HomeMy WebLinkAbout0611 OLD STRAWBERRY HILL ROAD - Health 611 Old Strawberry Hill Road
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TOWN OF BARNSTTABLE
LOCA.TON�n f O �iDc(�RIlE[1• SEWAGE # '
VILI,,AGE ASSESSOR'S MAP & LOT I Z
INSTALLER'S'NAME&PHONE^NOO..
SEPTIC TANK CAPACITY ��V l �YL
LEACHING FACILITY: (type) -IDS (size)
NO. OF BEDROOMS Ll c /� j�,
BUILDER OR OWNER Vu��a 1low,=
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PERMTTDATE: 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)�C ��C I Feet
Furnished by
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SEP 3 0 2002
COMMONWEALTH OF MASSACHUSETTS TOWN OF BARNSTABLE
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR HEALTH DEPT.
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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j' TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE;SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 611 OLD STRAWBERRY HILL RD CENTERVILLE,MA 02632 2-73 `Z I
Owner's Name: SUSAN ROBSHM'
Owner's Address: 611 OLDS.TRAWBERRY HILL RD CENTERVILLE, MA 02632
Date of Inspection: 9/18/02
Name of Inspector: (please print),, ; JOHN GRACI
Company Name: SEPTIC INSPECTIONS P
Mailing Address: PO.'ROX 2l 19 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the'proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section.15.340 of Title 5(310 CMR 15.000). The system:
X Passes-0
_ Conditionally, sses
_ Needs Furt ' valuation by the Local Approving Authority
_ Fails
Date: 9/18/02
Inspector's Signature: 4
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspec on. If t'r-system is a shared system or has a design flow of 10,000 gpd or greater,the
:;'a the report to the appropriate regional office of the DEP. The original should be
inspector and the system owner shall subrr
sent to the system owner and copies sent to tile-buyer, if applicable, and the approving authority.
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Notes and Comments `„
SYSTEM PASSED TITLE V INSPECTIC:N�'�RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****This report only describes conditions at the time of inspection and under the conditions of use at that time.This
i inspection does not address howjhe system.will-perform in the future under the same or different conditions of use.
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Page 2 of 1 I
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
1; PART A
CERTIFICATION (continued)
Property Address: 611 OLD STRAWBERRY HILL RD CENTERVILLE,MA 02632
Owner: SUSAN ROBSHAM :1 ;.
Date of Inspection: 9/18/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information 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:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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 Health,will pass.
Answer yes,no or not determinedl'i(Y,N,ND)In the for the following statements. If"not determined"please explain.
n/a The septic tank is metal and"over 2`O 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 o(d£is'avaiIable.
ND explain: n/a R
n/a Observation of sewage backup o`r 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): _:
_ brok j en pipe(s)are replaced
_ obstructio'n is"removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping,more than 4 times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)--are replaced
_obstruction is`removed
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ND explain: n/a
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Page 3 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 611 OLD STRAWBERRY HILL RD CENTERVILLE,MA 02632
Owner: SUSAN ROBSHAM
Date of Inspection: 9/18/02
C. Further Evaluation is Required by'the Board of Health:
_ Conditions exist which requirefurtherevaluation by the Board of Health in order to determine if the system is failing to
protect public health,safety or the environment..
1. System will pass unless•Board'of Health determines in accordance with 310 CNIR 15.303(1)(b)that the system is
not functioning in a manner whicti.will protect public health,safety and the environment:
_ Cesspool or privy is within•50 feet of a surface water
_ Cesspool or privy is within 5,0 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning,in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil.absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface°water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and "AS and the SAS is within 50 feet of a private water supply well.
_ The system has a septicttank 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 n/a
"This system passes if the well'water'analysis,performed at a DEP certified laboratory, for coliform bacteria and
volatile organic compoui d,s indicafes that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen` is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy
of the analysis must be attached to this.form.
3. Other:
•r
n/a
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Page 4 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
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Property Address: 611 OLD STRAWBERRY HILL RD CENTERVILLE,MA 02632
Owner: SUSAN ROBSHAM
Date of Inspection: 9/18/02 `
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no,'j to-each of the'following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool:is.less than 6"below invert or available volume is less than '/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped lilt Y 2002 BY OWNER.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool'ar privy'is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or:privy�s within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ X Any portion of a cesspool or privyr is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP
certified laboratory,for colifprm bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this f6rm.1
(Yes/No)The system':fai1s. l 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. '
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E. Large Systems:
To be considered a large system thelsystem must serve a facility with a design now of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
:
yes no .
