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HomeMy WebLinkAbout0130 MITCHELL'S WAY - Health 130 MITCHELL'S WAY, HYANNIS A= 290 069 I i I. i l i TOWN OF BARNSTABLE I-rOCATION SEWAGE#'L®��" �. VLLLAGE,!A ,VA,--�'J ASSESSOR'S MAP&PARCEL :Ifo �9 INSTALLERS NAME&PHONE NO. C ��, �✓ ' SEPTIC TANK CAPACITY'/�rj` LEACHING FACILITY:(type) �`°� '�'@J (size) O Y NO.OF BEDROOMS OWNER � � •�'� PERMIT DATE: 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) ,j Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet FURNISHED �'� � � i � � � � � �. w� �. �! �� � � 1 �8 la �?C � � .� `� � �, \ � No. / Fee A THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTHRDIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pplicaction for Xi6po5al *pgtem Cougtruction Permit Application for a Permit to Construct O Repair Olelul"pgrade O Abandon O ❑ Complete System Individual Components Location Address or Lot if Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. ,i Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building lT�.� io No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required)® gpd Design flow provided gpd Plan Date ® 7—A Number of sheets Revision Date Title Size of Septic Tank ���P'�,�Jlv� /S�O®, Type of S.A.S. .P4e!6-4d0_ .0104ce:�'.o,P v. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued b�Boa alth.1>4 0 Si ed Date Application Approved by Date �- Application Disapproved by: Date for the following reasons Permit No. — Date Issued .:ti.,, r a- .� �-..,."*"7'a.,e (;,.,.'�.. �;?a:�.,c..+ma.. . .._ �:. ..:'ti:� r-:✓t•°.... . e' 'ti.A^, `:w'. . �.u.r. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: W :PUBLIC HEALTH DIVISION - TOWN• OF BARNSTABLE, MASSACHUSETTS Yes 9 F W 2pplication for �DiOpo5al *p5tem Construction VVIndii It 'Application for a Permit to Construct O Repair(1-Kpgrade O Abandon O �'Complete Systemdual Components Location Address or Lot N� O��ff/ G LCf' Gj/�t Owner's Name,Address,and Tel.No. Assessor's Map/ParcelrD 9© a e r'9 c'rest ller's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: �✓ Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building P��� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) r0 - •gpd Design flow provided � d gp Plan Date ✓'�O Number of sheets. Revision Date Title Size of Septic Tank�X�J'T�/�',� /S"Om, Type,of S.A.S._..Pew Description of Soil " Nature of Repairs.or Alterations(Answer when applicable) Date last inspected: Agreement: - Tlie,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 Certificate of Compliance has been issued by this BqW of Health. Signed Date Application Approved by� Date 1-7 Application Disapproved by: Date for the following reasons Permit No. "" Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance ` THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (/1 ) Upgraded ( ) Abandoned( )by at has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _7— s dated Installer //�! L� dC�� Designer e,4 G'/!> 4-C �j.�Q.(��✓��''• fit? �'. #bedrooms Approved design flowPACs) gpd The issuance of this permit s II n r -construed as a guarantee that the system will funct' n' /y d�si ned. Date / Inspector --------------�j/------ No. i � Q Fee < `� THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS Wi6pool *p$tem Con5trUction Vermit Permission is hereby granted to Construct ( ) Repair Upgrade ( ) Abandon ( ) System located at -" 3 O /jam'/J`��1 '«1 J% and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. t Provided: Construction must�bvee co pleted within three years of the dat• of this p t: ,Date / a l� Approved by Town of Barnstable Q�tnEr. .. ReimlatoryServIeeS H� Thomas R.Geikr,Director y a public H6alth Division Thomas McKean,Director 2.00 Main Street,Hyannis,MA 02601 _ x Office:.508-862-4644- fax: 508-794-6304 Installer &Designer Certification Form Date: Resigner: Installer: �U Address: Address: " ✓�'-'c"�tYwlN � 0, � �.