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HomeMy WebLinkAbout0093 REGATTA DRIVE - Health 93 RECRTA"DRIVE, HYANNIS MM o:51.024 �I I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every, ttVd S-- Z_ 051 -OZ 11 MA 02632 07/12/11 _ page. City own wz State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, I use only the tab 1. Inspector: �"I q key to move your cursor-do not Mike Hudson use the return Name of Inspector key. Septic-wiz Environmental Services "�_V Company Name 31 Midway Dr Company Address Centerville MA 02632 Citylrown State Zip Code 508-367-5669 DEP SI#4252 Telephone Number License Number B. Certification . -3 I certify that I have personally inspected the sewage disposal system at this addresshand that they information reported below is true, accurate and complete as of the time of the inspection. The in�pecti4 was performed based on my training and experience in the proper function and maintenance of n site.o sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340•of = _ Title 5(310 CMR 16.000).The system: ® Passes_ ❑ Conditionally Passes ❑ Fails ' ❑ Needs Further Evaluation by the Local Approving Authority 'r ` 08/09/11 inspector'ssignatuf6V Date The system inspector shall submit 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. ****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. L/ I . . � I t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Di S tern•Page 1 of 17. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is Centerville MA 02632 07/12/11 required for 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: B System Conditionally P) y a y asses: ❑ 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. Check the box for"yes", "no"or"not determined"(Y, N, ND)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. ❑ Y ❑ N ❑ ND(Explain below): t5ins•1'1/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 . 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632 07/12/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) A1/4 - B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):. ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): A/t4 - 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 mash t5ins•`1f10 Title 5 official Insp ection Form:Subsurface Sewage Disposal'System•Page 3 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632 07/12/11 page. CitylFown State Zip Code Date of Inspection B. Certification (cont.) 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. ❑ 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 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 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 El ® 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'/z day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 � Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632 07/12/11 page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® 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 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 water to a surface wat supply. I . El ® Any portion of a cesspool or privy is within a Zone 1 of a public well. El ® 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 50Rfeet 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, F 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 r 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 L ❑ 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 1f 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. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5'of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ' 93 Regatta Dr Property Address Kathy Cassidy Owner owner's Name information is required for every Centerville MA 02632 07/12/11 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? ® ❑ 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) ❑ 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. Ei ❑ 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)] 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 t5ins-11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632 07/12/11 page. City/Town State Zip Code Date of Inspection D. System Information Description: 3 Bedroom cape Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes,❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No, Laundry system inspected? :4 ❑ Yes -® No° Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 2009-247 GPD` g ( y g (gP ))' 2010-519 GPD, Detail: Sump pump? ❑ Yes ® No Last date of occupancy: occupied 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: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632 07/12/11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: occupied July 2011 Date Other(describe below): General Information Pumping Records: Source of information: Watr pollution control-home owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: N/A gallons How was quantity pumped determined? N/A ` Reason for pumping: N/A 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): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632 07/12/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 14 years, installed 1997 via as-built/construction permit Were sewage odors detected when arriving at the site? ❑ Yes Z No Building Sewer(locate on site plan): _ • Depth below grade: 2111 Material of construction: ❑cast iron ED 40 PVC ❑other(explain): . rt Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 12" Depth below grader feet Material of construction: concrete_ ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: N/A.. years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑a Yes'Z No .. Dimensions: 4'10'Wx8'6"Lic5'8"H -1000 gallon Sludge depth: 4'11„(1°thickness) t5ins TWO Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9:of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632 07/12/11 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 1/4" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 15' How were dimensions determined? sludge probe, tape, LED floodlight, mirror Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): recommend pumping once every 36 months, inlet and outlet tees in excellent condition, tank appears structurally sound, liquid level normal in relation to outlet, no signs of leaks in or out of tank �I h 