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HomeMy WebLinkAbout0039 MIDWAY DRIVE - Health 39 Midway Drive `lyannis A = 252 - 071 COMMOMVE-AL'I'li OF AWSACIIUSL:'1"I'S EXI:CUTIVL OFFICL OF E NvillONMLNI'AL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TI17 E 5 OFFICIAL INSPECT*ION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORi11 PART A CERTIFICATION Property Address: 39 Midway Drive i Centerville ON•ner's Name:__Br; an & Krista Chase !( to Owner's Address: 39 Midway Drive M, Datc of Inspection: Name of Inspector: (please print) Sean Jones zi _ Company Name: tJiIIi L_ Robinson Septic Service { Mailing Address: P O Box 1 009 ilk- _CenLerville t•tn_ Telephone Number. CID r=; CERTIFICATION STATEMENT 1 certify that I have personally urspccted the sewage disposal syslcm at this address and that the infonnalivn reported below is true,accurate and complete as of Ilre time of the inspection.Tile inspection was performed based on illy training d system in cc in the proper fwrction d maintenance of on site sewage disposal systems. I our a UEI' approved system inspector pursuant to Se roll 15340 of Title 5(310 CMIZ 15.000). The system: Passes Conditionally Passes _ Needs Furthe • ation by the Local Approving Authority Fails Iusimclor's Signature: ` V,?,)C), Dulc: .. Tl►e syslcm inspector shall submit a copy of this inspection repots to the Approvutg Authority(Board of I(talOror UEP)wilhul JO days of conlplcliog this inspect, inspection If the system is a st>arcd system or has a dcsigrt (low of 10,000 gpd or greater,the inspector and lire syslcm owner shall submit the report to tilt appropriate regional oflicc orlhc DL;P.Ile original should be scut to the syslcm owner and co autlwrity. pies sent to lire buyer,if applicable,and lire appruv ink; Notes and Conuncnts "'This repurl only describes conditions at the Hine of inspection and under the coudilions of use at (list lime.This inspection dots not address Irony the system will perform in the future under the same or differcu( conditions of use. Title 3 Inspection Form 6/15/2000 page I r Page 2 of I I OFFICIAL INSPECTION FORM—NOT FOIL VOLUNTARY ASSESSMENTS SUIISURFACI;til;\VACL I)ISI'OSAL SYSTEM INSPECTION F0101 PART A CERTIFICATION (continued) Property Address: 39 Midway Drive Centerville Owner: Brian & Krista Chase Date or inspection: a0 Inspection Summary: Check A,B,C,D or E/ALWAI'S complete all of Section D ste A. SyV Passes: 1 have not found any uifuruiation which indicates dial any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated arc indicated below. Comments: B. System Conditionally Passes: J-\//A 1 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 IIcaldi,will pass. Answer ycs,no or not delcnnined(Y,N,ND)in the for the following statements. If"Uat determined"please explain. llie septic tank is metal and over 20 years old' or die septic tarn;(wlictlicr metal or not)is structurally unsound,exhibits substantial i ifhltralion or cxfhltration or tank failure is imminent_System will pass ins►cction if Uic existing tank is replaced with a compl)•iog septic tank as approved by die Board of I Iealth. l '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 die distribution box flue to broken or obstructed pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(will, approval of Board of licaldi): broken pipc(s)arc replaced obstruction is removed distribution box is leveled or replaced ND explain: llhc system required pumping more than 4 times a year due to broken or obstructed pipc(s).l he system will pass i lspcclion if(%vi►h approval of the Doard of llcallh): broken pipc(s)we replaced obstruction is runoYed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORMI - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE,SE«'ACE llISPOSAL SYSTEM INSPECTION FORI\I PART A CERTIFICATION(continued) Property Address: 39 Midway Drive Centervi e Owner: an & Krista ase Date of Inspection: C. Further Evaluation is Required by the Board of lleal(b:'11 A Conditions exist which require furdrer evaluation by Ole[bard of Ilealdi in order to dctcmiine if ll►e system is failing to protect public healdi, safety or Ore environment. 