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HomeMy WebLinkAbout0014 PEACOCK DRIVE - Health 14 PEACOCK DR. HYANNIS A = 269 206 I Commonwealth of Massachusetts Title 5 Official Inspection Form ISubsurface Sewage Disposal System Form - Not for Voluntary Assessments a 14 Peacock Drive Property Address Paula & Angela Collins Owner Owner's Name information is F3arnctahla required for -I-�V AYIVII 5 MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection Inspection'results must be submitted on this form. Inspection forms may not be altered in any way. Important:When filling out A. General Information forms on the 515 computer, use 1. Inspector: — 1 Ci only the tab key to move your Carmen E Shay cursor-do not Name of Inspector use the return key. Shay Environmental Services, Inc. Company Name ab 185 Ashumet Road Company Address Mashpee MA 02649 retwn City/Town State Zip Code 508-539-7966 3080 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑;. ❑ Needs Further Evaluation by the Local Approving Authority 1/24/09 } iiy A Inspector's Signature Date The system.inspector shall submit a copy of this inspection report to the Apprgo<ug Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,.the inspector and the system owner shall submit-the . report to the appropriate regional office of the DEP.. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only,describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Z/ 1 14 Peacock.Drive,W Hyannispon•03/08 Title 5 Official Inspection Form Subsurface ftsposal System•Page 1 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments �^ �J \a 14 Peacock Drive Property Address Paula &Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/ always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: No evidence of backup or failure noted - No.liquid in chambers 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 determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. * A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 14 Peacock Drive,W Hyannisport•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \a 14 Peacock Drive Property Address Paula &Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of.Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, ' safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 14 Peacock Drive,W Hyannisport•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts Title 5 Official° Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p 14 Peacock Drive Property Address Paula & Angela Collins Owner Owner's Name information is required for Barnstable MA • 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". ' Method used to determine distance: " ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/z day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ Z Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 14 Peacock Drive,W Hyannisport•-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments /p. 14 Peacock Drive Property Address Paula & Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems:. To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 14 Peacock Drive,W Hyannisport•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 14 Peacock Drive Property Address Paula &Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? N ❑ Has the system received normal flows in the previous two week period? ® El this large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) N. ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth.of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ 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) [310 CMR 15.302(5)] r 14 Peacock Drive,W Hyannisport•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 14 Peacock Drive Property Address Paula &Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes El No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 14 Peacock Drive,W Hyannisport•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form `J Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Peacock Drive Property Address Paula &Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) - General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): . Approximate age of all components,'date installed (if known) and source of information: 2001 - BOH Plan and as-built at.BOH office Were sewage odors detected when arriving at the site? ❑ Yes ® No 14 Peacock Drive,W