HomeMy WebLinkAbout0032 PITCHER'S WAY - Health 32 PITCHERS WAY, HYANNIS
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TOWN OF BARNSTABLE — -__._. •mod
LOC,-,TION � SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. =40
SEPTIC TANK CAPACITY �_ i
LEACHING FACILITY: (type) 4 XoC ,(size)'
NO. OF BEDROOMS ge
BUILDER OR OWNER r
PERMITDATE: COMPLIANCE DATE: .
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leac ng Facie �(If any wetlands exist
within 300 eet o le n V Feet
Furnishedy
r
_ r �
DATE: 5/13/02
PROPERTY ADDRESS: 32 Pitchers Way
-----------------------
Hyannis ,Mass .
------------------------
02601
------------------------
On the above date, I Inspected the septic system at the abo e d6%7
This system consists of the following:
1 . 1-1000 gallon septic tank . JUN 0 4 2002
2 . 1-Distribution box .
3 . ARNSTABLE
1-Leaching trench . 60 ' X4 'X2 ' TDW HEALTH DEFT.
Based on my Inspection, I certify the following conditions:
4 . This is a title five septic system. ��
5 . The septic system is in proper working order
at the present time .
6 . Pumped the septic tank at time of inspection . MAP
7 . Stone was dry within the leaching trench . PARCEL . 0 G5
SOT
SIGNATURE:
Name:-I, � Macomber J7r-______
Company: Joseph_P _ Macomber-& Son , Inc ,
Address : Box 66
Centerville , Ma . 02632-0066
Phone: 508-775-3338
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
COI.EBPOH P. MACOMBER & SON, INC,
Tan ks•Cesspools•Leachf laid:
Pumped & Installed
Town Sewer Connections
x 66 Centerville, MA 02632-0066
775.3338 775.6412
\ COMMONWEALTH OF MASSACHUSETTS
r EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 32 Pitchers Way
Hyannis ,Mass .
Owner'sName:David Smith
Owner's Address: Same
Date of Inspection: 5 13 0 2
Name of Inspector: ( lease print) Joseph P.Macomber Jr .
CompanyName:J. � .Macom er & Son Inc .
Mailing Address: box bb
Centerville ,Mass . 02632
Telephone Number: 5 0 8—7 7 5—3 3 3 8
CERTIFICATION STATEMENT
I certify that 1 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 pursua2,7passes
ection 15.340 of Title 5(310 CMR 15.000). The system:
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fai s
Inspector's Signatur?ubmit
Date:
The system inspector shal a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving
authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
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Page 2 of 1 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 32 Pitchers Way
yannis , ass .
Owner: David Smith
Date of Inspection: S 13 02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes
�Oo
ve not found any information hick indicates that an of the failure c
y ntena described in 310 CtvLR
I exist. ny failure criteria not evaluated are indicated below.
Comments:
. The septic system is in proper working order at the
' present time . Stone in the ieaching trench is ry
B. System Conditionally Passes:
A129 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.
410 The septic tank is metal and over 20 years old* or the septic tank whether. p ( 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:
4�0 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
distribution box is leveled or replaced
ND explain:
oa 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:
I
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Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 32 Pitchers Way
yannis , ass .
Owner: David mit
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
W,O 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:
Ah� 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.
, 4 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
4)P The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
A0 The system has a septic tank and SAS and the SAS is less than 100 feet b 50 feet or more from a
lie
private eater supple well". Method used to determine distance
"This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is 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:
O �
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Page 4 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 32 Pitchers Way
Hyannis ,17ass .
Owner: David mit
Date of Inspection: 1 0
D. System Failure Criteria applicable to all systems:
You must indicate "yes"or"no" to each of the following for all inspections:
Yes t.'o
✓ Backup of sewage into facility-or system component due to overloaded or clogged SAS or cesspool
T 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 dismb,u�tion box above outlet invert due to an overloaded or clogged SAS or
cesspool ' itlQ 4�.t4W, I
Liquid depth in crsspeol is less than 6" below invert or available volume is less than 'A 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 AS, 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
ater supply.
