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HomeMy WebLinkAbout0212 MEGAN ROAD - Health 212 MEGAN ROAD, HYANNIS TOWN OF BARNSTABLE LOCAT10N L'9qh SEWAGE # VILLAGES ASSESSOR'S MAP& LOT 2 9/ N 61 INSTALLER'S NAME&PHONE NO. y77-0 3 Y9 0S,--o4 SEPTIC s ANK CAPACITY /000 G,ol LEACHING FACILITY: (type) 715 hei (size) G D X Y X 2e NO.OF BEDROOMS BUILDER-OR OWNER 61 6&R11,sycg=— PERMITDATE: /0 — 3 D 9F COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching.facility) Feet Furnished by— 0 \ . au `r? �_ � ,� o t o �sy e P � � '<L,N Commonwealth of Massachusetts Title 5 Official Inspection Form 6 Subsurface Sewage Disposal System Form - Not for voluntary Assessments �d Property Address_ 144/ A- e t lo//,oce, Owner Owner's Name information is q ls d 2—/D required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: A. General Information I When filling out forms on the computer,use 1. Inspector:only the tab k // / to move your ey ya Y f o -,re. cursor-do not Name of Inspector use the return y�110 — key. /jJ ✓ L- l/] VQ Y Company Name nO /2O xoly� m Company Address_ ," Od 6 City/Town j�� / _ n ! 7 State �� D Ok Zip Code Telephone Nu er j License Number B. Certification 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 ah-d�naintenance ofm site sewage disposal systems. I am a DEP approved system inspector pursuanlAo Section 15.3 of Title 5 (310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ mails ❑ Needs Further Evaluation by the Local Approving Authority M rr, a -c23- iv Inspecto s Signature Date 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. "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. L� t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner s Name / l information is ��6C9 �—°�-3—/O required for State Zip Code Date of Inspection every page. Cityfrown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: 1 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: 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. 'A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): True 5 Official inspection Form:Subsurface Sewage Disposal system•Page 2 of 17 t5ins•09/06 I Commonwealth of Massachusetts Title 5 Official Inspection Form ivSubsurface Sewage Disposal System Form - Not for Voluntary Assessments aft I . /4I L.11 Q �,, �C/ Property Address W Cil An C Pi Owner Owner's Name _ ?_M information is /�� f S i/ 6�} J required for / / State Zip Code Date of Inspection every page. City/Town B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N El ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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 dletermines 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 t5ins•09/08 Titie',5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i Commonwealth of Massachusetts rn Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name, information is H //4 Od-L 0 /0 required for �' rf State Zip Code Date of Inspection every page. CityfTown B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ElQ/ 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 l� than Yz day flow Title 5 official Inspection Form:Subsurface Sewage Oisposal system•Page 4 of 17 ns•09r08 L 8 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c7q 4 Property Address Owner Owner's Name information is t�6 l -o2✓?—An required for n b117 Y � every page. Ciry/Town_ State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ 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. ❑ L� Any portion of cesspool or privy is within 100 feet of a surface water supply or u tributary to a surface water supply. ❑ 2""" 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. ❑ lJ�' 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 wail water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CM 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. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area — IWPA)or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•OW8 Tine 5 omdal Inspection form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C � Property Address /G q L Pi Owner Owner's Name information is h f % Da 60 required for State Zip Code Date of Inspection every page. City/Town C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No �❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Q� Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? ❑ Have large volumes of water been introduced to the system recently or as part of this inspection? �❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) [t� ❑ Was the facility or dwelling inspected for signs of sewage back up? [� ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner (and occupants if different 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: ❑ / [Er----- 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 U approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 3 Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 15ins-OW06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 i Commonwealth of Massachusetts Log Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address