Owner:_ bllp-4 levo Date of Inspection: C. Further Evaination is Required by the Board of Health: Conditions exist which requite 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 ilea Determines in accordance with 310 CMR 15.303(1)(b).that the system is not functioning in a er which will protect public health,safety and the environment: _ Cesspool or is within 50 feet of a surface water Cesspoo 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 su The system has a septic tank and SAS the SAS is within a Zone 1 of a public water supply. _ The system has aseptic d SAS and the SAS is within 50 feet of a private water supply well. _ The system has a tic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water sup well**.Method used to determine distance **This s m 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: Page 4 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: -40� �V& Vt Owner:_ 62U W r, Ve Date of inspection: av y D. System Failure Criteria applicable to all systems: You mast indicate`W or"no"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow — , Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of tunes pumped J� 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. T Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis.[This system passes if the well water analysis, performed at a DEP certified laboratory,for cofiform 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.l (Yes/No)The system Ms.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary t orrect the failure. E. Large Systems: To be considered a large system the system ust serve a facility with a design flow of 10,000 gpd to 15,000 gPd• You must indicate either"yes"or,`no"to ch of the following: (The following criteria apply to large ems in addition to the criteria above) Yes no the system is within 40 eet of a surface drinking water supply _ the system is within 00 feet of a'tributary to a surface drinking water supply the system is 1 ed in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone U of a p is 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 ve the large system has failed.Tine owner or operator of any large system considered a Section E or failed under Section D shall de the system in accordance with 310 CUR • significant threat under ech upgrade � 8n „ al office of the Department. 15304.The system owner should contact the appropriate region o . Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: a{ v V (J/z- Owner: lee, Date of Inspeetioe• Check if the following have been done.You must indicate')Ts"or"nor as to each of the following: Yes No Pumping information was provided by the owner,occupant,or Board of Health v 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? SL=�04 0 t- !(Have large volumes of water been introduced to the system recently or as part of this inspection? P�ere�as built plans of the system o ed 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 th m e 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: Yes no 1/ 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)P 10 CMR 15.302(3)(b)J l Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION erty Prop Address.• c;26z) I v V ')u k I Ig Owner: d11 elr Date of Inspection: G FLOWAQNIDIFOg �- RESIDENTIAL 7 OYl l Number of bedrooms(design): Number of bedrooms(actual): t/ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): l Number of current residents: b ��S 10� W e I J Per O� Does residence have a garbage grinder(yes or no): Is laundry on a separate sewage system(yes or no):AL [if yes separate inspection required] Laundry system inspected(yes or no): j* 01 Uf 4 3 r Di 8 .9 Seasonal use:(yes or no):7)W. f"da o Water meter readings,if avaable(last 2 years usage(gpd)): A467 Sump pump(yes or no):III �� G,�® �?, , Last date of occupancy:!e, /rat j&j-2®,&Y COMMERCIALANDUSTRIAL. . ' Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sq Grease trap present(yes or no): industrial waste holding went(yes or no):— Non-sanit waste di ed to the Title 5 system(yes or no):_ g Water meter rea ' s,if available: Last date pancy/use: OTHER(describe): GEtit RA INFORMATION Pumping Records tAI� - �i HST rtS pec1dv� pa►-F Source of information: Was system pumped as part of the inspection(yes or no):,v If yes,volume pumped:_gallons—How was quantity pumped determined? Reason for pumping: --� )- TYPE OF SYSTEM l.�G,G i� 2- �'�t'�rc`TU✓S) V Septic tank,distribution bo 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) T Tight tank Attach a copy of the DEP approval —Other(describe): Apprqximate a e o all con vents,date installed(if known)and source of informaUgn: s L 6 @GtN#W.Q/ ✓ dhh !