_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ Ahy 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. rom a private water
supply well with no acceptable water quality analysis. jTbis system passes if the well water analysis,
performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds
indicates that the well is 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 forma
A)c't (Yes"No)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 C
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 now of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no" to each of the following:
(71te following criteria apply to large systems in addition to the criteria above)
yes no�
L the system is within 400 feet of a surface drinking water supply
_ d he 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 11 of a public water supply well
!f you have answered "yes" to any question in Section E the system is considered a significant threat, or answered `
"\es" in Section D above the large system has failed. The owner or operator of any large system considered a
s,entficant threat under Section E or failed corder Section D shall upgrade the system in accordance with 3 10 CMR "
304 The system owner should contact the appropriate regional office of the Department.
4
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Page 5 of I I
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 32 Pitchers Way
yannis , ass .
Owner: David Smith
Date of Inspection: 57T7702
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
_ Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection ?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
-Z _ Was the facility or dwelling inspected for signs of sewage back up?
t� _ Was the site inspected for signs of break out ?
z _ Were all system components,#*eluding the SAS, located on site?
Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the affles 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:
Yes no
✓ Existing information. For example,a plan at the Board of Health.
v — 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)] '
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Page 6 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 32 Pitchers Way
Hyannis ,Mass .
Owner: David Smith
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL 15
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 C 5.203 (for example: 1 10 gpd x # of bedrooms): J*
Number of current residents:
Does residence have a garbage grinder(yes or no): s
Is laundry on a separate sewage system (yes or no): V,4 [if yes separate inspection required]
Laundry system inspected(yes or no): �
Seasonal use: (yes or no): �11)
Water meter readings, if available (last 2 years usage(gpd)):February200-01=54 , 000 gallons=147 . 9
Sump pump(yes or no):A&op
— — 0 gallons=15 6 . 17 G P D
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment: /q
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.): _
Grease trap present(yes or no): ,
Industrial waste holding tank present (yes or no):
Non-sanitary waste discharged to the Title 5 system (yes or no):/Vq
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records ,
Source of information: Alat/e
Was system pumped as pan of the inspection(yes or no):A
If yes, volume pumped:l�gallons-- How was quantity pumped determined?
Reason for pumping: Heavy scum & soids layers were present .
TYP OF SYSTEM
_ OF
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)
ItLb Tight tank tA) Attach a copy of the DEP approval
Other(describe):
Ap�ateate all components,�� date installed (if known)and source of information:
Were sewage odors detected when arriving at the site (yes or no):48
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Page 7ofII
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:32 Pitchers Way
Hyannis ,Mass .
Owner: David Smith
Date of Inspection: 5/13702
BUILDING SEWER(locate on site plan)
Depth below grade:
�f
Materials of construction: cast iron y' 40 PVC iLl°Jother(explain): 41/;
Distance from private water supply well or suction line: 6d r�
Comments(on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight . No evidence of leakage , System is vented
through the house vents .
SEPTIC TANK: (locate on site plan) /aG��i9• �t'S
Depth below grade: /9
Material of construction: _Zconcrete, metalr�fiberglass,�polyethylene
�G other(explain) AX
If tank is metal list age:AI,4 Is age confirmed by a Certificate of Compliance(yes or no)rr/�i (attach a copy of
certificate)
Dimensions: L�ite�i�' ylall7�Q ti��•�/IL
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: (D
Scum thickness: 6
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Pumped at time of inspection .
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Pump the septic tank every 2-3 yPnr.a Inlet & outlet tees
are in place .The tank is structurally sound and shows no
evidence of leakage.
GREASE TRAPf"locate on site plan)
Depth below grade;
Material of construction: concrete//&metaL&fiberglass�polyethylene�j/other
(explain): A/J9
Dimensions: ei�
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:—QIN-
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
Grease trap is not present
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Page 8 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Add resO2 Pitchers Way
yannis , ass .