� �-�� � l ��G' C�vas issued a. permit to install a (date) (installer)` septic' em at '��D _ � �� • � based on a design drawn by• , (address) �pc�l.lo � dated (designer) j certify that the septic system referenced above was installed substai t#Edl"• accordin. 'to { P '"fie design; which may include minor apprd�ed changes such as ltex locatiazi of the ; strrbution box and/or.septic,tank.<. I cerh�=fit the septic system referenced above was installed with maDc c]ianges ("e eater R ' u lateral relocation of the SAS or°an v P ' n - y erttoat' relocation'of any com on t of the.sept3"�� em}but in accordance with State&LoCal Regulations Plan revisroxk or certified as 'by designer to follow. (Installer's Si gaature) �E MASON f. QIgTel SgNITAR�P� (Designer's Signature) ( es�giar's S�amg genre) y PLEASE RETURN TO BA CSI'ABLF PUBLIC HEALTH DIVISION �ERTIFIGATE OF covcE . v �ssu�IoTHs Fay Arm s k BUILT LARD ARE RECETV D B '1 BAD STABLE PUBLI Q:Health/Septic/Designer Certification Farm v ..Iq16 12yj L! =DAOUI-Q l pMiucnuvno rrurn 117/r r. .„ytte Lr7✓r PIRCw► 17 10 nd plans and spsci8t ations for every on-site system shall be prepared as follows: (1) Every sy3kM shall be designed by a Massachtaseats Registered Professional Engineer or a b4asmhvaem Registered Sanitarian provided that such Sanitarian sfiall not design a system designed to dw*arge mm"2.WO gallons per+fay Dot rb 310 CMR 15.203. for dw of a designed m vvner l� � sYsoetn fined Any ocher.agent of the o . may ll� �dtscharga not more than than',=gallons per day pursuant to 310 CMR 152M provided dacy are owed by a Massadhusetts Registered.S and approved by dte approving anthonty: ' (2) Every plan submitted for approval moss be dated and bear the stamp and signature of the desigaw, (3) Every plan Sot a am system or plan far the OPFade Or r TBAsiou of an Vdsft systerrn vvhieh roquires a Vnimm to a property IM sd6®dc dim;must-also-dsc..-x a plan which beats the stamp nand signature of a---Masridcusctts. Liceasod Land Surveyor in accordatue with 1y+ GI—a 112.g BLD: /(4) Everp plan for a system shall be of suuable"c(one inch.-40 feet or fewer for plot ✓ plans and one inch a 20 ieet or fewer for details of system components)and shall include depkdon of: (a) the legal boundaries of the facility to be served: ` (b) the holder and ration of any easements appurtenant to o;which could impact the . /Y (c) the loeadon of the dw~)Pr bdiftB(s) and proposed on der facility and idwdfiir tion of thaw to be served by the cyst= .� '(d) -tfo'inwtion of rxi$dng or p areas. includuag driveways and p +g m= VIIe) location and duets of the symn(mcUdmg reserve am); (f) sygem design alcubdons.!deluding deslgq+d 6 sewage flow.septic tank capacity / - ingnhed sad :stoil sysr ]� (r, and and lV/ whedox syaaan is desk flat g ,($9 North ter and ajdWri and proposed comears: (h) , location,sati log of deaf obsuvadon hula tests,including the date of tept esisdng , graft devadtmas ruched not emcb wsg. and tine uaaw of do ocpremOtive of the a*wft aadiodty ad soil ovaURIM. Cl) lowdon and m=Us of paaoladou tale including did am of test and the Haines of the rep mewl the of tot:apprv:auganshopity and=a oraloam {i) awyn and oa amp rtiaaattec W d+a Sca Ewatmmpt;of recoil (k) locadon of every water supply..pabliz:and ptivaec. vdWm 4fl0 foes-of slut pmq med symm won In the cam of surface wager aster suppty wells. r Zap feu of dw proposed system location in the case.of tubular public wacer.aupply wefts,and ,- 3. widda}-h� feet of due,proposed system