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HomeMy WebLinkAbout0026 MASA'S PLACE - Health 26�Masa's Place: a � c ann�s x 2�= I I o COMMONWEALTH OF MASSACHUSETTS r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION ' i iT+ Property Address: 26 MASAS PLACE HYANNIS fir--�A , Owners Name: MALOCARIA `1�- ! ; Owner's Address: . r-n Date of Inspection:7/18/05 4 c s r Name of Inspector: (please print) Douglas A.Brown Company Name: Douglas A.Brown Septic Inspections Mailing Address:P.0 Box 145 Centerville,MA 02632 Telephone Number: 508-420-4534 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 7/18/05 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 PIT IS DRY AT THIS TIME STAIN LINE AT 1 FT FROM BOTTOM ****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 -Revised on la/3112000 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 26 MASAS PLACE HYANNIS Owner's Name: MALOCARIA Owner's Address: Date of Inspection: 7/18/0S 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 winch indicates that any of the failure criteria described in 3 10 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 Pase'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 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 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 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 26 MASAS PLACE HYANNIS { Owner's Name: MALOCARIA Owner's Address: Date of Inspection: 7/18/05 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 I 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: . Page 4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 26 MASAS PLACE HYANNIS Owner's Name: MALOCARIA Owner's Address: Date of Inspection:7/18/05 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 1/2 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. 5F 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 3 10 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 l l 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'm 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 Page 5 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner: 4 G/iG Date of Inspection:A W ?—/9-057 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:26 MASAS PLACE HYANNIS Owner's Name: MALOCARIA Owner's Address: Date of Inspection. 7/18/05 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 2 DESIGN How based on 3 1 0 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330 Number of current residents: 0 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): NA Seasonal use: (yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no): NO Last date of occupancy: 0 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow(based on 310 CUR 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: 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 —Si ngle cesspool _Overflow cesspool —Privy _Sared 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 awner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known)and source of information: 1978 ACCORDING TO AS BUILT Were sewage odors detected when arriving at the site (yes or no)? NO Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 26 MASAS PLACE HYANNIS Owner's Name: MALOCARIA Owner's Address: Date of Inspection: 7/18/05 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ (locate on site plan) Depth below grade: 9° 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: 1000 gal Sludge depth: TRACE Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: TRACE Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)- PIT IS DRY AT THIS TIlvIE STAIN LINE AT 1 FT FROM BOTTOM TANK LOOKS STRUCTUALLY SOUND AT THIS TIME 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.): I Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26 MASAS PLACE HYANNIS Owner's Name: MALOCARIA Owner's Address: Date of Inspection:7/18/0S 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: ealIons/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: (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.): Page 9 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 26 MASAS PLACE HYANNIS Owner's Name: MALOCARIA Owner's Address: Date of Inspectiion: 7/18/05 SOIL ABSORPTION SYSTEM(SAS):_(locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: I 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.): PIT IS DRY AT THIS TIME STAIN LINE AT I FT FROM BOTTOM 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.): NOT PUMPED DUE TO FAILURE 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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 2MAs is PLACE Owner's Name: MALOCARIA Owner's Address: Date of Inspection: 7/18/05 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. 