Owner: David Smith
Date of Inspection: 5/13/0 2
TIGHT or HOLDING TANY.44Wer-(tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: AM
Material of construction:VA concrete /t i metal ,j,4 fiberglass polyethylene laother(explain):
A114
Dimensions: d.4
Capacity: &1d gallons
Design Flow: AIR gallons/day
Alarm present (yes or no): A?1?
Alarm level: Alarm in working order(yes or no): 40
Date of last pumping: W14
Comments(condition of alarm and float switches, etc.):
Tight or holding tanks are not present .
DISTRIBUTION BOX: (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: X/b
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.):
Distribution has two latPral_s . No evidence of solids carry
over . No evidence of leakage into or out of the box .
PUMP CHAMBER4". (locate on site plan)
Pumps in working order(yes or no
Alarms in working order(yes or no
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Pump chamber iG not prpGPnt _
8
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:32 Pitchers Way
Hyannis ,Mass .
Owner: David m ' t h
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS) ✓ ((locate on site plan, excavation not required)
Leach trench 60 X2 , X4
If SAS not located explain why:
Located : See page 10
Type
4.'b leaching pits. number: _
/el leaching chambers, number:
� g
leaching galleries, number:n&e
: f
leaching trenches,number, length: io f/ �
leaching fields, number, dimensions:
iV/G overflo",cesspool, number: _
"VO innovative/alternative system Type/name of technologyj, y�
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
Loamy sand to boney fine sand . No signs of hydraulic failure
or pop ing , of s are dry . Vegetation Ts Trormat .
CESSPOOLSd/ (cesspool must be pumped as pan of inspection)(locate on site plan)
Number and configuration:
Depth —top of liquid to inlet invert: AM
Depth of solids layer: AY
Depth of scum laver:
Dimensions of cesspool: _
Materials of construction:
Indication of groundwater inflow(yes or no): 140
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
Cesspools are not present .
PRIVY(locate on site plan)
Materials of construction:
Dimensions: A?'?
Depth of solids: _41A
a Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
Privy is not present
9
Page 10 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWACE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properry Address: 32 Pitchers Way
Lan ni5 , ass .
Owoer: David Smit
Dstc of Inspcctioo: 5 1 02
SKETCH OF SEWACE DISPOSAL SYSTEM
FTovioc a sketch or the scwaec ditposal system including ties to el least two permanent rererenee landmarks or
ocnc"uks. Locatc all wells within 100 rcct. Locate where public water supply enters the building.
,32
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OPE
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10
Pape I I of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 32 Pitchers Way
Hyannis ,Mass .
Owner: David Smith
Date of inspection: 5/13/0 2
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtaine s stem des' plans on record - If checked,date of design plan reviewed:
Observed sit abunin prope bservation hole within 150 feet of SAS)
hecked with local Board o ealth-explain:
hecked with local excavators, installed(attach documentation)
l/ Accessed USGS database-explain: �.� .
You must describe how you established the high ground water elevation:
Used ; Gahrety & Miller Model 12./16/94 Grnnnd wa>:er above sea 1®vel
Used ; USGS__Wne.'.1992 091 rvatian ure11 data .
Used ; USG. T� rnj b1>i1e9*in 92-000 1 P1arA # 2 , nitarw 1999
Water le is annealn rangea
r u
Leaching I`
Z4 'eet
Groundwater Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method
Therefore, the vertical separation distance between the bottom
of the leaching pit and the adjusted groundwater table is
feet.
ll
r�
• •r-.^rtirv^rv—ern. arr.•nmm*r.zrr.rr..r,:•.�+•*ererr:m.�r�m�v*�a-�sr.rrst .r,R.����—...-. __
tT Barnstable '
1'UHN OF BOARD OF HEALTH
0 .^SUIISUItFACF•,9EHAGE DISPOSAL SYSTEM IN�SI'FCTION FORM - PART D^- CERTIFICATION
r �• -•
-TYPE OR PRINT CI.EARLY-
PROPERTY INSPECTED
STREET ADDRES$ 32 Pitchers Way Hyannis , Mass .