Owner Owners Name �1 ? information is V1e4�1 yd 60 -�J /� required for State Zip Code Date of Inspection every page. City/Town D. System Information Description: / coo G, /4" D Number of current residents: �/ Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes 2 'JO Laundry system inspected? ❑ Yes ED *No Seasonal use? ❑ Yes o Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes o Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: (Sins•og/oe Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 4- 4e Property Address Owner Owner's Name information is q, ✓�dl�j %� p required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ( too If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of S m: 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): TiUe 5 Officiai inspection Form:Subsurface Sewage Disposal system•Page 8 of 17 'Sins-09108 Commonweatth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address / Owner Owner's Name - information is ,� � Oa 60 required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer (locate on site plan): Depth below grade: feet Material of constructio��4OPVC cast iron ❑ other (explain): �D Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: feet Material construction: concrete ❑-metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•09r08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 177 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I )- Property Address / Owner Owner's Name /r r�, information is a,�0 If' /'/ 0d 601 required for / State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 �Ile 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.): ZC4 vll I 0 `'1'e, Grease Trap (locate on site plan): Depth below grade: feet 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: Date Title 5 official Inspection Form:Subsurface Sewage Disposal system•Page 10 of 17 15ins•Owe I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name information is ///�� A yt41s �/� Qa 601 required for State Zip Code Date of Inspection every page. cityfrovm D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): ' Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins-09108 7ille 5 Official Inspection form:Subsurface Sewage Disposal System-Page 11 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form kip Subsurface Sewage Disposal System Form Not for Voluntary Assessments 0" j C72 /C�- /�g PC Property Address // ! W 1/4ee- Owner Owner's Name information is �ff bo/ required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Distribution Box (if present must be opened) (locate 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.): o Z' Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page Q of 17 15ins•09l08 ' Commonwealth of Massachusetts 9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property Address Owner Owner's Name information is ,� tea 6 Ql wired for re 4 State Zip Code Date of In pectio every page. City/Town D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ eaching 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.): Z-4 V—I 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 ❑ No t5ins•OW8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 .tX - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments C2 Property Address Owner Owner's Name information is G S 1'� 0o�6 O required for A-7 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•09/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 9/c� iVC Property Address / Owner Owner's Name /�j l ? information is f /% required for State Zip Code Date of Inspection every page. City/Town D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: Bd-sketch in the area below ❑ drawing attached separately U I i5ins-09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•?age 15 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name information is Q 3-40 required for 14�CityRown State Zip Code Date of Inspection every page. D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water C ❑ Check cellar ❑ Shallow wells a� Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ 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: Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•06/08 Title 5 Official Inspection Form:Supsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address " //a cc- Owner Owners Name information is e---I� required for every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Ins ection Summary D (System Failure Criteria Applicable to All Systems)completed Sys em information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I t5ins•09/08 Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 17 of 17 Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLL"NTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 02 G H Reli a✓! i f, i9 00k b o Owner: L✓.4/11,c Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the se\vaQe disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells ,vithin 100 feet. Locate where public water supply enters the building. 0 C� /¢/r Ve, 14 i NOTICE: This Form Is To Be Used For the Repair Of Failed St.