locafm in the case of private watier. AM . t. ojfi to locationshoe wam�s of Qoweait6,rivers, bosrle�g've wedaads: salt -i dand or coastal beaks, regulaaoty floodway velocity zone,. swfaoe venter -M1 M water sn &% d veroal pow;pserate water supplies or .T paw or tabular public vvaioer vaells.. subsurface drains.leaching catch basins.or dry wells:and the 1 of aay:acaogei va-usea min 910 CNQi IS.2L5 within wldclt pmHo®s:gf't� - M b=M& . } 1aam�ca o!vvaQtsr Bates and oeber s tatilities cat the facatitp; - . a) obi sn 9a the viddW of the sysrear. o a o4tePWHD ofatre sytieemC = ,<; 111A (p) a�on the s1l as a the:progisions of 31t)CMR 1 saoght in wnjnW=aittr the plan: (q) the lo�oa and eta of ome .SO to 7j i of tin:iara�p VVVV✓✓ rich is no s bj=to didocesim or loss Ong eta ott theAlcaW When dosing js,pr%wsed&aanpleft.desigm 40 WdftoAon of-the dodo 9 ty; / proposed 11 but Imt rm tad to dung chatnha capacity(aqW-Wed WU Zus4 castes and teems.nonA r:of db�aa a cIM aa►d. vvhxrt:Ractcolaaing find ttology It VRMAOr /Y ga a complete plan and fcs the syrs +.>ni uag hgdrAtc Psti - t a IMus plata.m shmr the locaadA oe*i faQity inct ng t ie taasimg (n) the st:=nunito and lot momber,if any,of Town of Barnstable P# -5 Department of Regulatory Services Public H // sz�g� • Health Division Date ( 10 / 16 19.a��� 200 Main Street,:Hyannis MA 02601 Date Scheduled f Time:` Fee Pd, �� Soil Suitabil '•-��Asse s t3' V, . s� Tent for Sewage Disposal Performed By: VI,D Witnessed.By: � LOCATION&GENERAL INFORMATION Location Address o /�G _-_ lsfjffV Owner's Name Address Assessor's Map/Parcel: t�Q ®�? Engineer's Name v/,t7 ��,Q NEW CONSTRUCTION REPAIR". Tele hone# Land Use ��� � Slopes(%) �_•. Surface Stones Distances from:. Open Water Body possible Wet.Area ft Drinking Water Well ft Wa Drainage Y ft Property Line•-eft Other It SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests;locate wetlands�n proximity to holes) y IX Parent material(geologic) 00 `�, Depth.to_Bedrock -f. It Depth to Groundwater: Standing Water in Hole: Weeping from Pit Race Zd Estimated Seasonal High Groundwater Method Used: DETERMINATION FOR SEASONAL HIGH WATER TABLE Depth Observed standing in obs.hole: in. Depth to soil mottles: jp Depth to weeping from side of obs.hole: in, Groundwater Adjustment Index Well# Reading Date: Index Well level Ad),factor- Adj.Oroundwater Level_ 6 PERCOLATION` EST bate�. '!t'ltng FObservation co Time at h" eptof Perc . Time at 6" ' Start Pre-soak Time @ y _Tit.. G� End Pre-soak Rate Min./inch t Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed On Back----------- ***If percolation test is to be conducted within 100"of wetland,'you.must first notify the. Barnstable Conservation Division at least one(1)week prior to beginning. Q:ISEPTICIPERCFORM.DOC DEEP.OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA), (Munsell) Mottling (Structure,Stones;Boulders. Consistency.% ravel �D ,0 ZSrr o �.O t < DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. nsi c %Gravel) ff if DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color. Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. oGravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones'.Boulders. Consistency, Flood Insurance Rate Mae: / Above 500 year flood boundary No— Yes .L: Within 500 year boundary No JZ Yes Within 100 year flood boundary No V Yes Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious in terial,exist-in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pery ous material't_ Ly Certification q e roved b the • I certify that on �t7 (date)I hay.,passed the soil evaluator examination approved y above analysis is was performed b me consistent with . 