ASSESSORS MAP , BLOCK AND PARCEL #
OWNER' s NAME David Smith
PART D - CERTIFICATION T
NAME OF INSPECTOR Joseph P .Macomber Jr .
COMPANY NAME J.P.Macomber & Son Inc-"
COMPANY ADDRESS Box 66 Centerville , Mass . 02632
Street Town or City State LIP
COMPANY TELEPHONE ( 508 1775 _ 3338 FAX ( 508 1 790 1578
A
CERTIFICATION STATEMENT
Dr
I certify that I have personally inspected the sewage disposaj system at
his address and that the information reported is true , accurate , and
omplete as of the time ofiinspection , The inspection was performed and any
ecom►nendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems .
Check one :
_Z4? System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 16 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this forma
System FAILED*
The inspection which I have conducted has found that the system fails to
Protect the j-)ublic health and the environment in accordance with Title
.5 , 3,I0 CMR 15 , 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspectio form .
Inspector Signatur Dated
Ornd copy of this certification must be provided to the OWNER, the BUYER
here applicable ) and the 130ARD OF )JEALT'll.
* If the inspection FAILED, the owner or'"operator ehall upgrade * the system
within one ,ear of the date of the inspection , unless allowed or required
otherwise as .provided in 310 CMR 16 . 305 ,
partd .doc
TOWN OF BARNSTABLE
LOCATIO ( C��n.RrS SEWAGE#
,1 VII.LAGE 21�� ASSESSOR'S MAP& LOT
` INSTALLER'S NAME&PHONE NO;
SEPTIC:.TANK CAPACITY 'tc�yU C .l. Qk(J� Z—
LEACHNG FACELlTY:'(type) `L� (size)
NO.OF BEDROOMS V.
BUL ER OR OWNER.
PERIviITDATE: COMPLIANCE DATE: Sl t T C
Separation Distance Between the:
QO
Maximum Adjusted Groundwater.Table and Bottom of Leaching Facility Feet
Privafe 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 A
within 300 feet of leaching facility. _ Feet
Furnished by
III
b
0 0
TOWN OF BARNSTABLE G:G
LOOATIO• SEWAGE:# 14
VII,LAGE ASSESSOR'S MAP& LOT
INSTALLER'S NAMES&PHONE NO.
SEPTIC TANK CAPACITY 1�=c_'..LkGY� 7C
LEACHING FACII.TTY: (type) . �'� (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMUDATE: o 4,ir COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) ' Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) UA Feet
Furnished by
.v1
Ono
Vie- �°
No. G Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for Mopogol *pgtem Construction Vertnit
Application for a Petnut to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. _:Sd2 � Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 02 199 041
Installer' ame,Address,and Tel.No. Designer's ame,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms S' Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by s Board of Health.
Signed Qi Date 3'0- 9.6
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued � �
474
No. 9V , I� t�� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Yes
2pplication for �Dioozal *pmem Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel
Installer',Vyame,Address,and Tel.No. Designer's ame,Addre s and Tel.No.
Type i f Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persop</ f. . �Shb -6rs( ) Cafeteria( )
Other Fixtures
Design Flow ?30 gallons per day. Calculated dailI ION-- ° gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank { Type'611" .S 44-1
1 f
Description of Soil 7
Nature of Repairs or Alterations(Answer when applicable) =zz 2) a— i
'—�+a Ems' ��-�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
' ,-.
-, cate of Compliance has been issued by is Board of Health.