�Q s or no): Were sewage odors detected when arriving at the site(ye Page 7 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:. abo ZoAq V e0j�r2 MOO- Owner: figf,1,t2/'1le r Date of Inspection• BUILDING SEWER(locate on site plan) Depth below grade: 22� W Materials of construction: cast iron e/ 40 PVC_other(explain)- Distance from private water supply well or suction line: 101 Comments(on condition of'oints,venting,evidence of leakage,etc.): SEPTIC TANK;'(iceate on site plan) Depth below grade: Material of construction:Ycrete 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) / /I �'/ J� f d v0 Dimensions: / o X � Sludge depth: II It s Distance from top o sludge to bottom of outlet tee or baffle: a 7 Scum thickness: �l Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outl tee file: How were dimensions determined: /r V V� P Comments(on pumping recommen s,inlet and outlet tee or balfl condition,structural integrity,liquid levels as r lated to outlet invert,evidence of leakaaJ c.): l QS \ &v fW v �OP / am. $ Ca✓rdalP�! CU !� � -� uJ /IVC. Dvt� �C`2 GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction: 'concrete metal—fiberglass ethylene_other (explain): T Dimensions: Scum thici mess: Distance from top of scum to to utlet tee or baffle: Distance from bottom of s to bottom of outlet tee or baffle: ` Date of last pumpin Comments(on ping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related tlet invert,evidence of leakage,etc.): a Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORM/CATION(continued) Property Address: 440 ojM Owner: -- ._-� ._ : �r/LtpJ'i 1Q✓_ Date of Inspection: jp r ' 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: gallonstday = Alarm present(yes or no): Alarm level: Alarm in working or or no): Date of last pumping: Comments(condition of alarm an float switches,etc.): DISTRIBUTION BOX: '�(if present must be openedX1ocate 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.): L �� pee a�lP✓e��P e-< <s , D d'f`7�•e�T-F= o w p yr-A 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�ber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: v `p�� 40k Owner:_. "' 41rt 1P�I her Date of Inspection:i, 4 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type �/ �. �L4 0 teaching pits,number: / t7 X b / ! - leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow I 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.): w K U S�S 0 P hs H of �Jy' A o vL ,00/�. P12t�6Pp1 ap00A.. s NO CESSPOOLS: (cesspool must be pumped as part of inspection)(iocate on site plan) C�e 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 inflo es or no): Comments(note condition of4oil,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 ul.ic failure,level of ponding,condition of vegetation,etc.): r - Page 14 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(vmtinued) Property Address: ,Zloo Lo �4W Pe �.. Owner: �:_. icou e1'11'e� Date of Inspection: b O 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. Pal F. R D - 0-wr . .50 N O r� 2 ;- 3 = ' 6 =,535 �=,2Lj C5 LIA Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ✓ r`��w D Owner. Date of Inspection` SITE EXAM Slope Surface water Check cellar t Shallow wells J Estimated depth to ground water Please indicate(check)all methods used to determine the high ground water elevation: Obtained frogs 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 local Board of Health-explain: Checked with local excavators,installers-(attach documentation) _I/Accessed USGS database-explain: !3Q ouvk b 1•e V��COWIO Jr Maf You must describe how you established the high ground water elevation: z 9 6 1 z1"uKd w � No. Fee / 0 v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2ppfication for Miopool *pgtem Comaruction Verna Application for a Permit to Construct Repair( "1 Pgrade Abandon Complete System �dividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel otqer / a y� �� o f-� ?0,,f C F.vU' Installer's Name,Address,and Tel.No. S(S$ , �f�s p°pt> Designer's Name,Address and Tel.No. 71_ 356 411 iw ST tar-�i�iE' Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other 'lope of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 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 of Repairs or Alterations(Answer when applicable) 09 f 044 C£ /AvL C 7- G C/O`d £T '7Zr 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 ispw4 by this Board of Health. Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No.. ^M 4 Date Issued 8 N0. C 0 �1 Feet */U TQ., -' W THE COMMONWEALTH.OFd MASSACHUSETTS Entered in computer:` es ' PUBLIC HEALTH DIVISION -TOWN,OF BARNSTABLE., MASSACHUSETTS 3ppficatiou for'Otoogal *ps�tem Construction Permit Application for a Permit to.Construct{ )Repair( k4pgrade( )Abandon( ) O Complete System [�`l'ndividual Components Location Address or Lot No. 0 �Gti� l/I£w ( �S.C' Owner's Name,Address and Tel.No.p . F C�l�/'�u/ f.e ��,,5•£,0.5/ Assessor'sMap/Parcel (ni�/�� 5)-5 / I a-- �t 1 . v_6 0 ,1_v vj C F ti r. Installer's Name,Address,and Tel.No. SAY.. 7 9 f dti p'o Designer's Name,Address and Tel:No. 7-1- deg 04A/ Y 3 5 0 gl;11v gT 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title s Size of Septic Tank Type of S.A.S. Description,of Soil, Nature of Repairs.or Alterations(Answer when applicable) T ye G £T ^ 7 £ Date last inspected: r` 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 