1. Sys(cnr will pass unless Board of liealth determines in accordance with 310 CI1111 15.3U3(1)(b)that the system is not functioning ill a manner which will protect public health,safety and the 03(i)(environurhn t: _ Cesspool or privy is within 50 feel of a surface water _• Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. Systcnr will fail unless lire Board of lieal(h(and Public Water Supplier,if an)-)determines that (he system is functioning ill a manner(hat protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and Ore SAS is widrin 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 Ufa 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 front a private water supply well•• Method used to detemtine distance "This system passes if the well water analysis,perfonned at a DEP certified laboratory, for colifunn bacteria and volatile organic compounds indicates that the µ•ell is free from pollution from that facility and the presence of anunonia nitrogen and nitrate nitrogen is equal to or less than 5 ppnr,provided Oral no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. O(Ircr: I'agc 4 of OFFICIAL INSPECTION FORM — NOT FOIL VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A URTIFICATION (continued) Property Address: 39 Midway Drive Centerville Owner: Brian & Krista Chase Date or Inspection: t o06 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Ycs ;/Dischugc Backup of sewage into facility or system comonent due to overloaded or clogged SAS or cesspool or ponding of effluent to the surface of the ground or surface waters due to art overloaded or / clogged SAS or cesspool -1 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6"below invert or available volume is less than '/,day Iluw Required pumping more than 4 times ut file last year NOT due to clogged or obstructed pipe(s). Number or times pwuped_ _ Any portion of the SAS,cesspool or privy is beluw high ground water elevation. Any portion of cesspool or privy is widtut 100.feel of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply we1l. ✓ Any portion of a cesspool of privy is less Ihall 100 feel but cater than 50 Br f.ct Gent a private water supply well with no acceptable water quality analysis. IThis system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria arid volatile organic compounds indicates that the l%cll is free from pollution front that facilityand I ,he rescncc 1 or ammonia nitrogen and nitrate nifrogcn is equal Io or less than S ppm, provided that no other failure oiler is y are triggered.A copy of the analysis must be attached to this form.] Ny (1'es/No)The system fails. I havc determined that one or more of the above failure critcria exist as described in 310 CMK 15.303,therefore the system fails.The system owner should contact lire Board ul I Iealth to determine what will be necessary to correct the failure. E. Large Systems: /I P To be considered a large system (he system must scf-vc a facility with a design 1101t, of 10,000 gild to 15,000 gpd. You roust indicate either"yes"or"no" to each of the lulluti ing: (Tllc following critcria apply to large systems in addition to the critcria above) ycs flu _ tic system is Nvithin 400 feel of a surface driftkutg water supply — the system is within 200 feel of a tributary to a surface drinking water supply the systctn 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"ycs"to any qucs1lun ut Swum C the sysicut is umsidctcd a siptilicant threat,ur amwcrcd "ycs"in Section D above life large systctn has faikd.the trr•n:T tx operator of ntry large