26,E 2 4V - e� I i v � ,3 ° P(r i E Page 11 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM ] INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 26 MASAS PLACE HYANNIS Owner's Name: MALOCARIA Owner's Address: Date of Inspection:7/18/05 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: 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) Checked with local Board of Health-explain: Checked with local excavators,installers (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: FINE r � Town of Barnstable Regulatory Services + BAMSPABLE. M^� g Thomas F. Geiler, Director s639• ♦0 Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 10, 2003 Mr. John Malacaria Malacaria Family Realty Trust 3333 S. Atlantic Avenue Daytona Beach, FL 32014 RE: 26 Masa's Place, Hyannis Dear Mr. Malacaria, This home is limited to two bedrooms due to the capacity of the septic system. If you have any questions please call me. Sincerely, Thomas A. McKean TAM/pg enc •'./' `_,) 'i`:'Y,..i� '� r: .iy -_i:jai ���.�. 1�! .............f._ 1 \ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF * HEALTH ..:..............OF.......l�l.c6L�_..�L7 >.gip ....:..... �, ,� rlirtt#pan for Disposal Works Tonstrurtion Vamit Application is hereby made for a Permit to Construct (/-,<or Repair ( ) an Individual Swage Disposal r ' System at: �, t 1� , ........--••............. ::.............:..... �f' .. ...............-----•-----. ...._ . ; ................«««..««.... ... ........_... r Lot No. i• cation-Add n- '�: Address ..... .................................... ......................................................... .................................. .............� Installer Address Type of Building Size Lot----- ...Sq.;feet Dwelling—No: of Bedrooms............ ........................Expansion Attic ( ) Garbage Grinder (Mo) Other—Type of Buildin€` ............................ No. of persons............................ Showers ( ) — Cafeteria -( ) aOther fixtures ...:...: ...................... --......---•-••......................................................................:...•..... . .. sae+ - ............. W Design Flow.............�1�_........_...._._:=_:.gallons per ga -se>� per day. Total daily of ...... gallons. WSeptic Tank—Liquid'ca.pacityj�w..gallons Length-- _'�it.____. Width:4'«.... Diameter................ Depth_...'..... x Disposal Trench—No......................... Width................... Total Length.............................. Total leaching arm...................sq. ft. ............. Diameter.., Depth below inlet...la=.V.._. Total leaching area-__ 61...sq. ft. Seepage Pit No.___..t z Other Distribution box (t-f Dosing tank Percolation Test Results Performed by..-c4ty 1_.,511?:d� t - -a �• t .._. Date..... C./Z2.......•-•-. '� Test Pit No. 6kX i minutes per inch Depth of Test Pit.147(2...... Depth to ground water.bq �:?�_ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth water........................ ' x _ .._.. ................................. . oDescrpo;n�of? o' -- DAIV ..._ -. -•-•-- � ....... _ 1 Fi ... . -------------- ........... _ y 77 UNa a of Repairs or Alterations—Answer when applicable..................... ._.. N4:..147..O .. ......................... ._..-•-._...••-----•.........::........•----•-•....•----•------._...-----••.....---•------•----...............----.•-•-•-. Littl@� Agreement: S�O.NAL E The undersigned agrees to install the aforedescribed Individual Sewage Dispo in accordance with the provisions of i1'112' 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign -- -------------------------•-•-----------.....---.----• --------- . _.... _ Date APPlication Approved By.... .. . I. _- - ...L. -...-. -••--------•-- l' "- Application Disapproved for the f ollounng reasons:.............. — .................................................................Date «_ .... « Date « Permit No...................................................«.... IssuedL.7—.,eP::4,4- . Date ., ¢ V opt r Town of Barnstable ti Regulatory Services » U RNSrABLE. 9� MASS. ,�$ Thomas F. Geiler,Director A'ED 39. Public Health Division Thomas McKean,Director 200 Main Street, Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 September 10, 2003 07Mr. John Malacaria Malacaria Family Realty Trust 3333 S. Atlantic Avenue Daytona Beach, FL 32014 RE: 26 Masa's Place, Hyannis Dear Mr. Malacaria, This home is limited to two bedrooms due to the capacity of the septic system. If you have any questions please call me. Sincerely, Thomas A. McKean TAM/pg enc D, Fxs....' `...... No..........�P.. r THE COMMONWEALTH OF MASSACHUSETTS M I BOARD OF HEALTH i > ...........0`W..17..:.. OF.......f r. `.z Q� L ...r�74� V)Z2j 7 --••-----• 1pliration for Disposal Works Tonstrurtiun Famit Application is hereby made for a Permit to Construct (k<or Repair ( ) an Individual Swage Disposal System at:...................... �`f� ......................... ..................... .?]!`-.- ......-ot ... .� cation.Add No. /� , ..............................•. ..._....•-••-•--•---- ... .. .................. n-,1 Address W �. � •�............... .............. ................•---...........---......---......:..................................•-- .......... a ..................... ac::-• Installer Address '' d Type of Building Expansion Attic Size Lot.. l0G dergj feet g . . . 0-4 Dwelling—No. of Bedrooms............. --------•-- P ( ) Garbage ( ) p44 Other—Type of Buildings ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d '.: Other fixtures ...:..: ........_1� � �......... W Design Flow.............�1 ................ --.-gallons er r day. Total daily flow................ ............. Ions. WSeptic Tank—Liquid'capacityJPCO-gallons Length._ '�i2...... Width.4"1�.... Diameter....:........... llepth....'f�..... x Disposal Trench—No.."...................... Width....................Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No......t.....:....... DiameterJ0.-.V....... Depth below inlet...�i=l '_._. Total leaching area...261...sq. ft. Other Distribution box (lif Dosing tank (q ) � / Z Percolation Test Results Performed by---q - t�grkl.e-y..e •.�.Fr /&A..•• Date..... /.. a12 ............ Test Pit No. 10El,L p p Depth ground a.: minutes per inch Depth of Test Pit•12:7'0...... D th to ound water.f�lDas� nc Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth water........................ O Description of o' d. .........:a t-t.�.. U �'`...... -.... - 7 p -W......... -------------- -- x No. p .. . U. Na a of Repairs or Alterations—Answer when applicable..........:....... - ---•••-•------•-_------ --•--------•-•--------------••. :..-•..•..•••• •...........••--•••-••-•..........-•-••••-----•-•--•--•--•--•-•--•--•-. .....-•••-•----•-•-•---•. : Agreement: . S�ONAL E The undersigned agrees.to install the aforedescribed Individual Sewage Dispo in accordance with the provisions of iITI U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sn ......................................... •-••.�..•• ••-•-..... Date ....� :...By...Application Approved Date Application Disapproved for the following reasons:.............. ...-•-•--------•--.. ......._ ............. ...--•..............•--•---•--•-••---•-•-----•--•--............----•-•-------•--•------•^-------...........•-•-•-••---•-•-•--••-••----•--•---t-........ .............------••---• • -•••••-•----- Date Permit No................................................... ]SSlled..,f 1�� .......................... Date � Y i TOWN OF BARNSTA.BLE LOCATION -J1- `19aScLS /�- J aC a SEWAGE # V,LLAGE 94Pay 1 i5 ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NOO`U�CY_QS SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS 3 BUILDER OR OWNERq,�OCQ,N CG PERMITDATE: 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 Furnished by j�• l�PegeYO of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART C SYSTEM INFORMATION(continued) Property Address:26 MASAS PLACE Owner's Name: MALOCARIA t Owne r's Address: Date of Inspection:7/18/05 I SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at lease two permanent reference landmarks a benchmari6.Locate all wells within 100 feet Locate where public water supply emers the building. i At_yiG� '31-al��a 2-411r 2-x0i y o - - o Pcr t. LOCATION ' � SEWAGE PERMIT NO. VILLAGE IN WA LLER'S NAME i ADDRESS B UILDER OR OWNER DATE PERMIT ISSUED DAT E COMPLIANCE ISSUED �.._�� �.� f ILA t-I 'J is A .1', No........... f�.... rr ! ,,;`.,_Fm$....� .... r' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � o A �'1.11.t7....:.... .....OF.......( c lP__. .17..4� s f�� .......... ```��.• -, ppliration for Uhiposa1 Works Tomitrnrtion Permit Application is hereby made for a Permit to Construct (�or Repair ( ) an Individual Swage Disposal System at: A ry ' 11 ......... -- - .�:5....��lf: ..... -•-•-•-•-- ...................... ?T...l ... .--•-------- ................... ation-Add r Lot No. a ner:4 Address --�0 � 0 ,.a sh- — .......................................... � Installer �.--- Address Type jof Building- -�' Size Lot.....49', ...Sq. feet Dwelling—No. of Bedrooms_'._ ________________________Expansion Attic ( ) Garbage Grinder (1eb) Other—Type of Buildinj_ ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) l Other fixtures . 1-1 , = ......... laCr.1-2'a w Design Flow.............do........__ _._._.'�. ' _.._gallons per-pew-444-pier day. Total daily tflow................��__� _...__._.___ Ions. WSeptic Tank—Liquid capacity/!?W__gallpns Length.'5.12._____ Width4"1d __ Diameter................ Depth_&�®__... x Disposal Trench—No........................ Width.:..................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No......t............. Diameter._/_Q_LV.__.... Depth below inlet__. Total leaching area... ...sq. ft. Z Other Distribution box (✓j Dosing tank ( ) f j `" Percolation Test Results Performed by.._ ��l9 '?�' 31G 7z>�itla__-_ Date___._//... � ___-_______-- a.> Test Pit No. 10 2__..minutes per inch Depth of Test Pitlzz.V... Depth to ground water.�/M (i Test Pit No. 2................minutes per inch Depth of Test Pit................. Depth water........................ R; ......... ....... .............................. Ox Description o of 4 � - � DA " G ----------------------- c tS �, ------ ---7 tnr: w -•----• (�f�-- - -40----------- �� f� r(�^' � t� i � x U Nat e of Repairs or Alterations—Answer when applicable---------------- _________ No,-147 • .p ......................... - ---------•--=-••---------- ----------------------------------------------------------•---....--•------ ' -......................... Agreement: S�O.NA'L E The undersigned agrees to install the aforedescribed Individual Sewage Dispo in accordance with the provisions of iIT?.L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signot ----- ------- ------------•------------------------- -•-------------------- - 71 Date Application Approved By-• �.