HomeMy WebLinkAbout0047 SAINT JOHN STREET - Health .47 Saint John-Street
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Hyannis .. F/R` ' F. f ' `. .z
A = 291 027001
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�^ TOWN OF BARNSTABLE
LOCATION !K S�-'i 5,04A s ST. SEWAGE#�d
VILLAGE__ / Y/-� n ASSESSOR'S MAP & LOT �" 0X -001
INSTALLER'S NAME&PHONE NO./JRG N/R✓.37
SEPTIC TANK CAPACITY
LEACHING FACII.ITY: (type)(3)3e,.i D /A/fi�rQATsize) 5—,), 1-3 X 2
NO.OF BEDROOMS �,3
BUILDER OR OWNER //�eYS ����✓
PERMITDATE: 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 Weiland and Leaching Facility(If any wetlands exist .
within 300 feet.of leaching facility) Feet
Furnished by
ZY1 c/
gs
Cid 1/6
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YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates(cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town [which you
must do by M.G.L.-,it does not give you permission to operate.) You must first obtain the necessary signatures on this form at 200 Main St, Hyannis.
Take the completed form to.the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601 (Town Hall) and get the Business Certificate that is
required by law.
DATE: Fill in please:
APPLICANT'S YOUR NAME/S: j asin at-
BUSINESS S � a'
YOUR HOME ADDRESS: L(7 sa,,j 4 :7z J,A) s4— /ylc` 0-260/
DIANT LEPHONE # Home Telephone Number 2.2 Lj— 3a
NAME OF:CORPORATION
NAME OF.;NEW.
BUSINESS Q PE OF BUSINESS '
IS THIS AHOME OCCUPATIONS YEt NO
r
:. - ..
ADDRESS;OF BUSINESS. ?' MAP/PARCEL NUMBER � a —06 [Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit,requirements that pertain to this type of business.'
Authorized Signature*
COMMENTS:
2. BOARD OF HEALTH
This individual has bee formed of rmit r irements that pertain to this type of business.
horized Signatur
COMMENTS:
3. CONSUMER AFFAIRS(LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
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� FEs.......... ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH -
..................
�-'....1--...-1: ...OF...:.......�-............. t....L '..�..a.' �-c *...........
rlirtttiun fur .R.9pauttl Works Tonutrurtiun rPrmit
Application is hereby made for a Permit to Construct ( } or Repair ( ) an Individual Sewage Disposal
System at:
�) ............`----•---_....---:.__.`.:�....._...--•-............-=---------------- .---.. .------------ •-or �-r- _. ...._._.
Location-Address
_-•-------^--•. -----••••-•----••----...-•-------- . ••---•-•---••--••--••••-•------•--------------�t...........--•---..........._................
Address
a --•.............••----••-•••--••-----•..........-•••---•----•••---- ......'.... ....--•-•------......__........_............----------......_......._.....................--------
Installer Address .
Type of Building Size Lot_lz-jd--r--�--_?.:?Sq. feet
�-, Dwelling—No. of Bedrooms............. � ...........Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ... No. of persons..............t......._._._. Showers —
a YP g ------------------•-•--•• P ( ) Cafeteria ( )
d Other fixtures ..._..... -- ..... ....................................
W Design Flow............. ..............__...._gallons per person per day.'Total daily flow..._..-_._._._....��................gallons.
WSeptic Tank—Liquid capacity�_�s�sagallons Length•8-: .. Width:�:�. Diameter........'....... Depth_ _. a�
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area_________...........sq. ft.
3 Seepage Pit No..C .. .°_.. Diameter... q cFp Depth below'inlet ..= Total leaching areaA `?: _.sq. ft.
Z Other Distribution box (a< , Dosing tank ( )
''' Percolation Test Results Performed by.-_.. .: =!4! .' N�. Date._...-....J!9� 2-�a }......._... ................t....
Test Pit No. 1: .z-__minutes per inch Depth of Test Pit..... 2-._._-_. Depth to ground water__P4o Tl-=-....
fs. Test Pit No. 2.................minutes per inch Depth of Test Pit.................... Depth to ground water........................
.... ............ ...............•-•---............... ........-----
O Description of Soil......` __-Z-`} l�at-.� > ; s�,b �b I._.. z- - t ., ��ot-sue._sE>*�e�l..
if....... -- ..............
............... . _'
VW ••••=----•••••......•-••-•....................... ....-•-•-----•--...._.........----••---.._.:-•-----•---••--•--•-•••••....._.__....... .�O••-•-_....
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 LITL, 5 of the State Sanitary Code—The undersigned further agrees t, ace eejsystem in
operation until a Certificate of Compliance has been issued by the-board of health.