1 Protection and that the abo P Y f Enviro enta Y Department o the required training,exper'sea d ex ri nce described in 310 CMR 15.017 Signature Date O Q:4SEVnC\PBRCFORM.DOC TOWN O BARNSTABLE Al LOCATION �� Yll `' ����: W� SEWAGE # `�! `VL;LAGE ��c�a to N is A SESSOR'S MAP.&LOTS . . INSTALLER'S NAME&PHONE.NO� C, 1tJ �� . 'Lb SEPTIC TANK CAPACITY LEACHING FAC.I TTY: (type) K' (size)a_4o X Xa NO.OF BEDROOMS BUILDER OR OWNER PERMPIDATE: `'R COMPLIANCE DATE: 0 q\ 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 f of le Ching fa ility) Feet Furnished by (aJoil l� a .��45- r `I TOWN'OF BA:RNSTABLE LOCATION 13, i' r�_eS Z--9Y SEWAGE # V.L.LAGE •11Yi9._i,e1Q' ASSESSOR'S MAP & LOT 92? INSTALLER'S NAME&PHONE NO. SEPTIC TANK.CAPACITY _i_- •�i�it LEACHING FACILITY: (type) ' (size) ' NO.OF BEDROOMS Y. BUILDER OR OWNER h5 .dill LPL ??yTd A,--leThy PERMiTDATE: COMPLIANCE DATE: Separation Distance Between the: b 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 wetfands exist, within 300 feet of leachin facih Feet Furnished by voe S ` f �,X-� I 2 I � '210 I-D i TOWN-OF BARNSTABLE SEWA LOCATION GE # J + p li v1 .LAGE ��c lCK 0 N t S A SESSOR'S MAP`& LOT INSTALLER'S NAME&PHONE NO` C� e.D1�� J�J SEPTIC TANK CAPACITY J ` LEACHING FACILITY: (type) (size) —qo,)(geXa-o NO.OF BEDROOMS 4- BUILDER OR OWNER E d, PERMTTDATE: 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 W of lelch�ing facility) ( Feet Furnished by lrll E_�C� 9J (� r N � � � A �' 1�'�. �! �:, s �' o � ,. . TOWN-OF BARNSTABLE LOCATION SEWAGE # VILLAGE h'YIlv111J ASSESSOR'S MAP & LOT a!%0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY i car�vCsLi� �s�.o�c. LEACHING FACILITY: (type) ' (size) NO.OF BEDROOMS y BUILDER OR OWNER h.5• ^4e/l Z~ 7447,0E A�OC 7'H,e Fi9.��y TX�sT PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility F 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 2/-Z& ���� -� � � � � � r � �Sh�� � No........- _.... Fss. ....... THE COMMONWEALTH OF .MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apli iration for Diti-pa3lal Wur1w Tonfitrur#inn Famit Application is hereby made for a Permit to Construct ( ) or Repair (' , an Individual Sewage Disposal System at: `Mie `� S Locati n-Address j'. or Lot No. .�. a.... ' 3 `r`,1; ` `. ...................... Owner ^ v i dre ss 2�1 p 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 ( ) dOther fixtures ---------------------------------------------------------------------------------------- W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons. R: Septic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter----_- -------- Depth................ - 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 ( ) aPercolation Test Results Performed by....... -----------------•--••--•-•---•--•--••--------•--•---•-•....----_. Date----------------------------------•--- Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-..--...._.-_-_____-__ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.-......................... --------------------------------•-•-----••-•----•-•••••-----...... Description of Soil............... .. w,,,. ---------- U -•------------------------•....----•------------•-•-- W •-•-------------------------------- ----•--=------- U Nature of Repairs*or Iterations—Answer w n applicable..-.-----.. .5. -..�...............� 8__ c ..... ...�__. - -�-- �....................... ,.11...--�---�-----�------- ----- ---------- -....---------- Agreement: `f 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 Com)'an has been issued b'the.:board of health. Signed .C�-'L ------------------ ....1: ..�. .................. ' "� �. 'i Dare Application.Approved By �1 - - --- ---------- ----------------- ------------------ ��.`.`l!.