iss - by this Board of Health. Signed '" Date.. Application Approved by _ Date Application Disapproved for the following reasons Permit No. 3 Lt Date Issued 4`- ------- --- ------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Dis osal.System Constructed( )Repaired( L-)-Upgraded(" ) Abandoned( )by C V411V 5 7- Gam /C has been constructed in accordance with the prov' ions of Title 5 and the for Dis osal System Construction Permit No. �U,)'{`3,1N dated ?. Z w �1 Installer 55- Designer The issuance of 's a 't shall not be construed as a guarantee that the sy t ill function as designed. Date R: 7�0 s Inspector .. No. ��( U l Fee /�G THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Dio o.5al ztem� c�Con.5truction Permit � p Permission is hereby granted to Construct( )Repair( 4)-Upgrade( )Abandon( ) System located at /V 4 )/1 £ kv Z,/V7— 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 condiuo Provided:Construc 'on must be completed within three years of the da of this e Date:`/d�� Approved by . f w TOWN OF BARNSTABLE LOCATION ' SEWAGE # D VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. Q 6 4041v [J 8 7'7. A 2'Ve' SEPTIC TANK;CAPACITY In6r� LEACHING FACILITY: (type (size) NO.OF BEDROOMS ".=X) C 2L � P BUILDER OR OWNER PERMITDATE: n'� COMPLIANCE DATE: > 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 Fur;ished by y .b i COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 3 DEPARTMENT OF ENVIRONMENTAL PROTECTION ti < y TITLE 5 '. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS t SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM f ' PART A DFICATION Property Address: 260 LONGVIEW DR ,MA 02630 Owner's Name: ROBERT MISCRACA � `ff ` Owner's Address: C/O BRIAN COBB,CENTURY 211550 CENTER PLACE CENT Date of Inspection: 11/26/01 t �1 r Name of Inspector: (please print) {E JOHN GRACI v Company Name: SEPTIC INSPECTIONSr pEP ' Mailing Address: P.O. BOX 2119 TEATICKET,MA.02536 Telephone Number:508-564-6813 FAX 508-SGa 72 0 CERTIFICATION STATEMENT ' I certify that 1 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(31 U C 1 I It 15.000). The system: ' X Passes s . _ Conditionally P sses _ Needs Furt r valuation by the Local Approving Authority Fails ' Inspector's Signature: r x Date: 11/26/01 The system inspector shall submi copy of this inspection report to the Approving Authority(Board of Health or DEP)within y 30 days of completing this inspe ion. 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 y SYSTEM PASSES TITLE V INSPECTION.RECON,1NIFND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. h. ****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 inthe future under the same or different conditions of use.. S I.: r, r . F y k Page 2 of 11 ' g OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 260 LONGVIEW DR BARNSTABLE,MA 02630 '` Owner: ROBERT MISCRACA Date of Inspection: 11/26/01 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D a A. System Passes: x " 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. •tl ,,. A. �, Comments: SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE „ SYSTEM'S USEFUL LIFE. B. System Conditionally Passes: _ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, W 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. f ) 1�Z n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits -s.�t' 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. r *A metal septic tank will pass inspection if it is structural) sound not leaking and if a Certificate of Compliance indicating g P g , that the tank is less than 20 years old'is available. Y ' ' g ND explain: n/a n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed a pipe(s)or due to a broken,settled of uneven distribution box. System will pass inspection if(with approval of Board of +> Health): ' _ broken pipe(s)are replaced }rfy � t9 _ obstruction is removed _ distribution box is leveled or replaced , ND explain: n/a n/a 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): 4 i _broken pipes)are replaced , ' _obstruction is removed i E- ND explain: n/a d- Page 3 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . xk. CERTIFICATION(continued) Property Address: 260 LONGVIEW DR BARNSTABLE,MA 02630 Owner: ROBERT MISCRACAX �tpg Date of Inspection: 11/26/01 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 #f ' 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 W.. not functioning in a manner which will protect public health,safety and the environment: f Y _ 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 y g e: 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: 4 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"surfacewater supply. R t. _ The system has a septic lank and SAS and the SAS is within a Zone 1 of a public water supply. 1Y _ 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 n/a " "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. - f 3. ;.Other: , n/a , x << f Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACtSEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION(continued) K Property Address: 260 LONG•VIEW DR BARNSTABLE,MA 02630 „' Owner: ROBERT MISCRACA1 .