Signed Si
g Date c./_ �e'.- Fie
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
6 f
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CE IFY,that the On-site Sewage Disposal System Constructed( )Repaired (&/jUpgraded( )
Abandoned( )by _ „4
at has been constructed in accordance
with the provisio of Title 5 and the for Disposa System Construction Permit No. "p'" ' dated .�
Installer 4aa-*4.!!!� Designer OF
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector-
-—————------ — -----— -- ------------
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
x1h6pozal *p5tem Congtruction Permit
Permission is hereby granted to Constru t( )Repair C,-<pgrade( )Abandon( )
System located at .3.,2 ��T ,�.4 14 J—
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 er"`ii nit.
Date: 5/— .3 U— P 6 Approved b
1019197
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
s
3
hereby certify that the application for disposal works
construction permit signed by me dated t(— 3 — %ed ,concerning the
p property located at � , �/ ' ,�„�,� meets all of the
�02 1/��
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
• There are no private wells within 150 feet of the proposed septic system
• There Is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will nDJ be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map) _
SIGNED: DATE:
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].
q:health folder:cert
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TOWN OF B.ARNSTABLE
I.Q,CATION 4. SEWAGE
VILLAGE .ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. C�L ��'
SEPTIC TANK CAPACITY 'Z r,,A L.i.Cr
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR(PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: ZJ
DATE .COMPLIANCE ISSUED: 2) -13- 8 7
VARIANCE GRANTED: Yes No ,/�!
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA TH
----------------OF....��:Gv�c'.1�,1 � ......._.......-._..._......_
Appliratinn for Disposal Works Clunstrw nn rrrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage Disposal
PP Y P
System at:
Location-Address --•or Lot No.
•( Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
ang— Expansion Attic ( ) Garbage Grinder ( )Dwelling No. of Bedrooms...........................................
p, Other—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( )
aOther fixtures -----••----------•----...-----•----.._..-•-•-------•--.---•---•---------------------•---------
d13
WW Design Flow.........:: &(S ....................gallons per person er day: Total daily flow.-.._�....d........................gallons.
WSeptic Tank—Liquid*ca.pacity_�,OW.gallons Length...4....... Width__.�........ Diameter................ Depth...:............
x Disposal Trench—No..................... Width....................Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No........I_............. Diameter.._.kq......... Depth below inlet....... ......... Total leaching area..................sq. ft.
Z Other Distribution box ( )' Dosing tank ( )
Percolation Test Results Performed by__________________________________________________________________________ Date........................................
,aa Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....................
Test Pit No. 2................minutes per inch . Depth of Test Pit.................... Depth to ground water........................
x ....................-...............................................................................•--......................................................
ODescription of Soil...........................•-----............-•---•----------------...-•-••._...........-----•--•-••--------...---..................------------•-•--•-•.......-•---__-_
tiC
W .....-•----------- ..__.....
---------------------- .•----•---_.....•---•--------------------------------------•---------..- -------------------------•----•••. __________•--•-•••-....---•••••
xpto
U Nature of.Repairs or Alterations—Answer when applicable__.__ Z __cS_ L. ... ................................
u�2 .C\.........4V'M15 ---.5 -p:�.�i l�+�--...---��SQ..�?T4.....lr.s����. �..-•-..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ilTl IS 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the bo rd iea
Si ned_;_----- - �
Application Approved B
`e
PPPP Y...........................................••----•--- ...--------- ------••---------------• -'------- . ...--Date _. ..
Application Disapproved for the following reasons_...............•........................................................................•_................._--
..............•--........----._......----••--•--....••--••---.....__...---•----•--•-----._......------......••-=----------•---•----•---------.........................................................
Permit No..._... .. .T7__�-..! _�..._. Issued-...........................................D�..
te
...,-a..,yh...•w..^-..'"'_.s.'^'..`+.r-`w•�1y..- .......���....,�.;sx.a,...,Ja_.--Jad"+.._.F....� ...,.;.-.4=4.:...�..,..Y .�r'�r.._d+:.:,,�,,;�.� ter.....-.... ...W ..ti.,..-. �._�.. � ,i:.,.r�e:� w ti - -'^.