-`�J........ `�t�. Date Application.Disapproved for the following reasons:! .. ...................................... - . . .. . . ................................. ...............................---------------...__... ... .. -- `-------------------------------------------------. --------'-------------------------- -------- IS... Date t Permit No. ---------------------------------------------------- --- -.. Issued', .:.:.. . .._...q.. �----------- --- 'I ---- -��_e E Date 190 No. FEs. 0� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Aplilutttiuu for Diti-lxu at Wurk,6 Tomitrurtiun Permit Application is hereby made for a Permit to Construct ( ) or Repair ( n Individual Sewage Disposal system4 ..... L_ >rt t - Loot n Address )_ W Owner Address ..._ s.._.- C� Gy Installer Address Type of Building Size. Lot... ......................Sq. feet a Dwelling—No. of Bedrooms _-_ ___---__-Expansion Attic ( ) a Other-Type of Building , _ ___--_.- No.- of persons ( )Showers Garbage Grinder Cafeteria ( % dOther fixtures ------- ----- - ---------------•••--• 4t :� W Design Flow.... ...................................gallons per person per day. Total daily flow..................................... gallons. WSeptic Tank=Liquid capacity___-_-.___,gallons : Length-..-._--__ -_ Width_-------------- Diameter__.-. _-----._- Depth............... xDisposal Trench No .................... Width ..................Total Length-------------...... Total leaching area....................sq. ft. Seepage Pit No---------`- ...... ,: Diameter_________ _ _____ Depth below inlet.................... Total leaching area..............._..sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by------- ............................... Date_ ,.a Test Pit No. I----------------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.......... .......... -- --- -- - --- - O �, Descriprion of Soil - ...------ - W .....••- xs . ..... ------ ---- -- -------- -•--•-. -------- Ut l . Nature of Rep trs or Alterat •ons Answer, w rn applicable --� -.,_----• ---`/.Cm'QU•C? !t-_ ' t5 - - t 1 s - -- ... - ._._. Y- ..:L�_ ..... i e1 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 Compl.•aI'ne has been issued by t}e board of health. ^ Signed . _ 4 GS, :. .................. 1.Q...�-- f: _ Dace Application.Approved BY .-.---. _-- - --.- _--_ ----------- Application .... - 10"y-�,� ---- ', Disapproved for the following reason.(;• -. - ter. .- Date ' T Permit No �..::. Issued' P 5 1 --- � `4 __,b_ ----- .....------ „ A THE COMMONWEALTH OF MASSACHUSETTS j BOARD OF HEALTH TOWN OF BARNSTABLE TrktifiratE-of Tom lialtrE IS IS TO CERTIFY, h t the Individual Sew ",ge Disposal System constructed ( ) or Repaired y vr, t - .. .. Insr.Jic - _ t has been instailled In accordance with the provisions of TITLE of The State Environmental bode as escribed in the application.for Disposal Works Construction.Permit No. ..._.�_ .�..�. -_(.- dated THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACT� RY DATE..:.. - = Inspector ---- . ---- - THE COMMONWEALTH OF,MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE aJ No......... �r� � eriiti# - t Permission is hereby granted � -----------------�------- ="�-----------e---------------- --- to Construct --&r Repair (, ) an Individual Sewage Disposal System at No..-•-••• .......Q..1.IzGt4([.. W. f�1�1�cnnt S •-•• �... � Street r, �as shown on the application for Disposal Works Construction Permit No :-`�� Dated-___ ..�.o ��................... .....................�...._...._....._.___.______._. ._____.__._._....._.__..____._..................•.. _ y( /„ Board of Health DATE " !1 % ------•------------------------------- ' 11 FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS 1 r- :C I � -I- � � � - { - - - _ _ i - - - - - - -- - - - - � �Y _ � � � � { { r � � 1! rr _ i, _ .._ I .