system cunsidcrcd a significant Ilueat under Sectiun E or failed under Sccliun D shall upl•rade the system in accordance with 310(:NIll 15.304.The system omicr Should contmt the appropriate regional ofliLc of the Department. Pa.ge 3 of I I OFFICIAL INSPECTION FORAM-NOT FOR VOLUNTARY ASSESSMENTS SUIISURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART CHECKLIST Property Address: 39 Midway Drive Cen ervi e Owner: Brian & Kris a ase Dale of Inspection: Check if the followinR have been done.You must indicate"yes"or"no"as to each of the followin : l'cty No ✓ /Pumping information was provided by the owner,occupant,or Board of I lealdt t% Were any of the system components pumped out ui the previous two weeks / Has the system received normal flows in the previous two week period? Ilave large volumes of water been introduced to,tlte system recently or as part of this inspection? . tWere as built plans of the system obtained and examined?(If they were not available note as N/A) ✓ — Was the facility or dwelling inspected for signs of sewage back up? ✓ _ Was the site inspected for signs of break out? ✓ Were all system components,excluding the SAS, located on site? Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum T Was the facility owner(and occupants if different from owner)provided with information on the pro r maintenance of subsurface secrage disposal systems? f The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Ycs/no Existing information. for example,a plan at the Board of health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)13 10 CMR 15.302(3)(b)) 5 ]'age 6 of I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSUIVACE SENVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 39 Midway Drive Centervillle Owncr: Brian & Krista Chase Date of Inspection: no LOh 1Y CONDITIONS IIESIDENTIAL Number of bedrooms(design): Nurnber of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x a of bedrooms): 330 6 PSG Number of current residents: 3 Does residence have a garbage grinder(yes or no):n/D Is laundry on a separate savage system(yes or no):✓�o (if yes separate utspection required) Laundry system inspected(yes or no): /V ,4 Seasonal use:(yes or no):_A., Water meter readings, if available (last 2 years usage(gpd)): 1 /06-5/06 - 27,750 Sump pump(yes or no): No --t 5--5 4, 0 0 0 Last date of occupancy: �vrre CONINIERCIAUINDUSTRIAL /V�/� Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present Oyes 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: a o o3 - o ��-•�c.� Was system pumped as part of die inspection(yes or no): if yes,volume pumped:_gallons-- llow was quantity pumped determined? _ Reason for pumping: Tl'!:E OF SYSTEM u/Septic tank,distribution box, soil absorption system _Single cesspool _Overflow cesspool _Pricy _Shared system(yes or no)(if)-es,attach previous inspection records, if any) _Ittnovative/Alternative technology. Attach a copy of tic current operation and nnaintenance contract(to be obtained Gom system owner) _Tight tartk _Attach a copy of tie DEP approval _Other(describe): Approximate age of all components,date installed (if known)and source of infurtnatiun: , ,tie. D-Qal, d4©a - SePi-z -LA—K LQ�c� �I� Gre Were sewage odors detected when arrivutg at the site (yes or no):✓/0 Yap: 7 ur I I OFFICIAL INSPECTION FORM - NOT I Ull YOLUNTAIII' ASSLSSt\lLN7'ti SUBSURFACE SEWAGE INSPF,CTION FORM PART IC SYS• TNI 1NF0101ATION (cunUnucd) Proptrl)• Addrtss: 39 CMidway Drive enterville Onncr:Brian & Krista Chase Ualc o(Inspccllon: / a, BUILDING S NVU1(locate un silt plan) Dcpds below grade: /al ao i`lalcrials of construction:_call cull _dU I'VC _ utllcr(explain). DISIaItee (rum pris•atc ssatcr supply %sell of wcliun line: -- Cunsnsents lull cunditiun u(juinls,venting,cvid(ncc of leakage, et(.): .va SCI'71C 1-ANFi:JO"" — _(lucatrvn site plan) Dcpth below grade: lc2 r � Material of construction: i/eunucic Inctal Gbuglass _pul)cdlylene uthcr(cxplain) — — If LUIk is metal list agc Is age cunfuwcd b� a l cltilicatc of Cvnapliancc (pcs uI nu) —(attach a cvl,y ..,I certificate) — _ Dimcnsiuns: Sludge dcplh: DIs1aI1Ce from lull u(sludgc to Lvnuul u(uullcl Icc of balllc: O Scunl Ihiclsrscss:_/ _ (, -- Dislancc from Iup u(scum vu I o1)of llct Icc or 1)afIIc: l Distance (rum bulluln of scum Iu bulluin ur vutl I Ice or balllc: How %sere dimensions docnnincti. S --" 0�-ln(O` Cp✓l!l nn.._f' a r� alKla,f C U[III tic III(on pumping I cc o nu nc nda I i kill s, inlet alit uul It: Icc uI balllc cvndil ii.n, sll uc III AIIn ICt;I ily, Iitluld Ik\t.l. as IIclatcd to uullcl invert,cvidcncc of leakage, ett:.): /��`�r� �wr, 6✓� s6loY�dC �L C�-Ca� �V ye/ ,a m 1 t- 4,1 D✓� /'1e 'lest 4EF L.Per /� c f r Vr f lea 11 Il.A- GIILASC TIIAI':`�Iocatc un silt plan) Dcpol below grade: _ )slalcrial u(consumllull._collude Inctal Ilb(ll;lass__pul)ctll)Icrlc ulllcr (explain): -- — -- hincnsiurts: ---- -- - - --- --- - --- ----- Scum Illiculcss: _ __ Illwalm,fluln lop of scum to lisp Ill vuticl Icc ul balllc. l)Istancc (runs bOlIUM of Mill lu bvlt.,nl ul uullcl Icc oI balllc- - I)alc of last pumpinf,: ---.- Cvnunents fun pulnpnnl;IeeunuuendaUvn , Inlcl anal uullcl tee ,-'r balllc cun'llli;,.1, Sit mIuiA Inlet;ilt), lyunl Lcsd a,IclatcJ lu uullcl instil, cs ulcntc of Ical.a(•,c, cic ). , 7 'age 8 of I OFFICIAL INSUCI'ION FORM - NOT FOIL 1'OLUN7'Alll' ASSL`S111F,N'I'S SUUSURFACL WS'AGI; DISPOSAL INSI'F,C'I'ION FORM PART C S1'STBI 1NFOKMATION (continued) Properly Address: 39 Midway Drive _en ervi e Owner: Brian & Kris a ase Wit of Inspection: 5- 'FIGHT or IIOLOING TANK: Aank must be pumped at lime of inspeclion)(locate on sift Flan) Ueplh below grade: Malerial of eonstruclion:__cun(Iele_metal _— Iibclglass_polyethylene _ullicr(explain): l)imentiunt: ------ Capacity: galluns Ucsign Mow; gallvns/Ja)• Alain► icscnl O•cs I or no Alum level: Alarm in ssurl ing order (Jcs yr nu). DAIe of last pumputg: --- Cununcnts(condition of alarm and Iluat swilclics,ctc.). UISTIUUUTION UOX:✓(if I,rescnt must tic upcncd)(lucate on site r Ilan) Ocpth of liquid level above uuticl invert: �or •el aril distributrun ry varlets equal,any evidence of Solids cair)user, any evidence ul Cununurrt(nvle if box is Ies Icakase imu Hof out of box,etc.). A!t L- D-Ilia - M-r le-=1.4-, - �oX PUMP CIIANIULIU��Zlucalc un silt plan) I'umps in ssmking urdcr().es ur no). _ Alarms in ssoll,ing order ()-es ur nu). Cunlrrtcnls(nulc(ondiliun of pump cltanticr, tunrlttrvn rrl pump, and appurlcnanccs, cic.) ]'age 9 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSNIENTS SUBSURFACE SEIVACE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Midway Drive Centervi e Owner: Brian & Krista ase Dale of Inspection: 5,y- �rro,b SOIL AUSOILPTION SYSTEM (SAS): " (Ioca(e on site plan,excavation not required) If SAS not located explain why: Typ a/ leaching pits,number: 1 i 000 6a 1 toAr _leaching chambers,number._ _leaching galleries,number. _ __—_leaching trenches,number, length: _leaching fields,number,dimensions: overflow cesspool,number: __ _innovative/altcmativc system '1)7)c1lr3nre of tcclutology: Comments(note condition of suit etc.): , signs of hydraulic failure, level of poll ,Jamp soil, condition of vegetation, Sot wFJ ' C e A ' C4 It r _. CESSPOOLS:'Vj" (cesspool trust be pumped as part of inspcc(ivn)(Ivcatc on site plan) r Number and configuration: Depth—top of liquid to inlet un•crt: Depth of solids layer: Depth of scum laver:_ Dimensions of ccsspovl: Materials of construction ___ indication of groundwater inflow()•cs or no):_ Continents(note condition of soil,signs of hydraulic failure, level of podding,condition of vegetation, etc.): I'ltll'1':l1,,A(lucalc on site plan) -- Materials of cunstruction: Dimensions.