Signed.... : .. ......••••••••-- ram..ICJ..-------............---__....--- -•-•----•----•-•----•--..._
Application Approved By.... .'��. -__.. ._........................................................
Date
Application Disapproved for the following reasons:............................................................................................................
.......................:.........................................................:..•---....---•----......--•--••--••---•---.._..._..---•----.:_.... •------•-••--•-------.......---••••••-•-••-----....
Date
PermitNo..................................................._._.. Issued.....................................................
����/ Date
^
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF . HEALTH `
Appliration for Disposal Works Tamitrudiun tIPrmit
Application is hereby -made for a Permit to Construct (-,�-44 or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address ••-•-
or Lot No.
•= --` ---• ---•-•...............•-.....................__.....
W Owner Address
r„a •--••-•......................................................................................... ......••-._._.................-•--•--•----•-•----•....................._..••••....................
Installer Address
Type of Building � Size Lot...� _�•+i+___�. �.9Sq. feet
Dwelling—No. of Bedrooms.........�.! ISZ-�-91E ..........Expansion Attic ( ) Garbage Grinder ( )
WOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
QOther fixtures ------------------------•--------...._..........._.......------....-------•-•----------
W Design Flow.............S1_........__._...._...gallons per person per day. Total daily flow........... ,................gallons.
WSeptic'Tank—Liquid capacity!5'vsrgallons Length_g..:.�. Width;!"':!�K. Diameter................ Depth!1'n._.«=r-—
x Disposal Trench—No. .................... Width.................... Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No.!; ?!�!+!!�... Diameter... m ''!' Depth below inletG.. Fr.: Total leaching area.A�71.� .sq. ft.
Z Other Distribution box Dosing tank ( )
Percolation Test Results Performed b .-_..�'.:X-!'4!!5�.1 !9N!'�.. .' Date..........._-�►� 2.8 f
:Test Pit No. I.. 7?rm.minutes per inch Depth of Test Pit..... - Depth to ground water..! c�-N-�.....
4� iTest Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O Description of Soil----l •� � r''` - V b so..t... _Z`�' !r ., ram..'�ti.....
l�•---•-•-•••--•.
U ...............�:`...=1S.n__... �'_t .f._._y_...�� ! �- Gao4E'S :_ o..r+-�e�r �u!-r`t..�,_......�1..•
Nn H?_!;.........
U 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 TITLZ 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. �'� G�yj
Signed..... ................................. ..........................
bG0
f�:" ............. .:....-1- ••--•...................•--•-•----•--
Application Approved By...- J ....
Date
Application Disapproved for the following reasons:.........................................................................
••--_......
Date —
c
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................... .................:OF.... . ............................... ..........................................
(Irrtif utt#r of Toutp am
THIS IS TO CERTIFY, That thendividual Sewage Disposal System constructed ( ) or Repaired
by ..... ...........•••--••.......�_t_ 1.-!M:®rR!.................•--•••--.•... .....-..-•---..............•-------•--........._._..........._-•---..........._..._........
Insta r
at::.....•••....L�....-.- ......... ...._��h� ,.._.�.. 1` n+p
has been installed in accordance with the provisions of TITJ�1of �e(State Sanitary CodaJ� Vc
A9 in the
application for Disposal Works Construction Permit No................................
....... dated............../........._........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS RUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.....--•--
Inspector------••---3`p
p ........................................
......--•-••-•--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTHcl���ic ►
�(C�/ ...............OF.. ................................................................. ......... � a
No............... ...... FEz.........
aiminsal Vvr6i Tattutrnrtiun Permit
Permissionis hereby granted......'..............................................................................................
:..........................................
to Construct ( ) or—Repair an .Individual Srx
Age,Dispos�d_ stem
atNo...... -tz .. - ..... .:--......-�..S--•---- .--....... �rt�....---•--•--•--•--•------.....................................
' Streer
as shown on the application for Disposal Works Construction Pe rt No 101 ed... ...._5-..........
.•....... .........•--••--•-•-••-•--•••••-••--••••-•--••-•----•-•--••--•---•••.._...-•••......___.....
DATE. - 3 U v Board of Health
-------------•---•=•••........_
COMMONWEALTH OF IIZASSACHliSETTS
EXECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
C��I`��
FAILED INSPECTION MAR 2 9 2005
TOWN LTH UEPTABLE
=E.5.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSNIENTS -
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
iAP Z
Property Address: `7'7 r -70 sw s
Owner's Name:
Owner's Address:
Date ofluspection: //D��,,� /
Name of Inspector.(please print)4/,4 Y E.A/Lc/,l4
Company blame: _
Mailing Address: 13 ,9 X 5/ ��f
1/9.Y,yi /'77/3 D e U%
Telephone Number. S`O 7- 7 -2 -s
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was.performed based on my
training and experience in the proper fraction and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15—W of Title 5(310 CMR15.000). The system:
Passes
Conditionally Passes
ble6ds Further Evaluation by the Local Approving Authority
Fails
Inspector's Sign Date:
f,
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.