-ptic 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 /D concerning the property located at 1 i� �'�I��9� �� ���"�'�` meets all of the following criteria:. Zk—There are no wetlands located within loo feet of the proposed leaching facility There are no pri►ate wells within I so feet of the proposed septic system There is no incv.-ase in flow and/or change in use proposed ere are no variiances requested or needed. • If the proposed J.-aching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will ngi 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) S� _ B)Observed Groundwater Table Elevation(according to Health Division well map) — i I DATE: L SIGNED: _ y—✓C-- 9 LICENSED SEIE'TIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER fly, [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.cat I • a ------------ ---- 'THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of Compliance R y� THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( G,),.Repaired ( )Upgraded( ) Abandoned( )by a ."la s at M!,e f0 y 441 hp.,f,4 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. Tr4 99 dated — Installer /r'S �— ? Designer �/��rT (Z� r►..+o s The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE,'MASSACHUSETTS Migoai *pgtem Construction Permit Permission is hereby granted to Construct( 41,Repair( )Upgrade( )Abandon( ) System located at 2/2 ;;?Wog 4Z u�40X 041S and as described in the above Apphcation'to`ttisposal 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 t. Dale: /0 ; " 9,F Approved by _ k COINf-mo?NgV-EALTN OF'Vja.SSACH'uSETTS HT , EXECUTIVE OFFICE OF E'N-IRONTINIE I< r_ i t_A,;?e DEPARTME'\TT OF EN-VIRONTMFEN"TAL PR.OTECTTON TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORNI PART A CERTIFICATION Property Address: c cZ d 774 H,1r O L O Owner's Name: 4 ; ,a07 //.►cam Owner's Address: 6 - Date of Inspection: `f o2S o7 Name of Inspector. lease print) ra Company Name: p— 7-4-`GI-{ Mailing Address: o Qp ( pl g t Gf a od 6�J Telephone Number: E117 7 ; �J <: N ` CERTIFICATION STATEMENT CD I certify that I have personally inspected the sewage disposal system at this address and that the 6%ti,on reWed below is true, accurate and complete as of the time of the inspection.The inspection vL as performed b ed on r liv training and experience in the proper function and maintenance of on site sewage disposal systems.12 rn a DEF-- M approved system inspector pursuant to Section 15.340 of Title 5(310 CIMR 15.000). the system.: y . Conditionally Passes Needs Further Evaluation by the Local Approving Aut'nori—ty Fails Inspector's Signature: � Date; �C ots- O The system inspector shall submit a copy of this inspection report to the Approving Authori -(Beard of-1-1 Rh or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design f ova of a r�or; gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional ofr+ce o_"the DEP.The original should be.sent-to the system owner and copies sent to the buyer,if applicable.and the annro:-i _ authority. / _SC/0 A / 7�c /ti� w- 4eed�- AZ'W o ti He 4 CovP v G n c' Notes,and Comments m %eB """"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 t conditions of use. he future under the Salle or different Title S Inspection Form 611512000 f page 1 I , Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLL_NT_ARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM I?�"SPECT'IO>FOR AT P_-v-RT A CERTIFICATION(continued) Property Address: 5_;,2/c� . 4:�A�% 4.1 . Owner: Date of Inspection: aZ O Inspection Summary: Check A.B,C.D or E/ALWAYS complete all of Section D A. Systtee asses: I have not f an a rmation which indicate `h t failure 1 .o d any info s that any of�e_allure criteria described n�.0 C_fR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system, upon completion of the replacement or repair,as approved by the Board of Heahh will pass. Answer yes,no or not determined(Y,NV,1V-D)in the for the following statements.If"not detemined"please explain. — The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is s3ucturally I nsound. exhibits substantial infiltration or exfiltration or tank failure is.imminent:System will pass inspection if the existing tank is replaced with a compl}qng tan k nk 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 Co=liance indicating that the tank is less than 20 years old is available. Ni)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 wall pass inspection if(Li;th approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced \7D explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s). T h s_ste- pass inspection if(,with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed STD explain: T41. S T-...ti Page 3 of 11 OFl_F'ICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSZTENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: '5�/(7L n v, Owner: Date of Inspection: D 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. i. System will pass unless Board of Health determines in accordance with 310 CNIR 25.303(1)(b)that the system is not functioning in a manner which will protect public health.safery 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 txithin 100 et of a surface water supply or tributary to a surface water supply. _ The system has a septic tank and SAS and the SAS is within.a Zone 1 of a public w-ater saxppl:. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water si=Llly 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 laboratot?�,for coli=orrh bacteria and volatile organic compounds indicates that the well is free from pollu«on f om`Fat fac.ilit and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm_w-etided i�at 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 VOLUN A.RY ASSESS-,NTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM P_-Ik.RT A CERTIFICATION(continued) Property Address: C2/O� Ale �''► �� a,4 e7 a /IL Owner: ("11 C Date of Inspection: o? D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No ckup of sewage into facility or system component due to overloaded or clogged SAS or ces_000l Discharge or ponding of effluent to the surface of the ground or surface.waters due to an overloaded or �elogged SAS or cesspool Static liquid level in the distribution box above outlet inert due to an overloaded or clogged SAS or /cesspool liquid depth in cesspool is less than 6"below invert or available volume is less t an 4 dal io - ne­ REQuired pumping more than 4 times in the last year NOT due to,clogged or abstrucred pipe(s).N�-n of times pumped_.V &,�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 ti butar�-to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply a--ell. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private Rater 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 tree 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.] (yes/-Co)The system fails.!have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility,with a design flow of 10,000 gpd to 15.000 gpd You must indicate either"yes"or"no"to each of the follewing: l the following criteria apply to large systems in addition to the criteria above) yes o _ the system is within 400 feet of a surface drinking water supply _ the system is within 200 feet of a tributary to a surface driniting water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—Ttz o-A i a-^�-_�e Zone 11 of a public water supply well if you have answered"yes"to any question in Section E the system is considered a signit cane t eat- or aL_-,er "ves"in Section D above the large system has failed.The owner or operator of any large SVSteM,considered a significant threat under Section..E or failed under Section_D shall Upgrade the system.in-accorda-ce z=` 'M 15.304.The system owner should contact the appropriate regional office of the Department. T41. : T„c.orr; r c r,r innn Page 5 of 11 OFFICIAL, INSPECTION FORM-NOT FOR VOLL�"TARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAI, SYSTEM ni NPEC;'TION F"ORNT PART B CHECKLIST Property Address: "-We ! H Owner: //A 44e- Date of Inspection: Check if the following have been done.You must indicate"yes"or`moo"as to each of the folio-ing: Yes —o Pumping information was provided by the owner,occupant,or Board of Health v/Were any of the system components pumped out in the prey sous two weeks? v Has the system received normal flows in the previous two week period? --- -Have large volumes of water been introduced to the system recently or as part of-rhis.nn=pec-cion Were as built plans of the system obtained and examined?(If they were not available note as-i_A.) Was the facility or dwelling inspected for signs of sewage back up? (/ Was the site inspected for signs of break out? v C/ 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? c,-"'— Was the facility owner(and occupants if diff rent from owner)pro-,zded-%ith info rmatior_on Tile prop.- maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has beer.deterr~ined based on: Yes no� Existing information.For exarnple,a plan at the Board of Health. &-'/Determined in the field(if any of the failure criteria related to Part Cis at issue approxi-n non of distance is unacceptable) f310 CNM 15302(3)(b)] .r. T;tl- : T„c„A�r; Page 6 of I I OFFICIAL I\SPECTION FOR-Al-NOT FOR VOLU-ill aRY-ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM nTFORMATION Prop erty Address: 2-i'C�L �e 66L 6,9,/ Owner: wA Ai Date of Inspection: off' p OW COINTI)ITIONS RE SIDEY11AL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x=of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): Is laundry on a separate seurage system(yes or no):1W [if yes separate inspection required? Laundry system inspected(yes or no): Ifs Seasonal use: (yes or no): / Water meter readings;if available(last 2 years usage(gpd)): Sump pump(yes or no): Last date of occupancy: CON* E�ZERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CTMI R 15.203): gpd Basis of design flow(seats/persons/sgft,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 1'VTORVIATION Pumping Records / Source of information: l�o t e Ce j�crj off W as system pumped as part of the inspection(yes of no):&p P