• "• ` '''" Date of Inspection: 11/26/01 D. System Failure Criteria applicable.to all systems: You must indicate"yes"or"no"to each of the following for all-inspections: s: 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 SYSTEM WAS RECENTLY PUMPED. X Any portion of the SAS,cesspool or privy is below high ground water elevation. x+ 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. w _ 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'4 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 sr hT y•' 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.] ,; x (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 a necessary to correct the failure. t + Y 4. E. Large Systems: s• , ;; 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 X the system is within 400 feet of,a surface drinking water supply „1 _ X,the system is within 200 feet,gf.a tributary to a surface drinking water supply " _ X the system is located in a,nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped cj , Zone II of a public water supply well 1. dP If you have answered 'yest"to'any question in Section E the system is considered a significant threat,or answered in Section D above the lar a ssteni has failed.'rhe owner or operator of an large system considered a significant threat- yes" G �� . g 4Yuq: G._ P Y g Y g 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. �f i JA Page 5 of 11 • 4 4 } 1. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B 'CHECKLIST Property Address: 260 LONGVIEW DR BARNSTABLE,MA 02630 Owner: ROBERT MISCRACA r; Date of Inspection: 11/26/01 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 s, t 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? q, 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 dwelltng inspected for signs of sewage back up? t X _ Was the site inspected for signs of break out kyr� X Were all system components,excluding the SAS,located on site? X Were the septic tank manholesf uncovered opened and the interior of the tank inspected for the condition of the x . baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? ..4`<t X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance " *� of subsurface sewage disposal systems'? z;X, .Kc The size and location of the Soil Absorption System(SAS)on the site has been determined based on: t 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)] #$ s{ r. t - Page 6 of 11 t o f t • _i µ n � n OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C } SYSTEM INFORMATION Property Address: 260 LONGVIEW DR BARNSTABLE,MA 02630 Owner: ROBERT MISCRACA. ;. Date of Inspection: 11/26/01 ' FLOW CONDITIONS RESIDENTIAL } Number of bedrooms(design): 4 Number of bedrooms(actual): 4 "`s ( ) � z DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 s Number of current residents: 2 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): NO #' Water meter readings, if available(last 2 years usage(gpd)): n/a Sump pump(yes or no): NO 4 90, Last date of occupancy: n/a h COMMERCIAL/INDUSTRIAL Type of establishment: n/a Design flow(based on 310 CMR 15.203): n/agpd Basis of design flow(seats/persons/sgft,etc.): n/a Grease trap present(yes or no): NO Industrial waste holding tank present(yes or no): NO Non-sanitary waste discharged to the Title 5 system(yes or no): NO -i Water meter readings,if available: n/a Last date of occupancy/use: n/a OTHER(describe): n/a GENERAL INFORMATION r� Pumping Records � A Source of information: SYSTEM WAS P_U mpeA Was system pumped as part of the inspection(yes or no): ?W If yes,volume pumped: n/agallons--.How was quantity pumped determined?nft Reason for pumping:921& m 'fit a TYPE OF SYSTEM y r X Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _Privy a _Shared system(yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a co of the current operation and maintenance contract(to be obtained from �jrox; gY PY P - system owner) _Tight tank Attach a copy of the DEP approval s � Other(describe): n/a {� a Approximate age of all components,date installed(if known)and source of information: 1977 Were sewage odors detected when arriving at the site(yes or no):NO V, v 1 G Page 7 of 11 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ,,] SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM . .:r PART C ' SYSTEM INFORMATION(continued) 'b Property Address: 260 LONGVIEW DR BARNSTABLE,MA 02630 r '' Owner: ROBERT MISCRACA Date of Inspection: 11/26/01 '. BUILDING SEWER(locate on site plan) R Depth below grade:22" Materials of construction:_cast iron X40 PVC_other(explain): n/a `Ltk �r- Distance from private water supply well or suction line: n/a Comments(on condition of joints,venting,evidence of leakage,etc.): TOWN WATER SEPTIC TANK: X(locate on site plan) ; Depth below grade: 16" Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate) ',' Dimensions: 1000G L 8 6 H 5 7 W 4 10 Sludge depth:3" r Distance from top of sludge to bottom of outlet tee or baffler 31" µ .f Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 6" r Distance from bottom of scum to bottom of outlet tee or baffle: 14" How were dimensions determined: MEASURED4. Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. RECOMMEND PUMPING NOW AND EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE. Y GREASE TRAP:_(locate on site plan),,., 3 Depth below grade:n/a Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a Dimensions: n/a Scum thickness: n/a Distance from top of scum to top of outlet tee or baffle: n/a = Distance from bottom of scum to bottom of outlet tee or baffle:n/a 'sr Date of last pumping: n/a r ° ' Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): n/a s x 0 U I Page 8 of 11 t , OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS r . t ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 260 LONGVIEW DR BARNSTABLE,MA 02630 x Owner: ROBERT MISCRACA Date of Inspection:. 11/26/01 2. TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) hA Depth below grade: n/a .t; Material of construction:_concrete metal_fiberglass polyethylene_other(explain): n/a ". :.� Dimensions: n/a Capacity: n/a gallons Design Flow: n/a gallons/day Alarm present(yes or no): N/A Alarm level:N/A Alarm in working order(yes or no): NO '^ Date of last pumping: n/a , Comments(condition of alarm and float switches,etc.): n/a DISTRIBUTION BOX:X(if present'-must be opened)(locate on site plan) Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE 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.): Y'x' D-BOX IS STRUCTURALLY SOUND.D-BOX IS NEW. ' 7 PUMP CHAMBER:_(locate on site plan) r, R Pumps in working order(yes or no): NO Alarms in working order(yes or no):NO ` Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): N t n/aj, I irk s,. y a �. ,, �' *. �It c r� t x „fir: r ., t>j Q Page 9 of 11 .S =?:r; OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM x " PART C 4e. SYSTEM INI�'ORMATION(continued) v Property Address: 260 LONGVIEW DR BARNSTABLE,MA 02630 iwt"w Owner: ROBERTMISCRACA ram" Date of Inspection: 11/26/01 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) e , If SAS not located explain why: n/a Type 1000 GAL 6'X 6' leaching pits, number: 1 INFILTRATORS leaching chambers, number: 2 'n/a leaching galleries, number: n/a.. n/a leaching trenches, number, length: nla :° .. a„ n/a leaching fields, number: n/a �r'-TTM- .< n/a overflow cesspool, number: n/a �4 �! n/a innovative/alternative system Type/name of technology: n/a ' Comments(note condition of soil,signs of hydraulic f.1141;e, level of ponding,damp soil,condition of vegetation,etc.): ..;Y DID NOT EXPOSE.NO INSPECTION COVET: 1 AISED.INFILTRATORS ARE NEW.APPEARS TO BE .,, FUNCTIONING PROPERLY-SYSTEM SHO\1'S SIGNS OF FAILURE. 4 CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: n/a Depth—top of liquid to inlet invert: n/a r Depth of solids layer: n/a Depth of scum layer: n/a x? a; Dimensions of cesspool: n/a f .3 Materials of construction: n/a "' rs Indication of groundwater inflow(yes or no): NO I f Comments(note condition of soil,signs of hydraulic 1161 V, level of ponding,condition of vegetation,etc.): w ", n/a PRIVY: (locate on site plan) i ry w Materials of construction: n/a Dimensions: n/a } Depth of solids: n/a sir . Comments(note condition of soil,signs of hydraulic f;, !urc, level of ponding,condition of vegetation,etc.): f f sa n/a . 4 ' • Page 10 of I 1 • a. skr OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 260 LONGVIEW DR BARNSTABLE,MA 02630 ` Owner: ROBERT MISCRACA Date of Inspection: 11/26/01 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. i 7 , - 5 v y� "� � � � YF •r, i 14 4 �D 44 . •1� �� TX P � Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 260 LONGVIEW DR BARNSTABLE,MA 02630f' . Owner: ROBERT MISCRACA Date of Inspection: 11/26/01 SITE EXAM ' _Slope ' _Surface water y _Check cellar Shallow wells Estimated depth to ground water 12+feet Please indicate(check)all methods used to determine the high groundwater elevation: NO Obtained from system design plans on record-if checked,date of design plan reviewed: n/a k s{ YES Observed site(abutting property/observation hole within 150 feet of SAS) NO Checked with local Board of Health-explain:n/a NO Checked with local excavators', installers-(attach documentation) YES Accessed USGS database-explain: n/a t You must describe how you established the high ground water elevation: GROUNDWATER DETERMINED BY AUGER-NO WATER AT 12' BOTTOM OF PIT AT 9' Oj . r ' 4 k}. u t . Il 464 TOWN OF BARNSTABLE L097ATION `.c3 �. ��., SEWAGE # VILLA.`GE' __ i �, f 'ASS`ESSOR'S* MAP & LOT�'.,j� ll INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY (oo �\ LEACHING FACILITY:(type) ���� �c��C( = .. (size) ."r n \ 11tv NO. OF BEDROOMS' PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: ` ® kck:s DATE COMPLIANCE ISSUED: 'VARIANCE GRANTED: Yes No � ` � S� � � C Cl r' � ,� c . , -� No..........Apppa;?I�3ED Fas.,c,, ."