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: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632 07/12/11 page. Citylrown 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.): 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): 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M a 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632 07/12/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert even w/outlet 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 level, no solids. liquid even with outlet, no signs of leaks in or out of d-box Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): i Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located,_explain why: t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments- „ z 93 Regatta Dr Property Address Kathy Cassidy . Owner Owner's Name information is Centerville MA 02632 07/12/11 required for every ' page. Cityrrown k State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number:, (1)estimated 3' stone around ❑' leaching chambers number: ❑ leaching galleries number: leaching trenches number,-length: leaching,fields _ number,dimensions: El overflow cesspool number El innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition.of vegetation,etc.): 'loamy to med sands, no signs of hydraulic failure, no ponding, damp soil or abnormally.lush vegetation, bottom SAS 120"below grade, stain line 5' below invert in. r 4 _ 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 q r Depth of scum layer V Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes Ll No t5ins 1I1/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 , Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 93 Regatta Dr t Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632 07/12/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc.): -r+ Privy(locate on site plan): l�J Materials of construction: Dimensions Depth.of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins 11110 Title 5 Official Inspection Fonn:Subsurface Sewage Disposal System Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 93.Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632' 07/12/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑' hand-sketch in the area below ® drawing attached separately e S� a i5ins.•11/10.: Titles Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 93 Regatta Dr Property Address Kathy Cassidy Owner Owner's Name information is required for every Centerville MA 02632 07/12/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar N�� ® Shallow wells 4 Estimated depth to high ground water: 22 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 1.50 feet of SAS) ® Checked with local Board of Health -explain: Reviewed as-built ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database-explain: Reviewed USGS topographic and water resource maps You must describe how you established the high ground water elevation: Reviewed USGS topo and water resource maps and Google Earth satelite map.Water table elevation 33' bottom of SAS at 55'22'above water table elevation. SAS not in ground water. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 Title 5 Official Inspection Fong:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 93 Regatta Dr Property Address Kathy Cassidy Owner Ownees.Name Information is required for every Centerville MA 02632 07/12/11 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary[)(System Failure Criteria Applicable to All Systems)completed ® System Information-Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached.in separate file u t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 3 93 Regatta Dr Centervilke, MA 02632 B A D-Box 1000 gallon O 0 1000 9 anon Leach pit w/ 3' washed stone 3 2 1 septic tank (1975) 4 4 B1 51,3 0 B2 46.0, ' 6 B3 36,6' 65 B 0'" 4 24. r 7 TOWN OF-BARNST'ABLE LOCATION L O ` SE VILLAGE �7%�yQidt��I`S ASSESSOR'S MAP&LOT. 3 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (?type) r (size) NO.OF BEDROOMS 3 .r BUILDER OR OWNER_ 4 e v+ —<A PERMIT DATE:' A -a'3 COMPLIANCE DATE: - f Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility), Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by w { i �r s s � i { 4 N - 7M a No...... ....... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Db3p ial Wnrka Tvinitrurtion PrrvAit Application is hereby made for a Permit to Construct ( V) or Repair ( ) an Individual Sewage Disposal System at: � g 4 oc to i-,Idd r Lot No. ner Address :.. ........... I f��.1� Address 1 2-2-0U Type of Building Size Lot------- ..................Sq. feet Dwelling—No. of Bedrooms_________________________ Expansion Attic ( ) Garbage Grinder .( ) a Other—Type of Building _(A -- j) �� '`" -No. of persons------- ------•----•_ __- Showers ( ) — Cafeteria ( ) _________ Q' Other fixtures --------------------------- -- W Design Flow..............................._......-._--.gallons per person per day. Total daily flow-.-----.---•--------------------------------gallons. WSeptic Tank—Liquid capacity..I ©U_gallons Length---------------- Width---------------- Diameter---------------- Depth................ Disposal Trench—No. .................... Width--_.-_---.----_--.- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter--.--.------.----.-- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing ank ) ~' Percolation Test Results Performed by...................... ...�.....-.. ._-e-. Date.................... .� ...... ..` a Test Pit No. I..... .........minutes per inch Depth of Test Pit----------------.... Depth to ground water_. ...... G14 Test Pit No. 2................minutes per inch _Depth of Test Pit-------------------- Depth to ground water........................ - Descriptionof Soil••.�/J•-•-_ - ...!..!... --•-----•-------------------------------------------------------------------------•-------------...---. x W UNature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compli been issued by the and of health. Signed ...... --- ----- - .. { �F�� Application.Approved By ------------- �� - Application Disapproved for the following reasons- --------------_--.._----.----..-----.---..---------------..._.-------..._..---.-- ------------- ---------------------------- ---------------...:-....