Hyannisport•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 Commonwealth of Massachusetts c Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Peacock Drive Property Address Paula & Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 3.5 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): No evidence of leaks, plumbing properly vented Septic Tank (locate on site plan): 2 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No --------------------------------------------------------------------------------------------------------------------------- Dimensions: 6' x 8' - 1000 gallon Sludge depth: 2 Distance from top of sludge to bottom of outlet tee or baffle 29 Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6 Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Measured 14 Peacock Drive,W Hyannisport•03/08 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Peacock Drive Property Address Paula & Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and'outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank in good condition,lnlet Baffle in good condition; outlet tee in good condition Grease Trap (locate on site plan): Depth below grade. feet Material of construction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions.- Scum thickness ; Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: J Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 14 Peacock Drive,W Hyannisport•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ( 14 Peacock Drive Property Address Paula &Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract (required). is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert D-Box Present 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.): Two outlets to chambers. D-box in fair condition - 5' below grade-Riser present Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 14 Peacock Drive,W Hyannisport•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Peacock Drive Property Address Paula &Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits , number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool . number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): SAS fuctioning properly, Riser present . No evidence of backup or failure-Y liquid in chamber 14 Peacock Drive,W Hyannisport•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts _W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Peacock Drive Property Address Paula &Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 1/24/09 every page. City/Town State Zip Code Date of Inspection D. System Information'(cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool f Materials of construction Indication of groundwater inflow ❑ Yes ® No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 14 Peacock Drive,W Hyannisport•03/08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 14 Peacock Drive Property Address Paula & Angela Collins Owner Owner's Name information is MA Barnstable . 02601 1/24/09 required for ---- -- -- -- ----------- every page. City/Town State. Zip Code Date of Inspection D. System Information (cont.) 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. ;q� 27` w 14 Peacock Drive,W Hyannisport•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 14 Peacock Drive Property Address Paula &Angela Collins Owner Owner's Name information is required for Barnstable MA 02601 . 1/24/09 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water , ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 5 feet separation 'er plan feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health - explain: Plan on file- USGS topo maps ❑ Checked with local excavators, installers - (attach documentation] ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: refer to plan on file 14 Peacock Drive,W Hyannisport•03/03 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 Z -ZA�50 No. 11�1 Fee ' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION --TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for Diopoml *pgtem Cow5tructiou Permit Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) O Complete System RI/Individual Components Location Address or Lot No. 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. Bor�oLo�f C�et'S,T - 7 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder Other Type of Building �dd°lam-No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow `330 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ©00J' .