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.
f
Page 2 of i I 4
OFFICIAL INSPEMON FORM-NOT FOR VOLUWARY ASSESSM WS
SUBSURFACE SEVPAGE-.DEPOSAL SYSTTEMMI NSPE+CnON FORM
PART A
CERTMCAITON
(mod)
Property Address:y 7 l
Owner.
Date of Inspection: --3 a /7,--
Inspection Summary: Creek A,%C,ID or E/AL XS complete an-of Seenou D.
A. System Pass
I Dave not form any info n which indicates that any of the failure criteria described in 310 CKOt
15303 or in 3l0 CMR I 04 Any fadnre criteria not evaluated are indicated below-
Comments:
B. System Conditionally Passes:
One a\more system components as de bed in the"Conditional Pass"section need to be replaced or
repaired.The upon completion of the
placement orrepair,as approved by the Board ofHealth,will pass.
Answer yes,no or no determined explain. (Y,N, )i n the for-the following statements.If"not determined"please
The septic tank is m and a 20 years old*or the septic tank(whethermetal.or not)is struchaally
unsound,exhibits on or exfiltradw or talc fat7nre siu=in=L S r existing tank is replaced with c lying septic tank as y�w�Pass-inspetsiou i€1he
*A metal septic-tan] wr11 Pam 'on if e t �by the Board Cf�th.
indicating-that the tank is less 20 is available
telly sound,not Ieak�g and if a Certificate of Compliance
years old is available.
ND explain:
Ooservation of's oe backup r breakout cr
obstructed pipes)or.dne arsiatic watcr-level in the d'tsin3utianhox.due to broker or
broke
n, d orazoeven distribution box System wt�I
approval of Board of Health): pass. on if(with
broken - s}are replaced
obstfucti -is removed.
distrib -box is lei arreplaced.
ND explain:
The system required pumping more than 4 times a
p inspection with y�due to.broken.or obsiructed pipe(s).The system will
( approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
I-TD explain:
Page 3 of 1 l
OFFICIAL INSPECTION.]FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: ? J e_ , A; s'J
Owner:
Date of Inspection•
C Further Evaluation is Required by the Board of Health:
Conditions exist which ire further evaI tto6by the Boatel of Health in order to determine if the system is fading to protect public health, fety or environment
1. System will pass unless a of Health determines in accordance with 310 CMR I5.3 1
system is not fun me in a nner which will protect public health,safety and the environment:at e
or privy is within 50 of a surface water
ool or privy is within 50 ii:et a bordering vegetated wetland or a salt marsh
Z. System will fail unless the Boa of Health,(and Public'Water pplier,H any)determines that the
system is functioning in a manner at protect the public heal
safety and environment-
The system has a septic tank soil absorption (SAS)and the SAS is within 100 feet of a
surface water supply or tributary-to a cc wat sapPly-
_ The system has a septic tank and d the SAS is within a Zone l of a public water supply.
The system has a septic tank S and the SAS is within 50 feet of a private water supply well.
_ The system has a septic and SAS d the SAS is less than 100 feet but 50 feet or more front a
private water supply well".Method used to ermine distance
*'T system if the well water analysis, ormed at a DEP certified Laboratory,for coIiform
bacteria and vol- a organic compounds indicates the well is free from pollution from that facility and
the presence ammonia nitrogen and nitrate nitro is al to or less than 5
fail•,ae cri a are triggered.A copy of the analysis be attached to this formP�provided that no ether
3. Other:
Page 4 of 1 l
OFFICIAL]ENSPF.CTION FORM—NOT FOR VOLUNTARY ASSFSShMM
SUBSURFACE SEWAGE DISPOSAL.IYSTEMINSPRCTTON FORM
PART A
CF.RTIFjrCATION(cow}
Property Address: ;. 5—T J e �s 5T-
/5� y A iv y i S
Owner•
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate`des"or`rho"to each of the following for all inspections:
yes o
Backup of sewage into facdity or system component due to overloaded or clogged SAS or cesspool
Discharge orponding of effluent to the surface of the grozmd or surface-waters due to an overloaded or
clogged SAS or cesspool
Static liquid level m 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-vohume is lesst§an%day flow
Required pumping more than 4 times is the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
1 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 swface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy kwithia a Zone 1 ofa public we1L
_ y portion of a cesspool or privy is within-50 feet of a private water supphr:well.