If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYP OF SYSTEM Septic tank,distribution box, soil absorption system _Single cesspool Overflow cesspool —Privy Shared system(yes or no)(if yes,attach preN7ous inspection records;if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance cen^_ct to obtained from system owner) _Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of informatiou: Were sewage odors detected when arriving at the site(yes or no):_&O Title G.T»c»ontin»T7n_ �/1 C!,)Ann Page 7 of I 1 OFFICIAL INSPECTIO\FORM—NOT FOR VOLUN,l ARY ASSESSA ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORAT PART C SYSTEM INFORMATION(continued) Property Address: • ash S /� �c�6�/ Owner: Date of Inspection: BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _(` 0 PVC - other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:I (locate on site plan) Depth below grade: 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):_(an ach a cop<<of certificate) Dimensions: S X� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 02 7 �� Scum thickness: Lf 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:_ 'i'o/e e e-L . Comments.(on pumping recommendations;inlet and out t tee or baffle condition,struct°s-a:l integr1itt7_. liquid ie els as related to outlet invert,evidence of leakage,etc.): ��.,vr► ,�, �Re c ,. / el y 4, I,- �elf /1iet-, o u�l� 7L Cariev VL Tree. AAp Z—,ce.4j GREASE TRAPA. (locate on site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_over (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 struc-c aral ems--, h-0_d_e:=>s as related to outlet invert, evidence of leakage,etc.): Titlo G Tnenontinn�..r„. </1 Ghnrtn Page 8 of 1 l OFFICIAL,INSPECTION FORM—NOT FOR VOLL`NT_-,4.-RY ASSESSNIENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAR'd'C SYSTEM INF-ORMATION(continued) Property Address: Id- P1 GLol 5Gh•1i4 Oat6p/ Owner Date of Inspection: p�f TIGHT or HOLDING TANK: IV(tank must be pumped at time of inspection)(locate or site plan) Depth below grade: Material of constriction: concrete metal fiberglass_polyethylene otLer(t-aolain): 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.): DISTRIBUTIOhi BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: ;40 1'; 7 L Comments (note if box is level and distribution to outlets equal,any evidence of solids carryover, any e: Bence of leakage ' t or out of boy,. etc.): y �b PTJti1P CHalVIBER: (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.): i Tittc; T,c... Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSA1ENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: p2l Q rn /Q�-i q.�✓!r /� Do1-6 0/ Owner: 4-1 Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: l�1 g galleries,number: � g 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 pond)ing, damp soil, conditionf o vege anon, etc.): _ /ovt H SOr CleGvi eaH a✓ Ori CESSPOOLS: /l/(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 ofponding, condii�on of ve-getarion. etc.j: PRIM': (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil;signs of hydraulic faille,level of pondinff, condition of ve_etarion Titles Tncncrtinn Ln .n F 1 rl)AA l Q Page 10 of 1 I ,i OFFICIAL TSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBS I RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORT PART C F SYSTEM INFORMATION(continued) Property Address: Owner l✓a ll.�cs: Date of Inspection: ': _•' 4k' SKETCH OF SE WA DISPOSAL SYSTEM Provide a sketch of thee wage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all:, ells within 100 feet.Locate where public water supply enters the binding. )t �f.t �a a.; 2� E s ,;- r � Y. All a t �� ss T;tlo G T+ercrhnn �'n.-ire r. - nnn i!1 i • Page i 1 of 11 x4 it • OFFICIAL''.INSPECTION FORM—NOT FOR VOLU_N, _TaRY ASSESC-1:MNTS Ks SUBSV FACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR11 r PART C SYSTEM INFORMATION(continued) Property Address- Owner: -Date of Inspection: o2S STI'E EXAAZ Slope i Surface water Check cellar /7 Shallow wells /1-W Sa Estimated depth to ground water o?,P-feet r„ a Please indicate(check) 11 methods used to determine the high ground water elevation: �r Obtain from system design plans on record-if checked date of design pion rei�e ed: Observed site(abui ng property/observation hole within 150 feet of SAS) hecked with Ioca Board of Health-explain: Checked with lo4,,excavators;installers-(attach documentation) Accessed USGS database-explain: N You must desc 'be how ou established the high ground w ter/elevation: /,P a/e , r < n. k ; V, ,yam V�': $'An 0. r fil: E , 7_41. Tner cnfinn r, ,. �� i�nnn J . ta/9/9, NOTICE: This Form Is To Be Used For the Repair Of Failed Saptic Systems Only. t--:: r { S CERTIFf.3CATION OF SKETCH AND APPLICATION FOR A DISPOS xL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) e, � zh a S' ,hereby certify that the application for disposal works 5�,4yK construction rir t signed y ed b me dated 1�- 5� - `l� ,concerning the property located /Z 1,k '�V meets all of the �V following criteria.; Y�1' Z*-"There are no wet6nds located within I00 