� __ _ _ _ _ _ r � � � : t _ _ _ _ _ - _ - -- - - - + � t- �- - - -- - - } f � �- - - - �+- - - � � � � i t _ - - - - - -- -- - - - - - � � � � � I 4 � � � # t - -. t .t} t.. -� f,_ _._� - - -- - -i- - � f . i � ` t ' �` r . � � � � � r i 1 I i { a _. .... i y y i - � �. i r-—t.. t— .�—t —*—+ +�.}. s' —. _—�— —t -t — '{'� _�_ .- } � ..r. � � C a � r R fy) kc� K)K;, CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, °G hereby certify that the application for disposal works construction permit signed,by me dated ,l-� ���(� , concerning the property located at 0 Y�.� ; -�.�(,l e� I `S w , ,. meets all of the following criteria: • There are no wetlands within 300 feet of the proposed septic system • There are no private wells within 150 feet of the proposed septic system • The observed groundwater table is 14 feet or greater below the bottom of the leaching facility • There is no increase in flow and/or change in use proposed • There are no variances requested or needed.. . ° SIGNED �k Q 1 G"�. t- � �V 1-- DATEJO—q - 7s LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. CERTIFIED SEPTIC SYSTEM REPORT LOCATION 130 MITCHELLS WAY HYANNIS, MA MAP 290 PARCEL 069 PREPARED FOR SELLER MS . MARIE LOWE TRUSTEE FOR THE MCKINNEY FAMILY TRUST 815 PEARL ST . ELIZABETH, NJ 07202 BUYER MS . MARY ANN BARBOZA 47 WOLLEY RD HYANNIS, MA 02601 PREPARED BY HILLIARD HILLER, JR. P .O . BOX 250 CENTERVILLE, MA 02632 508-778-1472 �b OCT 3 1995 TOOF co c e 5 � . Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection Wllltam F.Weld Goaemor Trudy Cox* Secrelnry,EOEA . David B.Struhs Commoner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 130 Address of Owner: &1,5_ /VZ­-7eL 5T Date of Inspection: G02h r _ (If different) 'ffL/eA/3CT�� Name of Inspector: rj�ugeD �//LL1/L J� Company Name, Address and Telephone Number: CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Passes _ Conditionally Passes Needs Further Evaluation By the Local Approving Authority Fails. Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found'any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 8/15/95) 1 One Winter Street • Boston, Massachusetts 02108 • FAX(617)556-1049 • Telephone (617)292-5500 n �,J Printed on Recycled Paper r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION,(continued) Property Address: /30 �+�Gi/.LG[S t;v/9Y %may/d,Ls �s/9 Owner: . cjS. IV1410, L.oae-o4r TRe,67-,;7 o� ryt �'sc�`Ciittt�EY F/1�'iiG Y TiP�ST Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The wstern has a septic tank and sod absorption system and is within 100 feel to a surface water supply or tributary lu a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. V Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. (revised 8/15/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: /30 �siTG/ELLS l.. y /�1/9iY.�/s Owner: /!S. �i/9/1/ Lr �E iR✓r6TG� FUiC %N,a file iu�t/.EY i�i��y y TiQvSJ— Date of Inspection: DJ SYSTEM FAILS (continued): r 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet 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 well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no ' acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for colifo,rm bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: 4 The following criteria apply to large systems in addiiion to the criteria above: The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: a 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) The owner or operator of any such system shall.bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and,6.00. Please consult.the local regional-office of the Department for further information. a (revised 8/15/95) 3 i v A •c - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: >U3o � S c. Y N%Ayv�s Owner: h5. /E14R/L L�iE Ti�u5T.