�y portion of a cesspool or privy is lesstharr 100 feet but greater than 50 feet from a private water
supply well with no acceptable waterqualityanalysis.[This system passes if the well water analysis,
performed at a DEP certified laboratory,for eoliform bacteria.and volatile-3rganic compounds
indicates that the welt is free from pollution from that facility and the presence.of ammonia
nitrogen and nitrate nitrogen is equal to or less tb=3 gpm,provided-hat no other failure cdtrria
are triggered.A copy of-the analysis-must Imattaclseid.to the farm.
(Yes/No)The system fails 1-have determined that one or more of the above fail—criteria exist as
described in 310 CMR 15303,thereforethe-systeszt faiLs:-'The system owner.shonld contact the Board of
Health to determine what-wM be necessary to correct the Endure.
1« Large Systems: f
T o be considered a large system-the wrv:eafacMy witltadesign1low of 10,000 gpd to 15,000
ald-
Yon must indicate either or`nd"to of the following
(The following criteria large m addition to the criteria above)
yes no
— the system is wither 400 et of a surface drinking water supply
—— the system is with 00 f f a-tn'smary to a surface.drinking water supply
— the system is-1 in a nitrog sensitive area(Interim'Wellhead Probection Area—MTA)or a napped
Zone 11 of-a lic water supply 11
If you have answered es"to any question in S n E the system is considered a significant threat,or answered
"Yes"in Section D above the large system has.famed.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 CM R
15304.The system owner should contact the appropriate regional office of the Departmem
.r
page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART B
/ CHECKLIST
Property Address:
Owner.
Date of Inspection• a �"
Check if the following have been done.You must indicate`yes"or"no"as to each of the following
Yes No
,&,1' 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?
— _ZlHave 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)
y _ Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
Z-- Were all system components,excluding the SAS,located on site?
Were the septic tank manholes uncovered,opened,and the interior of the tank' ected for the condition
of the baffles or tees,material of construction,dimensions,de th'vf liP
p quid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
�- nanc.l 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 pl at the Boar�Health.
_ _ Determined in the field(if any of the failure criteria related io Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b))
f
Page 6 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBBURI+ACE SEWAGE-DISPOSAL SYSTEMIISPECnON FORM- .
RART-C
SYSTEM INFORMATION
h
Property Address:�7 T D Av
J/
Owner.
Date of Inspection: e)
FLOW CONDMONS
RESIDENTIAL
Number of bedrooms(desigp)- Number of bedrooms(actual):
DESIGN flow based on 310 I5203(for example 110 gpd x.#.of bedmnms): 3.3 0
Number of current residents:
Does residence have a garbage grinder(yes or no):�/
Is laundry on a separate sewage system(yes or no):atif yes separate-inspection required]
Laundry system inspected(y�es-AZ
no):
Seasonal use:(yes or no): v
Water meter readings,if available(last 2 years.usage(gpd)): /q`�
Sump pump(yes or no):
Last date of occupancy: J—
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15 03): Qpd
Basis of design Pow(seats/perso sgft,etc.):
Grease trap pies or no .
Industrial waste h idin� esent(yes or no):_
Non-sanitary w dis a Title 5 system(yes or no):—
Water meter rea " if able:
Last date of oc e
OTHER(describe):
GENML INFQ_ RMATION
Pumping Records
Source of information:
Was system pumped-as part ofthe inspection(yes orno)-,6Z
If-yes,volume pumped:Lgallon—Flo.w-was pumped-dmPd?--
._ �Y IMP �
Reason for pumping:
OFSYSTEIW s
Septic tank,distribution box;soil absorption system .
_Single-cesspool
Overflowcesspool-
—ivy
Shared hem,(Yes orno)(if yes, ,if anyy
_InnovativetAhernativm:technology:Attach--copy ofthe current operation and maintenance contract(to be
obtained-from system owner)
_Tight tank' —Attach a copy of the DEPapproval
Other(describe):
Approximate aQe of all componen ,date installed Of known)and source of information:
Were sewage odors detected when arriving at the site(yes or no)._L� l f�
Pi;!-e7ofII
O CIAL INSPECMO N. OMM—NOT FOR VOLUNTARY ASSESSMENTS
SMIS ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: "V7 �T �a�j✓� )j
Owner.
