HomeMy WebLinkAbout0204 MEGAN ROAD - Health 204 Megan Road
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TOWN OF BARNSTABLE
. I:Cr-ATION O /47 4L�/4 A' �� SEWAGE #
VIL SAGE ASSESSOR'S MAP & LOTA '�-°?
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Hv`5 'S NAME&PHONE N0.
SEPTIC TANK CAPACITY -S z f-T c- /A,S.-,',)ZC114
LEACHING.FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER I/ 05
PERMITDATE: / 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
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTEC_T_ION
pqM SVev
350 MAIN STREET J AN 0 8 2003
%sm WEST YARMOUTH,MA
508-775-2800 TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM T l O O
PART A 1
CERTIFICATION
MAP 291 PAR 265
Property Address: 204 MEGAN ROAD
HYANNIS,MA 02601
Owner's Name: VOSGANIAN,VAHIK
Owner's Address: 333 WASHINGTON STREET—ROOM 505
BOSTON,MA 02108
Date of Inspection DECEMBER 4,2002
Name of Inspector:(please print) JAMES D. SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yarmouth,MA 02673
Telephone Number: 508-775-2800
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:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: f,�� �' Date: l - `•
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 tot he buyer,if applicable,and the approving authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that time.
This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 204 MEGAN ROAD
HYANNIS,MA 02601
Owner: VOSGANIAN,VAHIK
Date of Inspection: DECEMBER 4,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all 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. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 204 MEGAN ROAD
HYANNIS,MA 02601
Owner: VOSGANIAN,VAHIK
Date of Inspection: DECEMBER 4,2002
C. Further Evaluation is Required by the Board of Health: N/A
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 CNIR 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 salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 204 MEGAN ROAD
HYANNIS,MA 02601
Owner: VOSGANIAN,VAHIK
Date of Inspection: DECEMBER 4,2002
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
J 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 leaching is less than 6"below invert or available volume is less than'/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 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 detennined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails. The system owner should contact
the Board of Health to determine what will be necessary to correct the failure.
E. Large Systems: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a
mapped Zone II of a public water supply well.
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system is failed. The owner or operator of any large system considered a significant
threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The
system owner should contact the appropriate regional office of the Department.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 204 MEGAN ROAD
HYANNIS,MA 02601
Owner: VOSGANIAN,VAHIK
Date of Inspection: DECEMBER 4,2002
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
✓ Pumping infonnation was provided by the owner,occupant,or Board of Health
J Were any of the system components pumped out in the previous two weeks?
✓ Has the system received nonnal flows in the previous two week period?
J Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
J Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
J Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum
✓ Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
✓ Existing infonnation. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
r -
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 204 MEGAN ROAD
HYANNIS,MA 02601
Owner: VOSGANIAN,VAHIK
Date of Inspection: DECEMBER 4,2002
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 220
Number of current residents: 3
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): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM 15.203):
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: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped detenmined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1997 PERMIT#97-697
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 204 MEGAN ROAD
HYANNIS MA 02601
Owner: VOSGANIAN,VAHIK
Date of Inspection: DECEMBER 4,2002
BUILDING SEWER(locate on site plan): ✓
Depth below grade: 16"
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 onsite plan): ✓
Depth below grade: 10"
Material of construction: ✓ concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 1"
Distance from top of sludge to the bottom of outlet tee or baffle: 29"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: ASBUILT AND TAPE
Comments(on purnping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AND COVERS 10"BELOW GRADE.INLET BAFFLE,OUTLET TEE.TANK AT WORKING
LEVEL.NO SIGN OF OVERLOADING SEEN.
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass _ polyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
f
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 204 MEGAN ROAD
HYANNIS,MA 02601
Owner: VOSGANIAN,VAHIK
Date of Inspection: DECEMBER 4,2002
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ./ (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.,):
DISTRIBUTION BOX IS 16"X16", 13"BELOW GRADE.ONE LINE IN,ONE LINE OUT. BOX IS CLEAN AND
SOLID.NO SIGN OF OVERLOADING OR SOLID CARRYOVER SEEN.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 204 MEGAN ROAD
HYANNIS,MA 02601
Owner: VOSGANIAN,VAHIK
Date of Inspection: DECEMBER 4,2002
SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
./ leaching chambers,number: 3
leaching galleries,number
leaching trenches,number,length
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
LEACHING IS THREE INFILTRATORS WITH 4'OF STONE. LEACHING IS T BELOW GRADE. DID TEST
HOLE AND PROBED OVER AND BESIDE LEACHING.NO SIGN OF OVERLOADING SEEN.
CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (locate on site plan)
Materials of Construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
Title 5 Inspection Form 6/15/2000 9
7
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: 204 MEGAN ROAD
HYANNIS,MA 02601
Owner: VOSGANIAN,VAHIK
Date of Inspection: DECEMBER 4,2002
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
U✓
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Title 5 Inspection Form 6/15/2000 10
V
Page I I of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 204 MEGAN ROAD
HYANNIS,MA 02601
Owner: VOSGANIAN,VAHIK
Date of Inspection: DECEMBER 4,2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 10 feet
Please indicate(check)all methods used to detennine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
✓ Observation 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:
HAND DUG TEST HOLE IO'NO WATER. TEST HOLE 5'6"BELOW BOTTOM OF
LEACHING.