- Depth of solids: Continents(mute condition I, slats of liNdraulic failure, Ievcl of podding, cunJitiun of vegetation, etc.): 9 s 1'agc 10 Of 1 I OFFICIAL INSPECTION FORM -NO T COR VOLUNTARY • -ASSCSSMLN[S SUBSUI ACE S1;N1'AGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Midway Drive Centerville Owner: Brian & Krista Chase Date of Inspection: d vuG SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including tics to at least two permanent reference landmarks ur bcnc ' a hm rks. Locate all wells within 100 feet. Locate where public water supply enters the building. �LE AL of- 4�00 S E F—ool O a t 3 `f'A,,J A-i�- 3Y 00A R- a= 35` L ee-c A Pi't- A-3- !o' 11agc l l of 11 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEIVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 39 Midway Drive Centerville Owner. rista Rri an Chase Dale of Inspecllon: a SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all mediods used to delennine 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 withui ISO 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: U-C Il TOWN OF BARNSTABLE 'IibCATION 3 2) Gv SEWAGE # 24,0 —5-2 t!J1I,LAGE �"� �' ASSESSOR'S MAP & LOT 'O�� '124STAttER'S NAME&PHONE NO. c oeltica 3 a9o7roo SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER Od£lPT 4 elf PERMITDATE: D Z COMPLIANCE DATE: I ca 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 O O _ � L /�i r`�4 '-�` w O .6' ' . • c �. a ., ,""�.- TOWN F BARNSTAUSEWAGE,# LOCATION �J (C _VILLAGE Cff,/nbfLJVCX--- ASSESSOR'S KJ&'LD�N "0o3 INSTALLERS NAME& PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER 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 I�i Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Migpogal *pgtem Congtrurtion Permit Application for a Permit to Construct( )Repair(/KUpgrade( )Abandon( ) El Complete System Iyl'f vidual Components Location Address or Lot No.L.[J v C £�r Owner's Name,Address and Tel.No. Assessor's Map/Parcel ��' d 9 / ��rn�� W,,4 Y a e C f•ti7— Instal r's Plajge,/Address,and Tel.No. 7s_ Designer's Name,Address and Tel.No. �f/C 0 s S S T-- Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �f ✓�/1t C Z ®k 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 issuH by this Board of Health. Signe Date��- Application Approved by r9 r C' Date Application Disapproved for the following rea(jn Permit No. ( - Date Issued Fee THE COMMONWEALTH,OF MASSAG`'HUSSTTS Entered in computer: � , �� Yes PUBLIC'HEALTH DIVISION -kTOWNOF'BARNS BLE, MASSACHUSETTS Yicatton for eg o= alY p0 erri Core uction Perutit Application for a Permit to Construct( )Repair( pgrade( b`-don ), O C.ariiplete System LJ°Individual Components r Location Address or-Lot fNo. '�" Owner's Name,Address and Tel.No. Assessor's Map C,;r/(-7^— Instal is N e,Address,and Tel.No. / _ Designers Name,Address and Tel.No. Type of Building: µ , Dwelling No.of Bedrooms Lot Size sq.fi. Garbage Grinder( ) Other Type of Building No:of Persons ik Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date `II Title Size of Septic Tank Type of S.A.S. k 1 Description of Soil ` Nature of Repairs or Alterations(Answer when applicable) I 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 _ 7/ � © ! Date Application Disapproved for the following rea: - Permit No. QL. Date Issued Cyr i j 11 THE-COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS k Certificate of Compliance .. THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( ')`Upgraded( ) y`= Abandoned( )by kc0 _ !!5v .K� J7�' 4u at 1�^ Al Z Qgf .rA,,7°'" has ee constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No �" d QQ Installer -n4 '. .s .�telta- Designer r� 61 The issuance of this permit�shall not ble 6 coon ued as a guarantee that the system wilPfunction asT design �d. Date 11; ! �-� � Inspector %���1 '11 �.