X the system is within 40Q,feet of a surface drinking water supply
X the system is within 200.feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public,water supply well
If you have answered:l'yes";to anyquestion in Section E the system is considered a significant threat,or answered
yes" iu Section tt�uvC the Istu�e s�;;lrni;l'i is fnilCd: The owner 0r 01TI.1-0f pity Inrf�e system cnnside.red 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.
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 611 OLD STRAW6ERRY HILL RD CENTERVILLE,MA 02632
Owner: SUSAN ROBSHAM
Date of Inspection: 9/18/02
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
a_
Yes No
X _ Pumping information was provided-by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period ?
X Have large volumes of water been introduced to the system recently or as part of this inspection'?
X Were as built plans of-the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
1.
X _ Was the site inspected for signs of break out'?
a
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge and depth of scum?
X _ Was the facility owner(and,occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems i?
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The size and location of tile.Soil Absorption System (SAS)on the site has been determined based on:
Yes no
X _ Existing information:For example,d plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)J
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Page 6 of 1 1
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 611 OLD STRAWBERRY HILL RD CENTERVILLE, MA 02632
Owner: SUSAN ROBSHAM
Date of Inspection: 9/18/02,
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4 'Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for'example: 110 gpd x#of bedrooms): 440
Number of current residents: 5 -
Does residence have a garbage grinder(yes or no); NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected (yes or,no); NO,
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 gears usage(gpd)):-p1a. OZ,- 2� gnQ
Sump pump(yes or no): NO 0 21 cro o K ��
Last date of occupancy: n/a 2tfG ,700 s& i
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CM 15.203): u;/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n%a
OTHER(describe): n/a
y GENERAL INFORMATION
Pumping Records
Source of information: JULY.2002 BY OWNER
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons-- How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box,soil'absorption system
_Single cesspool
_Overflow cesspool
_Privy c
_Shared system(yes or no)(if yes,attach oevious inspection records, if any)
_Innovative/Alternative technology.AttacIh a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
22 YEARS BY OWNER
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Were sewage odors detected when arrivirg'at'the site(yes or no): NO
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Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 611 OLD ISTRAWBERRY HILL RD CENTERVILLE, MA 02632
Owner: SUSAN ROBSHAM
Date of Inspection: 9/18/02
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan) .
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age',co►lfirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5'7 ' W.4, 10 :"
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to'bottoin of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP: _(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Continents(on pumping recontincndations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.);
n/a ' . .
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Page 8 of 1 1 ,
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE''SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 611 OLD STRAWBERRY HILL RD CENTERVILLE, MA 02632
Owner: SUSAN ROBSHAM
a.
Date of Inspection: 9/18/02
TIGHT or HOLDING TANK: :(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day'i - `-
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present'-must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
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.):
D-BOX IS STRUCTURALLY`SOUND.'
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or'no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber; condition of pumps and appurtenances,etc.):
n/a
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F Page 9 of I I
OFFICIAL INSPECTION!FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 611 OLD STRAWBERRY HILL RD CENTERVILLE,MA 02632
Owner: SUSAN ROBSHAM
Date of Inspection: 9/18/02
SOIL ABSORPTION SYSTEM (SAS): X'(locate on site plan,excavation not required)
6
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 2
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a ;leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a f .:,innovative/alternative system
i Type/name of technology: n/a
Comments(note condition of soil,sign's of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS
OF FAILURE. DID NOT EXPOSE PIT "D". PIT "E" WAS HALF FULL AT TIME OF INSPECTION. BOTTOM IS
AT 10 FT.
CESSPOOLS: (cesspool must be,obrnped as part of inspect ion)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a ,
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plaO,
Materials of construction: n/a
Dimensions: n/a ;t
Depth of solids: n/a
Comments(note condition of soil,signs`of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a 1 8 :
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Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 611 OLD STRAWBERRY HILL RD CENTERVILLE,MA 02632
Owner: SUSAN ROBSHAM
Date of Inspection: 9/18/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
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Page I 1 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 611 OLD STRAWBERRY HILL RD CENTERVILLE,MA 02632
Owner: SUSAN ROBSHAM
Date of Inspection: 9/18/02
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet
Please indicate(check)all methods used to detennine the high ground water elevation:
YES Obtained from system design plans on record- If checked,date of design plan reviewed: 9/18/02
NO Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators.,installers-(attach documentation)
NO Accessed USGS�database-explain:,n/a
You must describe how you established the high ground water elevation:
PLANS- 12+FT.
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TOWN OF BARNSTABLE
LOCATON , � SEWAGE #
VILLAGE l c ASSESSOR'S MAP& LOT,?
INSTALLER'S NAME&PHONE NO.�C2A Cl 71—S M 9 S
SEPTIC TANK CAPACITY M00 �P � ZS�C C6�l,Cl �
LEACHING FACILITY: $t(type) k 6 ��f (size) w n)r4 V ^t,
NO.OF BEDROOMS �
j i-
BUILDER OR OWNER / r
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility a`�� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) i Feet
Edge of Wetland and Leaching Facility(If any,wetlands exist
within 300 fe of leaching f ' ; Feet
Furnished by �-
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No. 26 6B 7 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pprfcation for Migw6ar *pztem Construction i3ermit
Application for a Permit to Construct( )Repair(t4Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. / c)1 Sgyz",J Hjj/ Owner's Name,Address 4iTel.No.
/ C1gCiA C6 t
Assessor's Map/Parcel � ��m �o2 j 1-04 ol Q �° i` G l_,r J frv,.)6c . 14-0 I ��/
Installer's Name,Address,and Tel.No 0- 1G/� Cj 4f 1�'` 7 ODesigner's Name,Address and Tel.No.
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0Qw I 775 'S id
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder A
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 i Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) (2 LJ
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 sued by�thpii��s,,Bo eatil. '—'—
Signed AT'�T Date — C/
Application Approved by e Date /I
Application Disapproved for the olio i g reasons
Permit No. Date Issued
x
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No. Fee_
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpplication for Xh5poml *pztem Con6truction Permit
Application for a Permit to Construct( )Repair(4pgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. �l O/ ..51�-C�,)bfJ Hl�l Owner's Name,Address and irel.No.
• / cJsGcn Cwvl f 1
Assessor's Map/Parcel � Z3—./p'1 L o-f a a G / G/d S f r-�.,�b-t/ l#k'I! 2r/
i InstCalll"er's Name,Address,and Tel.No. P��� 1,1 Designer's Name,Address and Tel.No.
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Type`of Building:
Dwelling No.of Bedrooms 12 Lot Size sq.ft. Garbage Grinder(Au
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) XC7 P)+ W t
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 sued by this Boar
Signed Date
Application Approved by Date
Application Disapproved for the ollowQg reasons
Permit No. li — & 0 7 Date Issued
———————— — — ——--—— - —— —— ——
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( )
Abandoned( )by co
at Cc / has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer r\ S ('ate Designer
The issuance o t 's permit shall not be construed as a guarantee that the sys will function as-d s
Date , Ins ec
�� P `�
—-—— / —————-----------------------------
No. d Fee _
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -.BARNSTABLE., MASSACHUSETTS
]Di5po$al *p$tem Congtruction Permit
Permission is hereby granted to Construct( )Repair'( Upgrade( )Abandon( )
System located at �4 0 1 Q d l C ,..t S ,
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
! comply with Title 5 and.the following local provisions or special conditions.
Provided:Construction must be
completed within three years of the date of this permit.
Date: // I / Approved by j
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LEGEND °F �a,,
►"' �' ti� CERTIFIED PLOT
EX/STING SPOT ELEVATION Ox0 /:.,�`?''�`�`'ssNe.
EXISTING CONTOUR ——— 0 - - - ,� POBERT, �,. zz '
FINISHED SPOT ELEVATION � 113 P. 1' ;`i �/ t
FINISHED CONTOUR 0 `� PUNIKIS H /' '
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APPROVED , BOARD OF HEALTH
GATE
AGENT SCALE: / -'30 DATE,
(')IVAI). i li c1
4�REDGE ENGINEERING CO. IN CLIENT
_ I CERTIFY THAT THE pAQt� ,• ,,:`�:�; ;
EGISTERE REGISTERED J08 N0. �� r' v BUILDING SHOWN ON THI8;,.PL;
CIVIL LAND CONFORMS TO THE Z0�1 N$ L, t '
DR.BY -1.. i r<<
ENGINEER SURVEYOR OF BARN A8 E^, �YIAB
712 MAIN ST,
YAN IS MASS.
H N SHEET-L. OF DATE REG. LAN. �W�'