��Ih812'`lR� Type of S.A.S. 1 -7/S-ri/{' Z✓��` 2 Description of Soil �"' C Del G�IT/�1��✓�S ire ` / -- N tore of Repairs or Alterations Answer when applicable) � � � �� C� Nature r ( rr ) ,�1` 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 issued b his oar f alth. / J Signed _ Date > Application Approved b Date 6� � Application Disapproved for the following reasons Permit No. °f Date Issued Af— A, , _._. T ' No. 14 ~ ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ~ Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for Migogar 6pgtem (Construction Permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) []Complete System L✓71ndividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel / . 7- Installer's Name,Address,and Tel.No.7 Designer's?Name,Address and Tel.No. 1� -7 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( lj Other Type of Building . eJ teCe No.of Persons Showers( Cafeteria( ) Other Fixtures Design Flow ZIK gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ,/ ztelinl/A2 Type of S.A.S. Z ✓��1'� $/- �' Z Description of Soil Z`- �OD °�C��I/1�b�✓S s Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: f 'P 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 issuWbth* oar f Health. / Signed C, Date Application Approved b Date Application Disapproved for the following reasons Permit No. - Date Issued Art- Y"' veo —————————— THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance ~; THIS IS TO CERTIFY, that the/On_-site ewa Disposal System Constructed( ) Repaired ( Upgraded( ) Abandoned( )moby �O � at B"�Q'l/JG Gv. / GJ has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit IQOA-- ed 40iI' / Installer Designer The issuance of this perm shall not be construed as a guarantee that the syst ill f C,t4 s desi Pied. Date G/ (/ZQ Inspector No. le0ld/ •r' �.._ ------------.----- ���'� Fee---- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 30igpo5al bpotem Congtruction Permit Permission is hereby granted to C nstruct( )Repa' (l/)Upgrade( )Abandon( ) System located at lly,710'/y/.514 '1_ 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 ermit. �--� Date: ''" �—Approved .y.-- ����i /4gr f .. � •ate � ., .z�-.. NOTICE: This Form Is To.Be'Used For,the Repair Of wiled SOtic Systems.Only: CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTR IICTION PERMIT (WITHOUT DESIGNED PLANS) , hereby cerffy that the apolicaon for disposal works coestntcdon permit siped'oy me dated Aoe/I concerning the property Iocated.at J'y ���GDG,� l/7�� /✓1�/�/1�19/ ®ess ll of the following criteria:. ae failed srtem is connected t0 a resldenual;iwei.lzng only. There-ar. ao cot=rcal or busiai ess „t^sses-associated with the dw +e t..--mQ. �•.// :ae soil is c:z sae as CT ASS I and:he^�-ciadon mm is iess ui-m or eo_tmi•:o. :niruits ocz mc.L. 1 e are no wetlands within 100 --' u` P _.._,of�e:,mxse�:sec here..re no prin-at e we_s wil 0 :of ht aroro se^ac,-yse:n... 1e:_is no inc se in flow and/or change in se propesea !a_^_ire a0 V^ar':anCzS.=L1S�e.1 Or 71 ne bottom.of the proposed leaching iac;iity will not be lxated less d=jve lett aocve Me uaLmua adjusted,poundwam.-;able ticatior- (Adjust the undaater: able using the:rim>✓tor /crhod when applicable]. if:thc S.a S.will be located with.=50 leer of arty ve;eated wetlands. the boron of-Lne propose: teaching facility will not be located less than fourie=n(14)feet above the t:ia�=ttm aditst=d groundwatez table elmrion, Please complete the foilowinb A) Top of Ground Surface=Ieation(using GIS information) a 3) Q.W.IIcvariall -th-2vfAX FEE GM. Ad�t:stmeat. �� _ � 3 : DIrFFEEiZEENCZ- BETWEEN A and 3 G 'T SICNrD G© DATE: . . (Sk-"=proposed pLan ofsystemon b2aJ_ Cb-fthr*ldw TOWN OF BARNSTABLE �ad1 - 3s3 LOCATION 19- 3)e SEWAGE# VILLAGE W ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY , LEACHING FACILITY:(type) -6b6 ^i.\64 Apg-g(size) �a.! X as )Ca NO..OF BEDROOMS OWNER c1C1z.�c� Co`�41\S PERMIT DATE: COMPLIANCE DATE: U 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) !v Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 306 feet of leaching facility) Ai Feet FURNISHED BY 6u-PK T.Zca S4QCS ® '� �`{ ' ��T © � L,.� . - �- � �� �� � � a a �.s � 3.