•-CAP P 61 No. t J Fee r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mie;pozal *potem Con!5truction Permit Permission is hereby granted to Construct( )Repair(40) pgrade( )Abandon( ) i System located at 2 4 9'" C V x.-"70' r 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: Constru tion st bey-eompleted within three years of the date of this pe .! �' C Date: Approved b J Y / PP Y V I , r ' TOWN OF BARNSTABLE LOCATION 12) W"f y SEWAGE # VILLAGE e £tiT ASSESSOR'S MAP&�� 8 0 0 n1grX=ER'S NAME&PHONE NO. I - SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER' £ �� PERMIT DATE: ®Z COMPLIANCE DATE:. Separation Distance Between the: � Feet Maximum Adjusted Groundwater Table and Bottom of Leaching'Facility Private Water Supply Well and Leaching Facility (If.any wells exist Feet on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by i i FAR 110 0 i i 4v TOWN OF BARNSTABLE LOCATION 9 9,y Qbl-iSEWAGE # VILLAGE _ r ASSESSOR'S MAP & LO'T4' INSTALLER'S NAME C PHONE NO. H/c Are�/ CjG� 5 SEPTIC TANK CAPACITY J 1550 d I LEACHING FACILITY:(type) Pi / (size) O ® c a of. .rn•w r. NO. OF BEDROOMS BLIC 'A_PRIVATE WELL O PUTE I� BUILDER OR OWNER ` DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No i �� s �� �-J� y�� �� �� f t� i �Wnn vl � .. ?� '� t� __ ASSESSORS MAP NO: Noo.�✓ PARCEL NO: THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Divi-Voottl Workii Toustrurtioo Famit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: n \ddressor ......... .�?'-:�. 1?.�...1�' . --• 5..2".11"- �..................... Lot No. ►W-a ��'r �, Owner '. •0±0 �� . tAd,dress � e f ... ------ ..................................` --- ----G ¢ Installer Address UType of Building Size Lot............................Sq. feet ., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) 04 Other fixtures --------------------------------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity---__--.__gallons Length-------_------- Width---------------- Diameter----.----------- Depth---------------- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date.................................----- Test Pit No. 1----------------minutes per inch Depth of Test Pit._.______--________. Depth to ground water........................ r, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a -----------------------------------------------------------•------------------............................................................................. 0 Description of Soil..... -------------- 2=--1------- ' X L........................................ W V ....•-••••••••--••••---•---•-------------•-••••-•--•••••••----•--•--•-•-----••---•-••--•••••••••-•--•••••------------•••--•--•--•••••---•------•-......--•••------------.............................. W x --------------------------------------------------------------------------------------------------- ----------- --------....------------------------------------------•-------------------------- U Nature of Repairs or Alterations—Answer when applicable.P_nI..___.____. ---- 1 ' . I__.___ -Jt.-!G�.....c p ?-. � - -d '-rQ+WJrA_..�--- . •-•-••... e.....-----�---- ------- ---- -- ------ --•- — .... ........a....,.Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Corn liance has been issued by the board of health. 1 Signed ......... ---- - -------------------------------- ........................... --------- - --- � S Application.Approved .. -- -------------- Dace Application Disapproved for the following reasons- ---------------------- ..._.._. .. ........................._........- ........._..... .��Dace - Permit -.o. .. .....__....... Issuedr4�,5 ---- Dace • r, NoF�s..... - e'er THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiult for Di-ripw3al Worku Tomitrnrfiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: 3°�....__ . _t ---------------------------- Location a� .._..__ -Address a-d-`-'--•---1 •-•--___-•----------•'•-•-•-•-•-•--or-Lot No. C— ..