-- ---- -------------------------- -------------------------------------------------------------------------------- ------------------------------------ , Date Permit No. ---------- 7.-.,J... �r 1:,� - Issued -----------,'.�­-'-- --�-15-------.------ Dut --------------------------- TF .: THIS b .-�1. r . y ar ` . t q . �� • r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Apphratiou for DiupniFal Workii Tomitrur#inn ramit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System a � I�localion- Addrrs �� or Lot No. `,�.�' cif J t.� C.....A.... .�l t - ..........................................------ - w er1���............... Address ---------...•••- ...................................................... Installer Address �2-0 � 'l VType of Building Size Lot..............................Sq. feet Dwelling— No. of Bedrooms-----------________________________________Expansion Attic ( ) Garbage Grinder ( ) p-, Other—Type of Building I _............. No. of persons............................ Showers ( ) — Cafeteria ( ) Q'' Other fixtures ------------------------------- - - W Design Flow------------------------------------ _-__--gallons per person per day. Total daily flow......... ----d_-_.-___. ---_--__--__---gallons. 9 Septic Tank—Liquid capacity---1-0.6_0_.gallons Length---------------- Width................ Diameter................ Depth................ Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing,tank_ ) a Percolation Test Results Performed by...r !t' ._._ ...�..:`^1'_______________________________ Date........__+�.'.._._��_ _.._._.... 4 Test Pit No. 1...!?:.'.._..minutes per inch Depth of Test Pit.................... Depth to ground water.. ..... ri Test Pit No. 2................minutes per inch Depth of Test Pit__.-_--__---_____- Depth to ground water........................ P ------------=r�= ...-�'�-•`••�=------------------------------:_.------...--•------;----••-----------•--•--•---•-•-•----------•------•-•--....--••---------------------------- O Description of Soil------x 1 ----------------------------------------------------------------------------------------- W ------------------------------------------------------------------------------------------'........................................................................................................... Z. Nature 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance-h-&s,..been issued by the board of health. -� Signed -,1`-ATT<..._:_;......!-• ..................... . �,./) ...q..;.... ✓ DLLe APPlication.Approved By .............. � S" �-- ..?..................... . ..- � e Application Disapproved for the following reasons- ------------------------- - .................... ............................... . . . . --------------------------- ---- ------------- -------------------------------------- -------------------------------- . ............................._.. .......... ......-------------------------------- Permit No. ..............:/., ��..�.: ... ...... Issued ------------.'z...-. ...?,.. - Daze THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH - TOWN OF BARNSTABLE Ce>r#ifi ak of Compliance THIS IS TO CERT F,Y, Thatrrthe Individual Sewage Disposal System constructed ( 1� or Repaired ( ) / � I s�ue at °-' l k_ ..... .......................�..q- 4..------s!.------- n ��'"''" -.... - .......... has been installed in,accordance with the provisions o TITI. 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. __..`fit;,---..-.. ...f...' .... dated ....__. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUEA AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. 0 DATE-------------------.:.---. .'_ ---�.._.-' -------------- ---- - -- Inspector .. �.-- -------- ......:........... �__ ------� -_,--_,_,----------- --_,----_._-.__,_,-___-__ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No...... FEE......... f?n �i��nstt1 nrk� �nuntrttrtinn��prmit Permission ist hereby granted---.F F-------"--�2!_K''2.......................................... to Construct( ) or Repair ( b an In ividual Sewage Dis osal System, � p atNo.--•- :-•-�r ............�1 ..---•- - • .....--= ---•--1 `'f ?.. � J t `Street ��-3 as shown on the application for Disposal Works Construction Permit No.._„________________ Dated........................................... -----------------•------•---------------------------------.......•--•--------•----•••--••-••-•••--•....-- Board of Health DATE................................................................................ FORM 395O8 HOBBS&WARREN.INC.,PUBLISHERS r �JES 16►J -PATA 5l1.6 F�11L�{ �o GA 3At;E 6 I11DE7Z .' CP6 gPAGE XIlo= 3 . SEPr I c TA�I� 33c x;ISo%• 5 GJ'o U ,-� ` �SPo A PiT 1- Loop GAL /S s rDN' 1e)8 SPx 2s - d71d66Yn, TDTAL t>e6i6tJ - 5 5 am —�� TOTAL VAIL ` I I OwEtu�o , ��l = 3'30 6�D 1,c?� V� � —7° Trc�aC.A'rt oN SZgTE. 1 g 1 4 ?,t�tlti�I.ESS v 4tj 0 r( SAX�. x. �;.3 J , ' ;a `%� `.:; E,. PETER S 'Ki1J No. 2�;.s3 '' DI2AiN ip- IST ; oaAL 8Z:=']2 "FG=7�. FG= 72 TF=T6 '_.___gym_" ----� -'�c�rr�•�� iL P.V.�' i.0 v 56 IoOo cud �o /rfeb �iST ivv JAJ G,AL 69•F SFl IaOo iy AV BoX c 1, a9a SEPTIC t TtiN 4GAL . �9 C S c 2.13/44d•` VZ WMN,EX;' : OrITE: ALL- 5TeucruQEs sr-T 1A L1 sTp9e .:. MOW TUA�i 4' 'Dee?n�.. Au— �E E[ 49 oPEIJ �PA�,E SUBZ+ViSivN MAP 252/51 253 /9 10 C�1�1® per- PCd N VELoPcT.:' 'PCzv l L r--- 83 Lor 421 SG�I L�� DATE A IVA-r�'t_ ____ - MAL.& laRr7 t4 WATE,�:.. EL=44 SFIcW ti I CEP-TIF`rr '.T�dT TI{Ec 6i.�..+�>JL _ PLAN ERFJ cz NE'ZEDN CoM'FL S yvlTµ T�1� 51�r=L1+JE PL ,8�. Soy Pam. "1� (E TDWN OF �A¢-NS-t•AZ � u I.�-r LoCAT-ED ,-rg i d THE Vxoo l.AQD CoL)zT •PL.AI. 366.1 DAYS 31'8 9S (Kif- pl?UU `filD�Jdl_ LAtJ� Nc1- ;�A�r=J oN n.N l�S-�'v�,4El�T' � Suev�/ac5 �urz4 i �iJp 1-N£ 01M- ' Ts .440ulD u r�- 13� o ��� L E061 IJ P-GL5 5T'Z-rzv I u.G MA Z,4 . APPLICAW T-, 7�3A sltt �BVI C: +� • :tOWN�OF BARNSTABLE LOCATION L O ' T ��'Q _____—SE AGE# ASSESSOR'S MAP&LOT —O; VILLAGE 02 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J EACHING FACILITY: (type) ��O O �i !G� (size) NO:OF BEDROOMS 3 i BUILDER OR OWNER_ a PERMIT DATE: a-2, ,, _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 Feet .on site or within 200 feet of leaching facility) •Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) j Furnished by 0 Le 2 J r. . -