� 3 a�- �,� '� � ��.. TOWN OF BARNSTABLE n� );CATION ��e� /'�.!L X/ i SEWAGE # VILLAGE AM / ,ASSESSOR'S MAP & LOT 6 INSTALLER'S NAME&PHONE NO. _IIO� f�L�,11 77/: SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (�ft&size) /-ZS-: ,9E X.7 ' NO. OF BEDROOMS 3 BUILDER OR(OWNER PERMITDATE: d S�- ®r COMPLIANCE DATE: Separation,=Distance Between the: MaximumAdjusted Groundwater Table and Bottom of Leaching Facility 771 `' Feet- vate 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) /N Feet Furnished by 64,r � II O �A L 0-C A T 10h SEWAGE PERMIT MQ. Pe - -�E VILLAGE. g INSTALL R'5 RAME ADDRESS 3 U I L D I RRROOR OWNER �D-A`TE . PERMIT ISSUED4111�zIkC`� QDATE COMPLIANCE ISSUED ,o � .....a ��..�.r-- � ._ �� tr �� \� `:v ti � �' �r� �6 �. -I 3 q ., ,�..... . FPS.No. .............. ... ......................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......- .k1__C�..............OF.......9: .?9'2< ....................................------•----•----•---•---- Appliration for Biiposa1 Works Tnnitrn.rtinn Permit Application is hereby made for a Permit to Construct (!U or Repair ( ) an Individual Sewage Disposal System at: ............. ........... .......... . ..... ................................................... Location;A dress or Lot No. ............. ` SI f...... 1I Cry I ............. .......------------------....------L =,��............................................... Address --•-•---.---.J..CA....D(Z:LS.0.._. ....------•-•....................... ................................... 5.................................................... Installer Address C4 Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms.... ................................Expansion Attic (I.l) Garbage Grinder (►.1 ) pa., Other—Type of Building ---0.0.r.2 ..... No. of persons_....:. __----------- Showers Cafeteria (� ) Otherfixtures ......P_A.��e --------------------------------------------------------------------------•-------------•------------••---.......-•--•---- W Design Flow...............5:_Y .................gallons per person per day. Total daily flow.........3..3 ........................gallons. WSeptic Tank—Liquid capacity..IM32.gallons Length----(_(2------- Width....a,.-------- Diameter---- ......... Depth............ x Disposal Trench—No. .._).04.4- Width...........:....... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.............. Depth. below inlet.................... Total leaching area...._fl&.V...sq. ft. Z Other Distribution box ( Dosing tank ( ) Percolation Test Results Performed by..... ,,r /Wa� ._�._.. �w —__. Date........................................ Test Pit No. 1....4 2minutes per inch Depth o Test Pit.................... Depth to ground water-----------............. Test Pit No. 2................minutes per inch Depth of Test Pit----------_......... Depth to ground water................... P4 ---------------------------------------•..........-•---•--------------------------•-•...........---........................................................ 0 Description of Soil........................................................................................................................................................................ W VNature of Repairs or Alterations—Answer when applicable_____________________________•_._..______............._........................._.............. --------•---------••-----------------••-----•--•-•----•-----•---•-------------------•--••---.................---...-----------••--•----------•-----••-•••--•--------------•--------------.......-------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL IAP LE 5 of t ate Sanitary Code— The undersigned further agrees not to place the system in ,epera4on n '1 a Certificate of pliance has been ' ued by three board health. Da pl ation Approved By............. .. -•-- .....P........................................................ -------- Date Application Disapproved for the f reasons-------------------------------------•-----------------------•----------------------------------------.....-•--•- --------------------•----•-••---------------•----------------...-•-----•-------------------•-•-•------•-------••-----•------•-••-----------------•--------•--------------••-------------••------------ Permit No.. S Issued.. Date ate 95•. ............. No....................... Fins.............................. THE COMMONWEALTH OF MASSACHUSETTS ' .,BOARD OF HEALTH ry .......... ......OF......3� Appfiration for "20,ispooal Works Tomitrurtion Prrutit Application is hereby made for a Permit to Construct (X-) or Repair an Individual Sewage Disposal System at: Location A t No dress > . .... .....................71----- ...... ........C.. ................ .................................................................................................. V ,X-dress ............0.. ......................................... ...................................�:5. ..............*--------------*------------- Installer Address Type of Building Size Lot____________________ ______Sq. feet Dwelling—No. of Bedrooms________ 3 Expansion Attic (>-j Garbage Grinder 6 X------------------------------ Other—Type of Building ...... No---of persons......�5 .............. Showers CafeteriaOther fixtures ..... . ............ .. .......................................................................................................... Design Flow..............- S: _.________....____gallons per person per day. Total daily flow........3-3 -4"0.......*..................gallons. 9 Septic Tank—Liquid capacity.11� zallons Length--- ....... Width....k......... Diameter--- ......*--- Depth....7......... Disposal Trench—No. Width.................... Total Length.................... Total,leaching area....................sq. ft. Seepage Pit No_____________________ Diameter__._.___._.._._:.__. Depth below inlet___________._.....__ Total leaching area....j;?A.Y....sq. ft. Z Other Distribution box Dosing tank Performed by..-_ Percolation Test Results .2 �..... Date........................................ Test Pit No. I....e�.minutes per inch Depth o Test Pit_ _______________ Depth to ground water_____._.._._..____._... 44 Test Pit No. 2................minutes per inch Depth of Test Pit__.____.________.__. Depth to ground water...___.._._._______..___ 04 ............................................................................................................................................................. 0 Description of Soil........*....................................................................... .................................................................................. ----------------------------------------------------*-------------------------------­-------------------*.-*-------------------------------------------*--------------------------*-------------------- .................................................................................................*--------------------------------------------------------------------*--------------*-----------------U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ............................................................I........................................................................................................................................... Agreement: The undersigned agrees to h install aforedescribed Individual Sewage Disposal System in accordance with - I e an the provislons,of TITLE. 5 of the 7 Sanitary Code— The undersigned further agrees not to place the system in operationftmota Cartificaflte of JC ' nce has been-is by the boardq health. Sig ed... ------ ------ ............... ................................ Date Approved By........ ... Appli' tiflon Approved By........ .... .. .... .... Date .5 Application Disapproved for tkdfollowing reasons:.............................7................................................................................... ..........--------------------------------------------------------------------------------------------------------------------t............................................................................ Date Permit No.-- issuedL-------4 ...1. ­4); .. --------------------- . ................. D4 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ....... ................OF..... Trrfifiratr of Tompliaurr THIS IS TO (7ERTIFY, Th t,the Individual Sewage Disposal System constructed or Repaired by........... ......................................................................................................................................... Installer . ....... cork at... . .......................................................................... has been installed in accordance with the'provisions of TITLE ,' ----------*--------------5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit dated--4-1 . .................... ---------------- �";l THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE 1( NSTRUEDAIStGUAR' ,T .57 THAT THE SYSTEM WILL NNCTI N SATISFACTORY. DATE.............'In ....................... ....... Inspector......... . ........................................ ......................... THE COMMONWEALTH OF MASSAC USETTS BOARD OF HEALTH ......I........OF.....I................................................... N3.............W.. Permission is hereby granted______" ....... ..... ................................................................................... ....... ........... to Construct (,X) or Repair an Indiyid Se age Disposal System ............. at N t4*4 0...... ------ ......L./ - -------- .... ......................................... ---------------­------ Street as shown on the application for Disposal Works Construction Permit Nj.�S-15 p . ...... --- Dated+/--).. ................ .................................... 04>_ic............................................ IA2,- h DATE------------(_V_ UL'n?........................................ FORM 1255 A. M. SULKIN, INC., BOSTON Q. vh0 v '• 3 'Ile �S EY IY'( a hf gg ,ALK A. Lr10RSE \ y q OF'li9 �ti . No 10951 ,O LEGEND EXISTING SPOT: ELEVATION x0 ELDREDGE V� No. 1936 ` CERTIFIED PLOT PLAN " EXISTING CONTOUR '-- 0 ----_ `���'� .�„� �o .�` FINISHED SPOT ELEVATION `ak'~�'°TF� �v _ ---� > - FINISHED..-CONTOUR, 0 � v 7 4;A n A cvc./c 1�� - ivy - /V/r NOTE The location of,-any existing un ergroun sewerage., IN wellor 'other'utiliti shown on this . tan i,s 'a rox n rr imate:only as determined from records and/or .verbal ' :, / information. The 'contractor:is responsible for-the,' ' verification .of the`existing locations in the 'field.' SCALE= / "=3vr. DATE 1 4�if b'S LDREDGE ENGINEERING CO. IN CLIENT �sioE 1 CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB N0. "OAS' BUILDING SHOWN ON . THIS PLAN CIVIL LAND A A •/7/, CONFORMS TO THE •ZONING LAWS ENGINEE.R S RVEYOR DR.BY� OF B97e�/s :�cr :c- MA53. 712 MAIN STREET ; CH. BYt -13 �' KYA N N I S, MA.S.S.' 2 — - -� - — -" � SHEETJ_ OF. DATE REG. LAND SURVEYO-R NO /F E/TH4aAr-;TNE SEPTIC TANK DR. Y • L,Esc"zv4G' PiT.ARE. JrIORE` `TNAIV IZ :SPLO,t'N /O Fr %N�iN o f 1R�DE :� E4'O/AMETZe. CovCR:ET.F CQi!ERt /l. SV.4 L-,OE BROt14SN7- TO GRADE.6AN EXTRA q'PVC p/PE CONCRETE /'�'EAYy C^5T /RO/Y CD�ER:Sf�ALL !3E USEO 3 n CovERs /,v L>R/V--WA Y g /g d7RAG.E CO VE SA/V O pi - : - DgUID LEVEL. _ D1A. _ 2•C.4YER 4.: SCHEouu4o r" - _ '2.2`e I�B_• -�/B.' . K f. P/PE o � o.~ o P /0oe GAL. * ► • • .'. . ► , •. f M/N.P/TCN DIST, • lV^SHFO 57 NE %4"PtR rT SEPTIC TANK • ; BOX • s f.) .�y ...•. �.• • ►. �•• e• a. 1 fo e s t•.� t:► �,�FtECTJ'YE � ',`i , 3 4 _-/ %2 . ' � _ • • off DEPTt1 • • • • 0 WA SNAFP.5 740 N E VJ& y O • • • �.. • • ► 1 e;• 1 �; � •.• 1 • • :.� • 1 • • 37� :. 15/ �. . Z 5 0 0 s • • ' ► • . �. s • • • ► D �r PRECASTSEI� GE P.4 c.c Y, 4 9 D GAL p�`►y � • • • • • � � ► a o P/7OR EOU/✓ lKVeRT EL EVATIc/ys /-.T CA �L ` 3 .0 �. fr: DiA�r: a - INVERT AT Bl/ILGING . 36.5:,FL rNLET SEPTIC TANK 3 � .I FT' !Z F7: :D/�4I►9. CC.SEE_n°.8U[...4TION� >;. d Or/-fLET SEPTIC TANK: INLET D/STR��t/T/CN`>80X 3 S?F7 #e GROuNo 1uATER T/�LE , SECT`IO/V 4F oo7zzTDISTRIB[IT/ON BOX 3 S S = lNLE7r LEi4CN/JVG.I�/T 3s:oFT. .SE1�V:4GE. :O/S�O�SAL SY.37'�M , TABIlLATIDN ,LEACHING �?/T , vr>tiEwsiow A zzT DIFS/6N CRITERIA sc.+LE 3110 _ / o or>y,F,trsraa. �_ t"r. D/ML'JYS/ON G FT. A Al NUMaER Of BEDROOMS 3 . , ';. GAR ,4GED/SPOSAL UNira n�� SOIL LOG. TO TA L.RIT44reD FLO H/ SD/L: TE3T G.4L.�DA�' SOIL T€ST#I SOIL' 7E57#2 35 T AWMQER TE SIDE.L&ACHI NG PER PIT -1_S'Q FT. p _.2 RESt/LTS /WITNESSED dr dOT'TOM L6�ICN/NG PAR PIT 3 PT . ' e Lo fY1 PEIt C4LAT/DJy ItAT� /.: /q/�/NCN + ; TOTAL LEACHING AREA Z6 4 SQ FT. Y Sv 35C� c AERCOLAT'/ON RATE /NCfI } RESEKYE LE.4CN/N6 ARE/► Z 4 y N OF <is of n ' SOME Q T" Fi r' Ar UGK .DR! ✓E LAN Ar _ �+ -�.'M o" ROBERT ALERT — B. ` UcC fED , � G No. ' n- 7/2 M/I/N ST., f/YA.NN•/61 MASS �rill 1. Nd GROVND. yyATER ENCOIINTEEO !.►Lf f�S RO UAID JO _ Nr iTER /1T ELE✓. U.�Sc C3 G .SrfE�T:�Za/� z- Upper Cape,Engineering - µ P.O. BOX 616,-EAST SANDWICH, MASSACHUSETTS 02537 . (617)362-6281 j - Se+p t 23, 86 r Board of -Heal th - Town of Barnstable Main Street , Hyannis- -_- RE; LOT"90 Johns -Path 4 , Dear Sir :For your -.edi f i cation ,' cl ar f i.cat i on and el uc i dat i on , _the, ,sep t i c system on I of 90 , was i nstalA ed in accordance to'the `design submitted by th-i s off ice . . ,�. . Thank you I i ` ohn Jacob-i E