... d r nt HE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH - TOWN OF BARNSTABLE Ap.pliration for Di►ipwml Works Towitrnrtinn emit- Application is hereby made for a Permit to Construct ( ) or Repair ( kl)/an Individual Sewage Disposal S stem at �cs-CZ ..... ....v_._L. ... .�.�e,.w.. c U c SAL. - c--� .....---d.. ...Q.Sl -- fa�i. -------------- ----- Location-}kjdress or Lot No. O,cner Address e _.. ate..-. S.an.� C<_... - .S? .��_.. `� �` ( Installer /Address Q Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.---- -------------------------------Expansion Attic .( ) Garbage Grinder ( ) 04 Other—Type of Building _-------------------------- No. of persons.--..1.-.-----.---------. Showers ( ) — Cafeteria ( ) a' Other fixtures ------._..._--------------_. - . W Design Flow............................................gallons per person per day. Total daily flow...........................................-gallons. WSeptic Tank—Liquid capacity-IMLYal Ions Length................ Width................ Diameter--- ............ Depth................ x Disposal Trench--No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.......k............. Diameter---G_XC Q.... Depth below inlet---................. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by....... ------------------•-----...-•--•------•--------------------...•... Date........................................ ,.a Test Pit No. I................ininutes per inch Depth of Test Pit.................... Depth to ground water........................ (r Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •-••---- -1 • _ 0 Description of Soil........... Y�N�C1-----------•--------------•---.-------------------- ------------------------ ---- ------ ----•--•-•-----•-•-••----•---------- W .................................•------------•....------........--•----•-------......-----•......------....--- --- - --. `------------- --------- ............................................ U Nature of Repairs or Alterations—Answer whenc�a�pp�licable... GNU.... ------a. C .....�`........Z................. .t�.?°s .`: r4a S ��r\ ,...a�c.�.'G..._G� 5 '2'---••-----••- ••••-••-•-•-•-•-........4...-•-----•-•--...... Agreement: ` The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5.of the State Environmental Code =The undersigned further agrees not to place the system in operation until a Certificate of Compliance�has been iss �f health. Signed .......$ ... �.�--... .... .............................. .. . �]. ..� Date Application Approved By --- -W -'0^-�-~- . .............................................................. .......�-.='. Application Disapproved for the following reasons- --------------- ---------------------------------------------------------------------------------------------------------------- ........ ..... ......................... ...... ................... ------------------------- -I ............................. ------I_ ................................. ....................................... Permit No. ..... ....��-.."--.. .. .............. Issued ....................................... ......... ..Date . Date r"`•d'�•�•s►�r=•--•-..iy�+4--.._''`-•�r.rJ�w''�..Y i:,�a�.RJ��^-Y+..�..::.�.J " �..i���,y ...�-.�y,-,..,,.�.;•�,.;�+ `��..v'_v's„�y:•y«• .. ..w� ._--: .:-y���;ti . --- -------- ..--. . e THE COMMONWEALTH OF MASSACHUSETTS I-V t BOARD -OF- HEALTH - TOWN OF BARNSTABLE , pphratinn fur Divjipwial Wnrk.6 Towitriirtiinn Frrntit Application is hereby made for a Permit to Construct ( ) or Repair ( �an Individual Sewage Disposal System at J -Lorrtinn-Address or Lot 1\o. �G..................... ----------- Owner �` Address .........•---••-•--.................. Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.___.`--4______________________________Expansion Attic ( ) Garbage Grinder ( ) ` a Other—Type of Building ............................ No. of persons------(_�................. Showers ( ) — Cafeteria ( ) d Other fixtures ..----------------------------------------------- W Design'Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.AW)lgallons Length................ Width---------------- Diameter-_- ............ Depth.....-.......... x Disposal Trench--No. .................... Width.................... Total Length..........._........ Total leaching area....................sq. ft. 3 Seepage Pit No-------t.------------ Diameter...(_o.Xa.... Depth below inlet--------............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........-.......... Test Pit No. I................minutes per inch Depth of Test Pit--------_........... Depth to ground water........................ LX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x --- ---.- ................................................-...............•.............................................................................. ODescription of Soil...-------- c > � ------------------•-•--•-----------•--••-----------•.------------------------ V .....................................•...................................