Date of Inspection: S�
BUILDING SEWER(loci on site plan)
Depth below grade: P2
14aterials of ems action cast iron PVC other(mTlaif
Distance from private water supply well or suction liae:
Comments(on condition of joints,vetrting,evidence of leakage,etc.).-
S TIC TANK:Zoocate on site plan)
Depth below grade: Z -5;/�
AIaterialofconstruction:2�co`ncrete metal fibergl=—polyethylene
I lain
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance -
certificate) P (yes or nor_ (attach a copy c
Dimensions:_7, X S-
Sludge depth: ape•
Distance from top of sludge to bottom of outlet tee or baffle:
Sc=,mr thickness:
Distance from top of scum to top of otulettee or baffle: O
Distance from bottom of s,^am to bottom of outlet t'_or baffle: p r�
How were dimensions determined: ryi L.9 sc-n .x, S -'
Comments(on ptmrping recommendations,miet and outlet tee or baffle condition,structtual integrity,
as related to outlet invert,elvidei of_ liquid I_ 'Is
XX leaf age,etc)-
LASE TRAP-(locate on site pl ) t
Depth below
liaterial of co fiber•
(E�lain): _ .--Metal a __polyethylene other
Dimensiotim
Scum thiclmess�
Distance from 10f s to top of outlet tee or baffle:
Distance from of s to bottom of outlet tee or baffle:
Date of last p '
Comments(on ing rec endations,inlet and outlet tee or baffle condition,structural irate
as related to' et invert,eviden leakag ): arty,liquid le���.ls
Page a of I 1
®INCIAL INSPEC-nON FORM--NOT FOR LUNTARY ASSESSMENTS
OBSMACE SEWAGE DLWSAL SYSTEM INSPECMON FORM..
PART C
T-S V-STM! A-rION(pled)
S rUperty Address:
Owner:
Date of fL9JMtioa: /L/ �2 5-
IG.,,'T or ROL DING TAP.W,. (tank-must be
a2time srf,;nspecdonXlocate on site plan)
Depth bxalmm
Itilarerian c metal fiberglass
other(explaia): _
Dimens
Capacity. gallons
Design mHons/.day
�`- Io):
Alarm leAlarm in king
Date ofl °�e'{yes or no):
Commfalmwand float switches,etc.):
TI U`T$�BT+I (ifpresent must be opened)(locate on site plan)
Depth of liquid level above outlet invert:_!�'0
COmmeests(note if box is level and distribution to outlets=gnat,-any evidence of solids carryover,any evid _of
l-akage intto or out of box,etc.):, _
Fuw (Io on site plan)
rumps ut�' g or or no}:
�ilarms in working o es or nor
Ceinine:its(nott to ofpamp chamber_tradition
fps tftil ip-p 3enanatt etc.)°
f
® i Page 9 of I l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property.Address:.'/ ]T p�,91
T A�✓Y�s
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):` locate on site-planrexravation not required)
If SAS not Iocated explain why: -
TYPe
leaching pits,number._
leaching chambers,number
leacbiag-galleries,number:
leaching trenches,number,length:
leachingftelds,number,dimensions
overflow-cesspool,munber_
inn ovative/ahernative system-:Type/name of technology:
Comments(note-coudition-of soil,-sigrmof hydraulic failure,level of ponding,damp soil,condition of vegetation,
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) '
Number and confi
Depth—top of liquid to' let inv
Depth of solids layer.
Depth of scum layer.
Dimensions of cesspool- _
Materials of constru on:
Indication of gro dwater' ow(yes or no):
Comments(n condition o Oil,signs ofhydraulic failure,level of ponding,condition of vegetation,etc:):
PRIVY' (locate on site plan).
Materials of construction:
Dimensions:
Depth of solids:
Comments(note cond' ' of il,signs ofhydrmdicc-failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL .FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPO FORM
PART-C
SYSTENrINFORMATION(continued)----
Property Address: y � ✓d J tis �
Owner.
Date of Inspection aZ/ v-5
SKETCH OF SEWAGE DISPOSAL SYSTEW'
Provide a sketch ofthe sewage disposal system including-ties to arleasttwo-penTment-reference landmarks or
benchmarks.Locate aQwel s within'100 feet:Locate where-public watm supply-enters the-building.
t
. a
; 33 `
vj,?Vx
1 13 o�f
Gf' wo _ L3 - ^ 33 ,
13 �= - � '
PeQe 11 of 11
0MC AL INSPECTION FORM—NOT FOR YODUN1TARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEIM INSPECTION FORM
PART C
SYSTEM I�'ORMATION(continued),
P:vge;ty Ac�dresr �2 -�e`i 1-r 5
Owner:
Date of Ids:
S11= le-£
Sur ice water iv t
Check cellar P.2 Y
Shallow wells A.-e t-
Estimated depth to ground water 13 feet
Please indicate(check)all methods used to demrmine the high groimd water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed t
b_esved site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Heakh-explain:%a y -V/3P S
Checked with local excavators,iastaile. (attach documentation)
Accessed USGS database-explain:
'17ou must describe bow you established the high ground water elevation:
13 e--7 seos
j
TOWN OF BARNSTABLE V
LOCATION Z-1 7 5� J Vs ST SEWAGE #;20®S- �6
' t r.,f
VILLAGE' ASSESSOR'S MAP & LOT Z�+ 0y) Ob
INSTALLER'S NAME&PHONE NO.9>1 -47 _7 5- i36�
SEPTIC TANK CAPACITY If-x i l D o v
LEACHING FACILITY: (.ty. pe)13�3DS b .✓F//l2.G►ralJ. (size) Six /3 Xa.