�6 Fo/l T?Y,E i1�/�ip. Y Gi9�i/GY T/lvST Date of Inspection: Check if the following have been done: _ZPumping information was requested of the owner, occupant,'and Board of Health. ZNone of the system components have been pumped for at least two weeks and the system has been receiving nonnnal flow rates during that period. Large volumes of water have not been introduced into the system recently or a5 part of this inspection. AeAs built plans have been obtained and examined. Note if they are not available with N/A. , The facility or dwelling was inspected for signs of sewage back-up. t/'The system does not receive non-sanitary or industrial waste flow i V/7he site wass inspected for signs of breakout. ✓AII system components, excluding the Soil Absorption System, have been located on the site. c-�5%.�vUL • _,ZThe• tk manholes.were uncovered, opened, and the interior'of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. ,k _jZ"The'Sk2 and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. _✓The facility q,tine; (and occcpants,''if different from owner) were provided \+-ith information on the proper maintenance of Sub- Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 130 .ti/lG/�'e4e w/i`Y /fYi9/Y.U/,s Owner: 11.5. TNL �!c,Cit'r y iri 16Y 75el/S7 Date of Inspection: 90 J FLOW CONDITIONS- RESIDENTIAL: Design flow: — gallons Number of bedrooms: Number of current residents: 7 Garbage grinder (yes or no):_,L� Laundry connected to system (yes or no):yff Seasonal use (yes or no): Water meter readings, if available: Last date of occupancy:�14 COMMERCIAUI N D USTRIAL• Type of establishment: Design flow: gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)�. If yes, volume pumped gallons %o 4Z /F�l�c,r,0 Reason for pumping: TYPE OF SYSTEM c/Septic tan soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) Other (explain) APPROXIMATE AGE of all"components, date installed (if known) and source of information: C14y—, w� Sewage odors detected when arriving at the site: (yes or no)_,LA:'7 (revised 8/15/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /3a �'/TGG1�G�t G�/Jry /�%/l;v,r/a Owner: /7.5• o"I lel,� Date of Inspection: e/a�/� SEPTIC TANK: v 157— sysT��y (locate on site plan) p Depth below grade: A19 Material of construction: _✓concrete _metal FRP other(explain) Dimensions: lip414 Sludge depth: A911 Distance from top of sludge to bottom of outlet tee or baffle:.fob E Scum thickness: S" p Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: d B Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 6 Y57 ,ti X",-ItZk2 ellY GREASE TRAP:_ y (locate on site plan) Depth below grade: Material of construction: concrete metal _FRP other(explain) Dimensions: Scum thickness: Distance from top of scum to top of•outlet tee or baffle: Distance from bottom of srum t- hottom;ot outlet tee or bafiie: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 8/15/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.0 SYSTEM INFORMATION (continued) Property Address: /30 Ar1rC V.",LS Owner: ^75 Lzw—B Ti�Us7.