-............-.................................................................................................................. W •----••----•----------------------••-----------•-•----.....---------••-......--•-----------• Z. `` U Nature of Repairs or Alterations—Answer when applicable_.--. C�U._.....�_.___Q �X_..__�.._._....Z)................. Agreement: The undersigned agrees to:install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been iss d-by-he-bear-d-of health. Signed ./ C. .:.......................................................... ............ ..... 1 J..et: . Dare Application Approved By ...... 1 ---.1..:......-........... .. ......... ........... >�� Application Disapproved for the following reasons: .... ................... ............................ . ................................---.................. ............................................ ........... ..... . ....................... . . ... ............... --.............................. ........................... . ...... Permit No. -,I`----- �� '7 Issued Dare..... Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ,Q TOWN OF BARNSTABLE c� TErtifirate IIf Tompltaare THIS IS TO CERTIFY, That the Indliiduaall Sewage Disposal System constructed ( ) or Repaired (�) by ....................... Installer at ........ ---......_ < n�..jV..� .-� .2-----------E)c..... ......C. r_4.�.�1 ......... ............................................ ......... has been installed it accordance with the provisions of TITLE 5 yo.(aThe State Environmental Code as described in the application for Disposal Works Construction Permit No. .....,/.. ..-.._L/...?-..T. dated ...................... ................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. �j n h r DATE....._1�.:... ..._.._..........G�.�.........._...- -............_ Inspecto ._.. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �J 7 No... {•� FEE.....!... .�. Disposal Works Tnnntrirtinn rrntit Permission is hereby granted----�If)j�---- -------- ..................................................... to Construct ( ) or Repair (V)- an Individual Sewage Disposal ystem as shown on the application for Disposal Works Construction at No.......a.60_ ��n `� .... �`7-•----- C street J I/ ruction Permit Noe l-12_7 Dated_-__ r._f��._._...... PP P V ..�•� -----------••••--- ------- -------•----- t� ' Q ---------•-•---- ---------- FORM Board of Health DATE.............. 36508 HOBBS Q WARREN,INC..PUBLISHERS - ' G c '� — LOCA.T10N : '— 5EWaC-4E PERMIT UO. VILLAGE '. x� ►��f — — — IW57&LLER 5 IJ&ME , ADDRESS — pseA04 - - - - - - - - - - BUILDER 'S Q &MF- ADDRESS DINTE PER"I-T 155UED 0 ATE COKAPLI &MCE ISSUED : i � ��'ia� o\ re -r � �.b G /, c x c� ��x i M e Z ,... �.,_ �- li s t No....--....... THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ...... ra ..........OF...... ............... ....... .. . ��.................... ..... Appliration -for 'Uiopooat Morkii Tatuitrurtion Vrrotit. Application is hereby made for a Permit to Construct (b<Or Repair ( } an Individual Sewage Disposal System at: .............------------ ----•-........................ ••••-----•-----•---••-••---•••--•-------------------•-•---••------- Lo tion•Add ss or Lot No. ner Address .................................. .................. ............................... ---•-•---•-•-----..._......_............... ---.................._---•---•-----...•-------------- Installer Address UType of Building Z Size Lot...AX,, ....Sq. ket «-, Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder per., Other—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ---------------- -------------- - - W . Design Flow...............................__..gallons per person per day., Total daily flow_-__-_--�A'a.__---._.__.----------gallons. ISeptic Tank—Liquid capacity/-gallons Length---------------- Width................ Diameter---------------- Depth-------.._-.---- xDisposal Trench—No. .................... Width.................... Total Length..................... Total leaching area---------------------sq. ft. Seepage Pit No..................... Diameter-------------------- Depth below inlet_-._ ____ ._-__ Total leaching area._--_____-_------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Q6 �e_4;i" aPercolation Test Results Performed by------- ----------------•-----•----•-----.......-:........-----..._...... Date---------------------------------------- Test.Pit No. I................minutes per inch Depth of "Pest Pit-------------------- Depth to -round water........................ �14 Test Pit No. 2----------------minutes per, inch Depth of Test Pit.................... Depth to ground water........-_____-_.....___ W ----------------- ---------- --- / ..... r t O Descript' of Soil ---^ ---- L " L� .2 Z U ---------- -- •. - --- ------------------W --------------------------- U Nature of Repairs or Alterations—Answer when applicable.........................................:.....................................................