NO. OF BEDROOMS
BUILDER OR OWNER '�IA ZIY X C�f3,✓
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
L
1
rA
�7fib
o
� II
NO
i
No.
'2,0 0 S sI P Feel.—�D
1
THE COMMONTEALTH OF MASSACHUSETTS " Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYication for ZiopO �pmem Construction Vermtt '^ °`
Application for Permit to Construct( )Repair, )Upgrade.( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
y,
Assess s ap/Aa a P_ A/ /
Installer's Name,Address,and/ 1.No. Designer's Name,Address and Tel.No.
,9 It 65-41' 6 A' sr C �� A n C ,) /"e-
s_0 S 72 3 62
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 5 5-,K� gallons per day. Calculated daily flow -3 3 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �X i s % �O D Type of S.A.S. .r 2`=
Description of Soil
i
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 issuadby this Board of Health.
Signe, Date G e B '
Application Approved Date 1- it G—
Application Disapproved for the ollowing reasons
Permit No. �il G S � Date Issued 4 t I Its-
----------------_-4---_—--- - - - -- - - --
.' •�F'' s.r'...v.. ,. :Y� d..._�?+.-�t�i...r.. 4.t�".r;�. ti.,, y r..�..._ -+1.",�.�'.,i ��,} b . .�r'"^r
V-s^Y
No.
T4 COMM.OQVkEALTH OF MASSACHUS6'TS*1 Entered in computer:
Yes
(.
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zi pplication for Migpoga .&potem Cottgtruction Permit -7°`
Application for a Permit to Construct( )Repair(;-),upgrade Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Locatio ddress o Lot No. Owner's Name,Address and Tel.No.
Assessor's Map/Parcel � 7
Installer's Name,Address,and Te'l.No. Designer's Name,Address and Tel.No.
C
sG �� 13 5� sv 7 02.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
771 Design Flow J y �� gallons per day. Calculated daily flow _J-3 gallons.
Plan Date Number of sheets Revision Date
Title
r.k 5 ( /0 0 0 T e of S.A.S 3 � /� , ,;ii,� 2 f ;Y j.2./C.►'-� '�
Size of Septic Tank yp ( '
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* this�Boar�d of Health.
Signed-:� `_`� `r=--t--- Date
Application Approved`yr ` t�» S: Date � j 1 G S
r
Application Disapproved for the following reasons
Permit No. } -/6 y Date Issued. III-kill S
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired Upgraded( )
Abandoned( )by 1�'Z'G
at has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction PerrriMt No.�2 1'0 - 6 y dated _q1_: 11°
Installer"G ! Designer �-
The issuance of thispertt; sh 1 m be construed as a guarantee that thLsyste3,14i1 cti n as designed.-;-..
Date Inspector
--r--`—/—=-`--`=--------- ---- --------=---
No. aL UtJ��f �� —— Fee Q
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Miqogal *pgtem Congtruction permit
Permission is hereby granted to Construct_( ),Repair(Upgrade )Abandon( )
System located at- el 7 5
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 `ust pb-c-completed within three years of the date of qhiZDqrmi
Date:_ /`� I � S Approved b
( ,TOWN OF BARNSTABLE
LOCATION �/!/7 �/a��✓7 J a �j ST SEWAGE
VILLAGE " ✓ay) ASSESSOR'S MAP &LOT
INSTALLER'S NAkE&PHONE NO.09✓L•4 H ZA V-47 to S oS 22S 1316
SEPTIC TALK CAPACITY
LEACHING FACILITY: (type,�(a 5 b ,V C., >2.g7�I'(size)��'�x �-3 X-
NO.OF BEDROOMS f
BUILDER OR OWNER A y-S �/l A i✓ o
PERMITDATE: 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) Feet
Furnished by
ii
PP = ��
ci )POP
�r
Scl
L3
v
54 . 0P
�,135�dZl��i�o�
�m� f
9116/03
Notice: This Forna Is To Be used For the Repair Qf Failed
Septic Systems Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
oet'�
d�� l• 2 f RR � certi that the en 'neered lan si ed b me
Id'1, hereby fy g1 p � Y
dated ,concerning the,p%petty located at
P'r To meets.. all of the
following criteria:
• This failed system is connected to a residential,dwelling only. There.are no commercial or
business.uses associated with the.dwelling:
• The.soil is classified as CLASS I and the'perc lation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data-to conclude this fact or may conduct deep
test holes and percolation tests at the site without a health agent present.