�._1+ __...---._--------------------••-•---------•----- --`"r '' ---•------------..-•-......_.......---...........--- Owner Address .------.....Q --------- i 'c5-------- =-= ------tt`'' �`'!c` ................................ Installer Address Type of Building Size Lot____________________________Sq. feet �., Dwelling—No. of Bedrooms----- --------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—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 capacity___-_______gallons Length................ Width---------------- Diameter---------------- Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length-------------------- Total leaching area....................sq. ft. 3 Seepage Pit No---------------------- Diameter_-__.._..--_._______ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by---------------------------------------------------------------------_ Date........................................ a Test Pit No. 1----------------minutes per inch Depth of Test-Pit-------------------_ Depth to ground water..................... Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a •---••••--•-----------------••-•-••••-•••---•-----••---•----••--•••.=-••-•--•----•-.....-•••-----•-......................................................... Description of Soil------ �-----.19��-----------------2=---- �---c- -`- --•--.................................... U -•-•-•-•-•-•-•-•--•------•••••--------••••-----•----••---•----•---•••••---•-•••-•--•------•••••--•----•••--•-----------•--•-----•----•------------•--••-•-••-•----•--•-•-•-••--------------•-•••--••--• w ----------------- U Nature of Repairs or Alterations—Answer when applicable.` �)n_4------ �____._%t!I?_.__._`/%��!WG .._._c ��p6dl-. � _ _- (W J�"!> .ZbK-----•--- ,-i4 �� T i S AWL• ---........_ r___________ _____�._.c..._._.________•.__. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Cam liance has been issued by the board of health. Signed ---------- ---- ------ ------------------------- -------3a.a .5 r ApplicationApproved ----------------------- ---------------------------------- -------------- Application Disapproved for the following reasons: --------------------------------------------------------------------------------------------------------------------------------------- ....._........... ............................................ ... Permit No. ------------ Issued ...g�"_�i' �" �-,5- Dale THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ker#tfirate of CTAIntyliala e THIS IS TO CERTIFY, That the dividual Sewage Disposal System constructed ( ) or Repaired byt K-E '- ---'�------------------ ..-------------------------- --------- - - h.,t:�uet at ---35----------- �y� '��' C Z t V l- ------- has4 k AJ_A?`_S-------------------- been installed in accordance with the provisions of TITLE of The State Environmental Code as described-in- the application for Disposal Works Construction Permit No. ��9 �T'� dated �" . .._. THE ISSUANCE OF THIS CERTIFICATE SHALL NO BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCT ON SATISFACTORY. DATE... . . ---------------------------- Inspector=� ��? ' -------------------------------------------------- -.----- ------ - - ---_- ---, ,_,_,----,-_,-__,-_,-- •---,_._ _ _----_ V r? THE COMMONWEALTH OF MASSACHUSETTS — BOARD OF HEALTH �Z -,;, '•' TOWN OF BARNSTABLE 4 Difyusttl World Tono#ru#iun rrntit Permission is hereby granted itc.`C-t< 0�1-`�---------- to Construct ( ) or Repair (,W an Individual Sewage Disposal System at No._._3 ✓Y!_,awr y, - elv_ /t•...ftrvs.-{----------------------------------------------------------------------•----------- Street as shown on the application for Disposal Works Construction Permit 1 o,i____''__�'� �_d____ Z_..':%j.:�.. -- ................7 - `� Boa Health Health • _may G DATE. - -•--'° ----------- FORM 36508 HOBBS♦!WARREN,INC..PUBLISHERS