- .. Date Application Disapproved for the following reasons------------------------ ------.._----------•------•--•-•-------•-•-••-• -••-----------•••-- Date PermitNo......................................................... Issued_.,,e7-.,P^/_7 _-----------•--------•------- k Date 1 v 1 /Cj .� Fss.....' ..`............. _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....-----T.Cd1r7.................OF....... :s<t t 40... r i1 a..a.)6.)_........_. l ►►-,. ,� �r�irtt#t a for lli ivoii al Works Towitxnrtion ramit Application is hereby made for a Permit to Construct (A-l'or Repair ( ) an Individual Sewage Disposal Sysern at: -- ,•- "Fu ... . �!. `. ......•--•-•--•-•----....... -•.......--•--•-----1,jt• r ...... ----- - - ------------------------ --------------------- ---=-------- --- _-__---------------------------------------- t t, Zr Address ............................................. ............................... Installer Address U Type of Building Size Lot_____l��l a> _._Sq. feet Dvelling—No. of Bedrooms........;__ .........................Expansion Attic ( ) Garbage Grinder (No) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ----------------•---------------._.._....-•• ------------------------ ----------- ....................................................... WDesign Flow.....____.._/10.......................gallons pe> W s per day. Total daily flow................ _ .............gallons. WSeptic Tank—Liquid capacity/P gallons Length_Ei.1(_____. Widths / _ Diameter................ Depth_ �____. x Disposal Trench—No_____________________ Width.._ ................ Total Length.................... Total leaching area___._ sq ft. 3 Seepage Pit No......I__-.__-___-- Diameter ZO..42L ._. Depth below inlet____/,__ram..... Total leaching area... ...sq. ft- Z Other Distribution box O Dosing tank ( ) a Tes Percolation Test Results Performed by..Cj- •`� �U 1 fit. llTf?�yZa...: Date_....fp�,� ,l ` 1.4 Test Pit. No. 1( t2.___minutes per inch Dept offi t;yPit.J2:.?._.____ Depth to-ground water fir'.e,<rx, 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to .............. Ikm Description of 7 of ---- --- -� . . G�/M r .- .. -•--•-------•••--- x j� rJ�Gtaa►i �.� _T ;t- �J F t W rn U . •. � , � � �. _....Ems... •------------ NE No..�i4764••p . U Nat re of Repairs or Alterations—Answer when applicable_ ---:.___. . . ___- -�-• �; -Q Y Agreement: The undersigned agrees to .install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of T IT 11L 5 of;the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been'issued by the board of health. Sign ..............................................`-•-••--• ............................... D Application Approved By--- . •---•-. -- . ..................................................... ` .......�"'. f. -��:-'--_------ Date Application Disapproved for the following reasons:. .............. ..................................•---------•------•-------._...-•--••---•••••._.._....:.._.. `=--•------••---•---••--•-••••---•---•-•-•-•---...-------•------•---•••-=---•---••--••--•-..___....--•-- Date Permit No.--•-••--------•---•••-•__. •-••_... Issued_...... -.1� 7 7... ....................... Date 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD gF HEALTH ...... .................................OF..................:.............................. .............................. Tr ifiraatr of Tompliaatt THIS IS CER , , Tha t ndividual ewa e Dispos e ' c strutted (�or Repaired ( ) by-------------•• _ .....`. -._. ........ Installer has been installed in accordance with the provisions of T - � f� e State Sanitary Cc ��sdes jbed in they., application for Disposal Works Construction Permit N ......................................... dated.................................................. THE ISSUANCE OF :THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE.THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........ZZII.=Zl...•-•-•.................•------...----------. Inspector--- --_..:.s.!. . .................................................. THE COMMONWEALTH OF MASSACHUSETTS ,. BOARD O HEALT © 14 ..........OF.............. 2 S� No......................... Flu........................ UWpopaa1 rkvr lermi# PermissionA.Hereby a(ed�•-�. -- •-•-- ... .......�:....`_...... .......-••- -- -- '...... ..............:':...................- to Con t or r d I Sevca a Dis S stem *• "..4. •J Str +��+ - a as shown on the application for Disposal Works Construction P rlfi Noted: ..._........ -=-•----.. t 77 Board of Health r !! ty vvv DATE............ ..... ............ ........ � FORM 1255 HOBBS & WARREN. INC., PUBLISHERS LOCATION . SEWAGE PERMIT NO. VILLAGE IN SCA LLER'S NAME i ADDRESS S UIIDE R OR OWNER DATE PERMIT ISSYID . DATE COMPLIANCE ISSUED ..._�� ��� I " r� 1 , 9 9 31 W � I ,1.)!,r'..'_ -, ,_ " "I-,��,' -�t 4*.,i-,�-,,*�w-:-�, ���o*-� ��'_#�tj I I I ,� �I , I ­ __ - " - e-I',-,R;,�­�,�_t 4, * - _' -'f -�_ ", ,Z�- 1,4,t4 't _., , . 't -, - ' � ��-'­�� 1*'�;* -4-"!�4� "' ix -M,r � �,7"t 4,�.�,,&�,,v�,1;110 I , _. .7%� - . 1, . — i r"-��,,e�",$tt",.�!:y f - ,�7,(, - I , � ?.,, - � I W!�;!*,� - ��"- 7 , . 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