feet of the proposed leaching facility There are no pris to wells within 150 feet of the proposed septic system There is no in in flow and/or change in use proposed k Mere are no viAa ces requested or needed. • if the proposed lching facility will be located within 250 feet of any wetlands,the bottom of the proposed leachQ-facility will MU be located less than fourteen(14)feet above the maximum adjusted groundwater 4194levation. Please complete tle fallowing: Cl") . ., A).Top'of Ground Elevation(according to the Engineering Division G.I.S.map) B)Obs Groundwater Table Elevation(according to Health Division well map.) ? rrw , IJI Y�r SIGNED DATE: %Lj—3t-y-- y L Y. LICENSED SEIP�iC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 579, em:Also if the licensed installer posesscs a certified plot plan, [Attach a sketch plm41 zf the proposed cyst this.plan should be s'i- itted]. z q:health folder:cent �'3 �,ya T s fy. }:.R': a. -------------- 44, 'THE COMMONWEALTH OF MASSACHUSETTS F: : BARNSTABLE, MASSACHUSETTS (Certificate ©f Compliance THIS is TO CER YTIY,that the On-site Sewage Disposal System Constructed( repaired ( }CTpgraded (. ) Abandoned( )by !` -- jn3y- =����5 at 2 2eo 4z"_,ft,4/ has been constructed in accordance with the provisions of Title 5�and the for Disposal System Construction Permit No. Er-6912 dated tJ— Installer / Designer c1.Y�.a� 9 The issuance of this;permit th 11 not be construed as a guarantee that the system will function as designed. ` �f .q Date_ -� { `;`�i„ � Inspector No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIS.HEALTH DIVISION - BARNSTABLE.;MASSACHUSETTS , IMP05al *Pgtem (Conelruction permit y grantePermission is hereb d`to Construct( repair( .)Upgrade( )Abandon( ) System located at q!2 4T fd— I g, : and as described in the abgve Appli ,cation dr isposal System Construction Permit.The applicant recognizes his/her duty to h• comply with Title 5 and the following local provisions or special conditions. Provided: Construction musA completed within three years of the date of this t. tom, Date: �� 3U A oved b t � PPr y .t �kwr. .. E No. (� / Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: • ' PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS V/Y 01ppfication for Migogaf *pgtem Construction Permit Application for a Permit to Construct(/'Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Q!Q li19 970/9 4.,,a Owner's Name,Address and Tel.No. —S 6/—Fi 7 — 74/7O Assessor's Map/Parcel w S• A1ar,-*uvrS ✓1 Installer's Name,Address,and Tel.No. dj jyJ— O1,V Designer's Name,Address and Tel.No. V, 1�rarvol� Type of Building: Dwelling No.of Bedrooms _5' 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 Size of Septic Tank Type of S.A.S. Description of Soil .Si� �� Nature of Repairs or Alterations(Answer when applicable) fj4:5,- E/ ' S'/'oM-t- 4 r�,//!mil 9 " 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 Health. Signed Date !D-4'- 9'.;' Application Approved by z Date /C/ss y 9` Application Disapproved for the following reasons Permit No. Date Issued ' ... . ,.. .. .,1, '^�t� n,,y,,.,,.ti; ✓�ti ,rw.v...f+,a +i, .-'�<.F�::. .•Y. :::' .. .' ,....:ci f+.� 'J±+�r.�v ,.� ,.•=r'"t No. / Fee . / _ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1/ f PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes ' 01pprication for Migpo!5al *pgtem Cow6truction Permit ° Application for a Permit to Construct(�-Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. 2(2 A".e ao a Ro od Owner's Name,Address and Tel.No. —,f�Gr—$7,5' 7'1%O Ny�+ti�,s 7 u11'11;4,z4 Assessor's Map/Parcel k Sr ���!✓'iS 491'1 v �9� 2GG s`y al r /r_ r S Installer's Name,Address,and Tel.No. 4,.7,7— al cr,? Designer's Name,Address and Tel.No. ,/os�p� /�•� Q�r<^D S 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 1 Title Size of Septic Tank l Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) -;4.11 'r 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 Health. Signed Date Application Approved,_by Date /0 C, g' Application Disapproved for the following reasons Permit No. 9' Date Issued /e —3 Q- 9 co 'THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( . Repaired ( )'Upgraded( ) Abandoned( I)by ,-,, "/4-5c,04 e at �,�� / T�r� ,[�c0 �L� has been constructed in accordance ~0 r with the provisions of Title 5 and the for Disposal System Construction Permit No. 3Y-6 9` dated lG-30 } Installer / 04, 0­4 ----Designer The issuance of this:permit shall not be construed as a guarantee that the system will function as designed. Date { f ?f Inspector No. �G� {��"/ ---------------------=__—Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BAR NSTABLE1'MASSACHUSETTS M!6po5ar *p5tem Con5tructiou Permit Permission is hereby granted to Construct( repair( )Upgrade( )Abandon( ) System located at 2!:2bo r2"Z J and as described in the above Applicato 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 it. Date: _ /'0— 30-- 9F Approved by F _2- r la/9/97 NOTICE: This Form Is To Be Used For the Repair Of Failed Styptic Systems Only: CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) 