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Title 5 Inspection Form 6/15/2000 11
TOWN OF BARNSTABLECJ
L( ATION Aegiti SEWAGE # C7_
VILLAGE��is ASSESSOR'S MAP Cz LOT
INSTALLER'S NAME St PHONE NO. A & B CANCO 775-6264
-SEPTIC TANK CAPACITY /C Cal
LEACHING FACILITY:(type),3-/,�vf/ke�rS. (MAX) (size)
NO.OF BEDROOMS_3 PRIVATE WELL OR�BLIWATER
'4AX6RER OR"`OWNER 11®SC.q 9y1. 1J
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
P..
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THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01pphratton for Mtzpozal *pztem Construction Vertu
Application for a Permit to Construct( )Repair(Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. oho/7/c On /2� t Owner's Name,Addr ss and Tel.No. I91- �od&,A
4yA
Assessor's Map/Parcel
1A tJ;16ue 6t. W4kAA UA /2c
Installer's Name,AddreA0 S.GANCO Designer's Name,Address and Tel.No.
350 Main Street w/q
W.Yarmouth, MA 02673
Type of Building:
Dwelling No.of Bedrooms ..3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow °�l05 gallons per day. Calculated daily flow 3�y gallons.
Plan Date Number of sheets Revision Date
Title `
Size of Septic Tank �OO�J Irisfe,l Type of S.A.S. ✓I i l��� �
Description of Soil 1S10 z-tcQ
Nature of Repairs or Alterations(Answer when appli able) Zn f A(( -' T a y 1 f P A f o T na A)e�.�-,".2 e r5
I.Jf Hr c! '417 � CL, —oa r%C .30' X II X a '
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Healt .
Signed J� Date T
Application Approved by Date �� 7
Application Disapproved for U follow g reasons
Permit No. 77 - &%7 Date Issued
F'
Nu. t. Fee �f
THE COMMONWE�►LTH OF MASSACHUSETTS Entered in computer. ✓
',-^"--•-. Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
2ppfication for ;Dioogar Opmem Con!5truction Permit
Application for a Permit to Construct( )Repair(XUpgrade( )Abandon( ) ❑Complete System ❑Individual Components
i Location Address or Lot No. ")Q t(, Owner's Name,Add ss and Tel.No. '7,F/, F9/- (ad 6o1
Assessor's Ma /Pazceb V�k,.tA V V S AYl j fi/�
p 91 S 16 t:' b Jq 1�11A 4
^°Installer's Name,Address,*&1190CANCO Designer's Name,Address and Tel.No.
356 Main Street
W. Yarmouth, MA 02673
Type of Building:
Dwelling No.of Bedrooms i"� 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 336) gallons.
Plan Date Number of sheets Revision Date
Title
i
Size of Septic Tank /oad x,rf�ncJ\)Type of S.A.S.
Description of Soil S-A, ,
Nature of Repairs oror Alterations(Answer when applicable)�� �a(( 2\- f`n f<<s fe/' n a r+x� q,;'z r5
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Healt��.
Signed .1;J \ �.�.., c Date /d Col - 9 7
Application Approved by Date /-1 7
Application Disapproved fort fo11ow4 g reasons
Permit.No. 27 - 6 F 7 Date Issued +
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( • "Upgraded( )
Abandoned( )by
at )cAl ,12Z 4_j has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. _ ! dated 17
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the syste ill function-as' esigned.
Date 17 - 7-- 2-7 Inspector
———————————————————————————————————————
No. Fee U ,.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
lwigogat *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair(..-TUpgrade( )Abandon( )
System located at 00�/ ,f�IE. ,�42,42
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: / _ C - ' ) Approved by
o r
l 1
SEPTIC --.SYSTEM DESIGN
.A- BZD A(S AT . GAL/-DAr/BJrDJW0M _ . . GAL DAY
. . GAL/DAY z 2 DAYS = _ GAS
USE GALLON SKPT IC TANK (EXIST
LFAC'HING AREA:.
USE S INFILTRATORS MAXIMIZER CHAHBFIRS
-WITH 4' OF STONE ALL AROUND (W x if z 2' DEEP)
SIHR AREA: , (30 + f)2 z .2 164 SP (.74) _ GALI DAY
BOI 'OM ARZA:• W If _ SF (�'4) � G�/D IY
CAPACJTY GAL/DAY
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated Q - q - 9 7 , concerning the
property located at o)0 ct 114,e 9 AvJ 12.0 `(' meets all of the
4
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
.."• There are no variances requested or needed.
J If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will 114.t be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map) .
��) �SIGNED : G.�.�.— DATE: 102' '('
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
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TOWN.OF:BARNSTABLE
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AGB # -�7�
.:.-'Y.ILLAGE 4114Ajol S ASSESSOR'S MAP 6z LOT
,;INSTALLER'S NAME 6z PHONE NO.. A & B CANCO 775-6264
'SEPTIC TANK CAPACITY ADD
I:EACHING FACILITY:(type), -/m /64< s llA (size) aLX ll
,(
NO OF BEDROOMS—) PRIVATE.WELL.OR PUBLI WATER
R-OR'OWNER VOSCAIv&l --
a'`; " TiATB PERMIT ISSUED:
I?ATB COMPLIANCE ISSUED: .+2
.:::VARIANCE GRANTED:. .Yes No
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