• There is no increase in flow and/or'chaige in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table;elevation. [Adjust the groundwater table using the
Frimptor method when applicable]
Please complete the following:
(,c;
A) Top of Ground Surface Elevation(using GIS information)
B) G.W.Elevation +adjustment for high G.W. _ iv 1A
N; %
DIFFERENCE BE EN A and B
SIGNED . DATE:
NOTICE
Based upon the above information- a repair permit will be issued for bedrooms
maximum. No additional bedrooms are authorized in the future without engineered septic system
plans.
�;� 'q:\Sepric\percexaW.doc \
Town of Barnstable
'He, ti Regulatory Services
0
Thomas F.Geiler,Director "
snRrisrasL ,
9 Public Health Division
aTFO �, Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer &Designer Certification Form
Date:
Designer: I �i1 Y✓(i 1 Me V6� Installer: Agal 6NAP
Address: ] 'V ��( b ' Address: l'G 13ox.
MCA
On Ago 0'Y�` was issued a permit to install a
(date) (installer)
septic system at 4 'e7,-INr- ��s Sr. based on a design drawn by
(address)
IDA V✓e*l !i✓ dated
(designer)
certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any comp9RICTIt
of the septic system)but in accordance with State&Local Re a .ons. Plan rev' on o
certified as-built by designer to follow.
H OF MA
o`er ARR
O M.
i YER C
(Ins ller's Si afore) 1140
�4PaISTEREO V�
lSgNITWKN O u
ti
(Designer's Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARN ABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL N BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
-SECTION - SEWAGE -
t,
-SEPTIC TANK- -"D"BOX - -LEACH TE '
TOP O�F'FD j �--
(MSL)t+ "2"OF t/aT0 4:"
4 WASHEDSTONE i
Z�
Ll
IN• -OUT• 1
IN• Ol1T• �
N'• 1 1
1 e:�TNIKC
ELEV. ELEV. .. ELEV. ELEV. ���
ELEV. ELEV.
z f
- - . .. EIS./. ./'1•�_ io -i-� ., � � - '. _ \\)
` z _OF Va r'-14z"
WASHEDSTONE / l:
TEST HOLE LOCI /� ( / ���
TEST BY 3.a.L1
INITNESS
TEST DATE ,A'V a-le, t`%64 BEDROOM HOUSE J � s. I` 'o
n
DESIGN . , n
T:Et. t: T.H.. 2- ( �— s; 3� # l�
op-�L ELE�f 4`l.3 ELEV. NO T
< Z MIN/IN. DISPOSER DISPOSER /
z4y a0,1 PERC RATE h / `J L/! /-
FLOW RATE 334=1 (GALIDAY) 33� ✓ / /
c o..-
SEPTIC TANK .33� �,_6)_ I � j / j QItfi
a�d. REO'D SEPTIC TANK SIZE
LEACH FACILITY
SIDE WALL `TrC���C�.�=taB. �Z.$) 4� 1 .Z G/D.
rO.NG t BOTTOM '�',c>2/g• _ '�e.s�. � ),. n 0.5.G[D. `•� - Zc�'.r _ !
TOTAL . Zco-1.� S.f. = S4g•'1 v�t'� �
�.� ill 1
USE: LEACHING
Iv Q!
WATER.ENCOUNTERED r -t•'' �� r �111
NOTES": (UNLESS. OTHERWISE NOTED) € ". �--- a:e •3a
1.DATUM(MSL)+TAKEN FROM _.._.QUADRANGLE MAP
2.MUNICIPAL WATER___ (------AVAILABLE
3.PIPE PITCH:W"PER FOOT `�N OF ZN �f 4fgsJ" 1
4.DESIGN LOADING FOR ALL PRECAST UNITS:AASHO- -44 aY�``
5:MIN.GROUND COVER OVER ALL SEWAGE FACILITIES:(1) FT. ctiG ; ARNE
6.PIPE JOINTS SHALL BE MADE WATERTIGHT ARNE H. c H. y
7-CONSTRUCTION DETAILS TO BE ACCORDANCE WITH COMM.OF MASS. O QJALA -+ C OJALA H SITE PLAN
STATE ENVIRONMENTAL CODE TITLE 5 v CIVIL y #1Z6S No. 30792 io .t LOCUS:
"' I RED Pam.