15 we,4 n..3 ,hereby certify that the application for disposal works construction pei rik signed by me dated — lef- Vef ,concerning the property located at V 2 /'it as zi &�el /&do/I4s, meets all of the following criteria.,, A--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 change in use � 'n flow and/or proposed %There is no increase t 6 ere are no variiances requested'or needed. If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the proposed leaching facility will nZ be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation. Please complete ithe following: A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) 510 ._ B)Observed Groundwater Table Elevation(according to Health Division well map) </'7 _ SIGNED: - _ DATE: LU�3e)-- 9 el LICENSED SEIE"TiC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER (Attach a sketch pHarl.of the proposed system.Also If the licensed installer posesses a certified plot plan, this.plan should be submitted). q:health folder:art t 14 11,41 1000 0 u� rti S rah L P Gi X�sT�Ny O i �r. "LO-C-Q-T-1-O-N-� SE - -Q Cz-E—P-E-EMIT-A1-O: A caE — — — — 1-Iv-ST-A -l_E-R-•S-►J-� - --��-A D-D-R-E-S-S— �A D D R-E-SS D AT_E-C.O_N%l_P t`I-AIt`l CE I_SS U-Ea f \ �-. .. � � . }= `N' _ �_ ]t 1 �. � � 4} F�. � -' nor �` � � ' _ .: � 4 6 1 Ila cu �naoq - / It ��?w No..------. ..... Q............... THE COMMONWEALTH OF MASSACHUSETTS rd BOARD OF HE _TV6, d,/ O F....... ............ .. ........... ..._.... - - -- .,+ q, ApplirFatiou -fur Bhipooal Worho Tomitrurtiou Vrrmft Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at Location-Ad e s or Lot No. p Address --- a ---� ---- / ------ Installer Address Size Lot____/� v ` v Sq. feet Q Type of Building `� ________________ U Dwelling—.No. of Bedrooms__________________________ __ _____Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ---------------------------- No. of persons.---..-_---_______---:------ Showers ( ) — Cafeteria ( ) Q' Other fixtures ------------------------------- -- W Design Flow............. _---_---___.-_.___-gallons per person per day. Total daily flow-------------------- �--._-_-.gallons. WSeptic Tank—Liquid capacit 'allons Length---------------- Width................ Diameter---------------- Depth-.__--_.-._.. x Disposal Trench—No. i ht---- Total Length---_....I---------- Total leaching area--------------------sq. ft. tal leaching area---- Seepage Pit No.. � -<...... t elo t _V-.-s( 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...-_-__--_---._-.--._ ;Tq Test Pit No. 2................minutes per inch Depth of Test Pit.-_---=-_________- Depth to ground water--_-_ --__.---.--_-:--- P+ .............. -------------•----------------------------------......---------------•--------------........................................................... Descriptionof Soil------------ -----------------------_---- -------------------------------------------------- -- U -------------------------------------- ---------------- . ---------�--�---.... ..--- ---- -- W ---------- --------------- -- --- ---------------- ---------- ---------------------------------- -------------------------- UNature of Repairs or Alterations—Answer when applica e..---------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has be n 'ssu- y.the bo d QL health. r� r � Sig --- ------ - -------•----------- ------- -------.-- --- ----.------------ -- --------�-�--y------ Dattee ----------- Application Approved B ------------•--- & 7../ PP PP Y "-' _ _ Date Application Disapproved for the following reasons��_ --_ d10 -------�2-�.....-•----------- ----.....---••----•----•-•---------•--------------------------•-•-----------•-•--------•-•-•--••-•------------•-•-•-----•-•---------------•-------------------------------------------------------.----- / / Date Permit No......................................................... Issued------�{--'� i /_� - -------- / Jat `� - A THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH Appliration for lliipaoat Works Cnowitrurtion Vrruift Application iso hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: eg's f Location-Addr or Lot No. - =l -' L(t" '�^ __/2�.- - ------------------ -•--------------•-•------•••------••••......----•-••-••-------•---•---•...-•------ /' Owner Address l Installer Address U Type of Building Size Lot------� __�`_�`-----_Sq. feet Dwelling—No. of Bedrooms---------_____------------------------------Expansion Attic ( ) Garbage Grinder ( ) per-, Other—Type'of Building ____________________________ No. of persons._.-_--_-_.-__-____.-.-_.__ Showers ( ) — Cafeteria ( ) a' Other fixtur's ----------------------------------- W Design Flow-------------- ---------gallons per pe son per day. Total daily flow.....____..._...._ _. _.':_.____..gallons. 04 Septic Tank—Liquid cal)"ity,:__;_4•__-gallons Length................ Width---------------- Diameter---------------- Depth-__.-_.___...- * t ...� lr x Disposal Trench—No Width--------------- Total Length.................... Total leaching area____ -------sq. ft. Seepage Pit No !