�—` l-rat %h'£ Date of Inspection: �/12IS6-� TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material.of construction: _concrete_metal _FRP—other(explain) Dimensions: Capacity: gallons Design flow: aallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:_ (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribur.icn is eq::--!, evidence of so!ids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /3p /TLGLS G�iis'Y h'S'��/�/�CS Owner: AxS. 1*i/9e1Z Gl. /•E 75�'1i51X-X FUV' 721e �ic�Ci, i y �/�i�i/Ly T�v:5 Date of Inspection: CV a L�� SOIL ABSORPTION SYSTEM (SAS): (/ (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number:_L Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) .yd P-/;%/L TtiiS S 1S i< o/F %t}.0 54-,"rC Ti9,z� ALiQL',fDY CESSPOOLS: / (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: /Si'� c7p�i G`��� CW� Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) //4;2F XS TTb 64' <Zet.!?c Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) 7_&Z TLI�, 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.) (revised 8/15/95) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: /30 A-i rGf1e 9S 4//4 y NY�.vev/S Owner: NS .VA eIX Gv►%✓F_ 7--er.67YE Fa4 Tl/-- iy�.�i.�f/JY Y %ifi9,�y 7XG67- Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' � [ TEo 4Y Ot i�GTWC FALL Gk'$SR��`� GoNVE/tl`E� 1 ON y DEPTH TO GROUNDWATER Depth to groundwater .3.y,5 feet method of determination or approximation: 7 LL,fuATiacl /1 d/�yr'/ryBO L Ifrz/l • T/I.3L14' ,Tv. /55;a Sfkx� T/f2 �rr9i/1 T�i31� /9T 16 . r&,c /S ` gi2 . Try' o7 A��sC G fSe,'Aa 6 «r9S 'I-Ya 33,2-A- - y 9 - 9:ya = 3. yS (revised 8/15/95) 9 C ASSESSORS MAP: TEST HOLE LOGS PARCEL: -� � .: NOTES: SOIL EVALUATOR FLOOD ZONE: i , WITNESS: , 1 ! 1) The installation shall comply with Title V and Town of Barnstable Board of REFERENCE: dJ � .: DATE. I . . Health Regulations. PERCOLATION RATE. ,G. t S / 2) The installer shall verify the location of utilities, sewer inverts and septic ' 9�------ �' V1 �' components prior to installation n t'�'Eii2 D p p and setting base`elevations. F TH- I TH-2 r 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot. The first � two feet out of the d-box to the leaching shall be level. _. g 4) This plan is not to be utilized for property line determination nor an other C� Ifl purpose other than the proposed system installation. 5) All septic components must meet Title V specifications. 6) Parking shall not be constructed over HlO septic components. LOCATION MAP ,� .TS, '� � 7} The property is bounded by property corners and property lines. 8) The property owner shall review design considerations to approve of total I design flow and number of bedrooms to be considered for design. Receipt of Vx payment for the plan and installation based on the p D, lan shall be deemed +�D approval of the design flow by the owner. 12/ 9) The existing leaching or cesspools shall be pumped and filled with material O YZ qi � per.Title V abandonment procedures..,.Those within the proposed SAS shall be - � removed along with contaminated it r 0W t�ttQ� g a ed so and replaced with clean washed sand C�J�1 W Srtt ,l� specs. per Title V s p 10 System . ) components to be 10 feet from water fine. Sewer fines crossing the .. g water line - , ne shall be sleeved with 4 inch SCH 40 PVC with ends grouted if ��- SEPTIC SYSTEM DESIGN applicable. J 11) If a garbage grinder exists it is to be removed and is the responsibility of the P Y r I FLOW ESTIMATE owner o to ensure such. '� 12)The installer is to take caution in excavation around the as line if applicable. g PP 1 D 00 GAL/DAY O 1BEDROOMS AT GA!/DAY/BEDR M SEPTIC TANK I I O50GAL/DAY` x 2 DAYS - GAL I USE VOL" GALLON SEPTI C TANK rE�C.I �I b 1 ABSORPTION �. _� b µ SIDE AREA: - N BOTTOM AREA: - � :�.�.. _ T I. C SYSTEM SECT I q 17 t�1%04. ' 04A ML _ IkA'f� brr 'd'lwhs -_i:r Ain - , CAL _.-00VSEPTIC TANK ---— / 53 6?7 7 ze. 4 POP v% - 777 .7" a6 s r ti SITE AND SEWAGE PLAN - O� LOCATION !3DmtfLVAAA/� PREPARED FOR : 6 - - Ono w SCALE: 6 - W DAV I D B . MASON I�5 DATE: DBC ENVIRONMEN AL DESIGNS W DATE HEALTH AGENT EAST SANDWICH . MA � ,-. ( 508) 833-2177