Fss
THE COMMONWEALTH OF MASSACHUSETTS
F t BOARD OF HEALTH
Appliration for Disposal Works Tonstrurtion Hermit
Application is hereby made for a Permit to Construct ( ) or Repair ( Q an Individual Sewage Disposal
System at: R �(
..... `^ 1't`\ {r.. I/�� C�' 3 .....................................«....
.........:......» .........................._........................._..._............ _................. ................................
Location-Address l or Lot No.
-•--_1i1C1�f _ T_ .......................... .........•--• `�i� l/L ;.---.. ....------.............._....._..............
Address
,Wa - - '�- `•--.-l `.'.r/�°: 1{ - = ..........
--...............
..........
----••.. n u l! r`....._... ......_..................._.._..
Installer ` Address
Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms......3....._..........................Expansion Attic ( ) Garbage Grinder ( )
py Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
p' Other fixtures ......................................................--..........------............----.............----.--•--------------------------.....
WW Design Plow.......... ---------------------gallons per person per day. Total daily flow.....5.......r�..........................gallons.
WSeptic Tank—Liquid capacity.CO2.gallons Length-- .....:. Width...�4........ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length....................Total leaching area...................sq. ft.
3 Seepage Pit No........J Diameter.....{_u........ Depth below inlet.......'L(........ Total leaching area.................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
6.4 Percolation Test Results Performed by...........
•--•---••...............•-...-----------------................. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit...--...__.......... Depth to ground water........................
fjr Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
I+d -------------------------------•--•-----......_..............-----'---._................ p
0 Description of Soil......
- ,. ---------------•-••---•--------------------------------•-•-•--•................
U1 .. •- ---.-------- -- -------- ----------------- ----.---•-------.------•----------.-------------•-----------.---....._..
.................
•-----•-----------•----------------------------•---•--------•----•----.-.•_.--.-----------.-------------------.--•-•-•-•----------------r---
c
U Nature of Repairs or Alterations—Answer when applicable.... rnr to��__G z- s ________________••_..•____._____.._...
�. . f ....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance.with
the provisions of TITLE 1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of-health��
¢. ._ ., .-
Date
Application Approved By................. '7
Date
Application Disapproved for the following reasons-................ _....
...................•--------^....................................•--......•-•--•--•^............................_..._..._...................•••-----.............................._....................
DatePermit No............. Issued......................................... ......
Date
— r^----�- '`-'-----------------------------------------------,--
THE COMMONWEALTH OF MASSACHUSETTS T
BOARD OF HEALTH }
l
F...... .r v�Via` c�. !�....................................
f9rrtifiratr of %ja mar a"It
THIS IS T0. CERTI.FY, That the Individual Sewage Disposal System constructed ( ) or Repaired
by.......................!!;i� ......--- .:��.. ::.g .......................•--•----•-------•--..................---.............---•------.....---............._......._.
Installer
at....................... '.._.... 3 -Y�=- ------ r t= 04
�-
application for Disposal Works Construction Permit No+`z'� 7 7 --._�1 �.... dated___�.���.��described in the
has been installed in accordance with the provisions of T' TLE 5 of The State Sanitary Code as descr
- l c— `-. .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED-AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE ..... ?.. a. = ,2 .......--'-----...... Inspector._ -.,�,..� ._�...4. .. ..........�...........
....
----------------------------- ------------------------------------®
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...............
No......................... , ....... F$E ......
Dispogal,lforks Tonotrnrtion ;prrntit
Permission is hereby granted.........................................................".. .....----�- ------•--•-----•-------•.......................................................
---- ----- ti-
to Construct ( ) or Repair ( L-).*an Individual Sewage Disposal System
k at No............................ ? __. (tV �s _.... ....i_'!.__ .� __......_......_.. ....... ..................
.. ..---
,.
• -`� str et _�-3l�
as shown on the application for Disposal Works Construction Permit No . .1"7 D'ated.._... ............................
- ........................................................
a . , .
�� /g Board of Health
DATE........ •_•,................
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