- ---------------------------------------------------•----•-•---•••----•--•-••---•-----------------------•-----------------------•------------•---------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary C e— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bepAssVdby the board of he lth. q Signe ... ......... ------------------------------------------------------------------ f�/ Date / Application Approved By-------- - ------ ------ -------- ...... Date Application Disapproved for the following reasons------------------------------------------------•---------------------------------------------------------------- --•••••......-•--•----...-••----•........................................................................................... -------------------------------------------------------- Date PermitNo.............................'---•-•----................... Issued....................................................... Date No........................ FRic .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH ..... ...OF...... ........ ........ x--.......................--.... Appliratiun -fur Dhipaoal Hlorkii Cnunwtrurtiun Vrrniit Application is hereby made for a Permit to Construct (b_�or Repair ( ) an Individual Sewage Disposal System at: .........1 -- j ......................... � - = '.... Lo .ion.Add or Lot No. ner Address a ..................................V_............&.r.•.... --�............................ -•-••----•--------------------•--•••••------•-•------•-- Installer Address Type of Building Size Lot_.. 3_S` -____Sq. et Dwelling—No. of Bedrooms .............. -----.Expansion Attic ( ) Garbage Grinder p, /66 Other—Type of Building ____________________________ No. of persons...-_______-------------___- Showers ( ) — Cafeteria ( ) 0.1 Other fixtures •-------------- ------------- W Design Flow................... f12)._____._______gallons per person per day. Total daily flow......... ....................gallons. WSeptic Tank—Liquid capacity/X-TV__gallons Length................ Width-----------..... Diameter__-__..._...____ Depth....______._._. x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage"Pit No.-_________________ Diameter.................... Depth below inlet_______ -------- Total leaching area_____-_._..__..._.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 4- 1-96 '-' Percolation Test Results Performed by-------------------------------------------------------------------------- Date--------._._._-------.------_---..-----. a Test Pit No. 1_---------------Minutes per inch Depth of "Pest Pit-------------------- Depth to ground water...................... 44 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water...-. -___--_._____-.-. a' {{� O Descrip . .n of Soil-- �� ' �r- U•-•-•="�✓------ ------ ;�^C_ 7 w 7----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable..--------------.----------------------------------------------------------...._----___--_-__ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary C e— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b iss e y the board of health. r- Sign . •-•---. =---------------------------- -�-----17---- Date Application Approved BY ... � ........ -- �1 ��4 Date Application Disapproved for the following reasons:----•--------------•---•-•------••-----•-------•-------•--------.----•.--•----------------- ------.---•-•------ ..........................•-•-----•••-------•-------•--••••------------...•••------•-•••••••.----------- -Date PermitNo......................................................... - Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH ........ G ........OF....... . ....,................................................ T.prti$iratr of Qlamplinnre HIS IS TO rCR IF. ' hat the Individual Sewage Disposal System constructed (�) or Repaired...:.1� __.__------- nsaller 1 ----------- �•'------------- ---------------------------------------------------------•---------•---------------------- has been installed in accorda ce with the provisions of Ar 'cl� I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. . � _.{ __ ______________ dated. 1.1_-l7_'_7�0___.__........ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....----\ Inspector- ---------- ----- - THE COMMONWEALTH OF MASSACHUSETTS CBOARD HEALTH 7 .............OF..._.... �.(r( ...._......._.... No.....E/.......... FEE-/_101............... BinpIn l urkq n tr uit �lrrmit Permission is ereby grantedGZ -----------------...-.---------�1'L -- -- - to Const c ) or Repair ( Indivi ,ual Sewag D s oral Sys em at No. ---�---"- . ..-•• / .. Street as shown on the application for Disposal Works Construction er'ii_t No�. .............. . Dated.. } " _ _-7G........... Board of Health DATE-- ------------------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i , i k t W � .` � '�� •• ��y ors � � - r kr j ��r hr G - •} � 4_ f •7i '' 1 - t �{}� ;'f l T� � _ � s'�.. •r \ � =a ; f m n ram. r 1 - _� - ��r f i t z_• f Vl Frl u/�1MitL3Ah;M Y _ -749 TO `• 4 � , WC