• ��.<` 9EClST R `� _ � s LA a So ___ ' %` F-IYA�r�.��S , r��.-S�
AL E EG.PRO S ENGINEEtR" Y
t REF: CoZ
down cane engineering► PREPARED FOR:
E.. CIVIL ENGINEERS ----
LAND SURVEYORS -- -----
BOARD OF HEALTH �` REE LAND SURVEYOR
CONTOURS (EXISTING)•.--- _ 8L
(PROPOSED)�-0-•O-O- APPROVED DATE p` cMA SCALE
Yaww�..MA. DATE
40
� ASSESSORS MAP III NOTES:
E 2 TEST HOLE LOGS
PARCEL: 017 001 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH
+y
t RS C5�
s SOIL EVALUATOR : �• N� THIS. PLAN, I995 _ MASSACHUSETTS TITLE V & TOWN OF
FLOOD ZONE : CIO rJ �A2ft '
3 MARYA W I TNESS � VY�'O �P, IS`r $c-E BOARD OF HEALTH REGULATIONS.
0 REFERENC E q DAT E APW 2Do$' 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES,
M� SEWER INVERTS AND ' SEPT
o , PERCOLATION RATE Itic�} IC COMPONENTS PRIOR TO
1 I INSTALLATION.
�• `�' GLkSS 2 So1Lh LTAlr-- 0,7+ y
SUfA)q/4U K 8 6-0,�� '► TH- I TH 2 3 THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION
1` _ E.L. 61-4-T ) o
- ONLY, AND SHALL NOT BE USED FOR '' PROPERTY LINE
13 1tJ 1 D I'E- 6 R�EN E P L S-
�! DETERMINATION.
?e _ n
T < IZ 4 ALL PIPING TO BE 4" SCHEDULE 40 1/8 'Y FOOT. UNLESS
p� I,o�M ) @ �
l ,� _Sn �Ryt� '3 SPECIFIED OTHERWISE)
LOCATION MAP (t4•rs' 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A
GARBAGE DISPOSAL.
SAW
6) SEPTIC TANKS AND DISTRIBUTION BOXES .(WHEN 'INSTALLED
Vey)iW - MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON
C � G A BASE OF 6"OF CRUSHED STONE.
-7 Ewsn LEACA Pl7r IV PVMPEO, cP6 fEV r_iLlIkD
40,41
NO
No k&WbJ 1`124uATC5 WELt ,5 W/lp1 I9.J VP
9- I�o_Vum4wo Who ISv or- aRolP. (,Eattrt
SEPTIC SYSTEM DESIGN -
10, Ao VWA-N(.GS. M T1LIE
_Y c91L._ ry 0 -�.�JS.
5/
FLOW ESTIMATE " iDhR.� @ �'E.ALTIfi �irlgS rL�Qt/2Kk�.
BEDROOMS AT «U GAL/DAY/BEDROOM - 3 GAL/DAY -
� 12000
SEPTIC TANK
f l2•IL' �� , 33C� GAL/DAY x 2 DAYS GAL
51
USE 1 000 GALLON SEPTIC 'TANK
/ S�Pi�c TxHvlc 1 FAQ un OAM%"
l rn f, L O T S a SOIL ABSORPTION SYSTEM
AREA - 12000 s{
I
O ! [ VN+1 L
I N r-1 t:.-(�2.AcTD� 3oSo `�S w 3 Or- STD
1 ,
E o` 2 a ac,� Y
E
t GAS S Z 12.1 x .7
. � z � / � 2 �2 o ti / /o
`- SIDE AREA �l
GATE
r y 3 BOTTOM AREA: ZS x IZA(o X p 7
} l 1 p -44� TER ' y ZZ H•9(�
cr J n r GA�'O
�33o GPO re
Ivsn fJo y o` SEPTIC SYSTEM SECTION e
v I. (0''0r "I�h 9 MiN ,+ 4 +
i
0 9 �1�
� W �nsfa� � q Q '
(aas Baffle q B.14
� f, y E3� w''Stant 7
D-BOX
1
GAL -7,��i ►nlasf
70 SEPTIC TANK �tN IV(�„CS+S, 47. 7b
i r � +
BENCH MARK Dr�-3 l 25 (.. 5_23
(IV, rTOP OF CONC BOUND ��RGff/� 06T�'lC , S,
ELEVATION 50.95
USGS DATUM ASSUMED C� oivm DF 7ESnfo LE EC 4a 47
I a3 ► d
2
Sf"c SITE AND SEWAGE PLAN
:1:2:4" �3 " `/ 1/2LOCATION : 47 5A rjr Tohw ST.
f,
H OF Mgs ILL/�
3 _ F tJv7, MA
4S PREPARED FOR : CH4rl j gxr_4 CoMST,
M ER
# No. 1140
/ ago 12.t(o • � _ �
a S�nriraaIr•N DARREN M. MEYER, R.S. SCALE
DATE:
P.O. BOX 981 y/
z
EAST SANDWICH, MA 02537
z
DATE HEALTH AGENT Ph: 5081362-2922
W
3
1