-------, ,�Dia�ne'ter��___�epth�below i t_.�� ,6tal leaching arert._ �r'r_2sq. ft. z` Other Distribution box ( ;)x Dosing tank ( ) Percolation Test Results Performed by----------------------- Date Test Pit No. 1________ ______minutes per inch Depth of Test Pit_:------------------ Depth to ground water...._._..___.-_._-.----- 44 Test Pit N(o 2.::...:.........minutes per inch Depth of :rest Pit.................... Depth to ground water-----------.______--.__. P4e ...........................-------------------....._.._.....---.....-----......................__...__......__.........._..------......----......._..•---. DDescription of Soil-------------'f-------------------------------------------•--------------------------------------------------------, � Yx At ' a '-"W y =- ......... --- /------------------ ------------------- --------- ---- � � UNature 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 X00he State Sanitary Code—The undersigned further agrees not to place the system in operation until Certificate of Corripl>ance hags been issued,iby the board of health. Sign - ---•--------------- ------ ---•-----=•----------------- -------------------------------- Date Application Approved By. �,,y���� 1-t --•Cy • .r, _`_ fir. . - — lla�--- - Applicatiod spproved for the f ollo Og reasons------------------------------- - ------------------------------ ---------------------------------------------------- - ---------------------------- Date Permit No................ - Issued. �2l 7 ate ° THE;COMMgN.WEAALVH OF MASSACHUSETTS BOARD OF x H`EALT' ` !f.......... :..:..........:.OF..1.. :r(/.t !...... ......................... a - i. 1Q.1rrtifiratr of 'Tomplianrr THIS-IS TO CERTIFY�Thaf the?I•ndivid al Sewage Disposal System constructed or Repaired ( ) 1 at. elegy^- -wrs t r�' -�f-------••------------•---••--------------•-•---•---------------------------------------•-•-•---•-••----•---------------------------------•----------••-•-•---•--••-•------- has been installed in accordance,-with the,provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction"Permit No______________ _..._._._. dated....... �_.> _ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BECO CONSTRUED AS A GU RAN' EE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. k �i by �.:i DATE............ :_.S .............. Inspector -- ................................................. " THE COMMONWEALTH OF MASSACHUSETTS BOARD OF .ollE~A`L• TH f ................................... - .:.. No.----tj...l._...... FEE... %nVoml, )arks Towitrur ion Vrrmit Permission is hereby granted--------�-11f_l - ` ...................' ' to Construct (—) or Repair ( ) an Individual,Seyvpge Disposal System at No ---�--------=�f �-•.-- ° � !.,......................./7/ f'� --.------; l- r .{, _ --------------------------------------------- Street as shown on the application for Disposal Works Con". ruction P it N Dated___:_� '�.----------- oard of ea DATE-------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS ' -. �-- •ssessor's map and Itx ntirrb,�?" ` Sewage Permit number ......... . .. �pTTNETpi TU `-v N OF BARNSTAB LE p t MAO& 1i BAH3STSIILL, i If�K p� 1NI ��n1�� NAB iLVI 1�n�1�r�? I/IFil. uY y\0t' t5i� �ld� b U LS.�J ® u W APPLICATIONFOR PERMIT TO ...(..: :...................................................... ..................................................... r; TYPE OF CONSTRUCTION .......C�l.: f'. ''C'k.......... ,..�t..t./t-:..........^.........................:................ .. .! 1 . . ........ .....19././... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby laappplies for a-pfermit according to the PIlowing information: Location ...` ...... <..... .. ...... /,Lll� !t. ').......... . ..4 ............ [/((`J./ tilZ�( ................ . ProposedUse . ...................................................................... ..... Zoning District ...4-e.............................. ..........................Fire District ........ A41... , lc.�.E '.. ..... �i:' ....Address ... .................. `� : Norne of Owner /. ��1A //� r. C� t'llYl f/ l.. < Nomeof Builder Address .................................................................................... Nameof Architect ..I..........................:....................................Address .............................................................................. Number of Rooms ......ai. ..............Foundation .....(..C.J.. � /............. ��L%•rr .... ..... �� �.�(„K....` L�`. . ..L�............................Roofing ....� . Exie;io . :.......... ............................................. L'� �.t.:L `- ('. / .......Interior ../. 1 ..../. ... i Gr,. r 5 f... r h ' ......(11 ...Plumbiney. ...............:r Fireplace ! Approximate Cost ......s . �l ..................I................ p .............. ........................ . r. Definitive Plan Approved b Planning Board -6:Z�'{� -----19_/__ Area .......................................... PP Y 9 � -- - -- Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH C ) I r I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction.