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HomeMy WebLinkAbout0135 SCUDDER AVENUE - Health 135 Scudder Avenue,Hyannis A= 289 - 093 - 002 I 0 III Town of Barnstable Barn Regulatory Services Department ANAMOdUCR 41 "RN Public Health Division Q D 1639 A 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Richard V.Scali,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL #7012 1010 0000 2851 August 7, 2014 Suzanna R Turyn 135 Scudder Avenue Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5. The septic system located at 135 Scudder Avenue, Hyannis, MA was last inspected on 7122/2014, by Matthew Gilfoy, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Fails" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) Due to the following: • At time of inspection the distribution-box was in poor condition and needs to be replaced. You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF THE BOARD OF HEALTH No Itr sent Thomas McKean, R.S. CHO Permit # 8/5/2014-259 Agent of the Board of Health Q:\SEPTIC\Conditionally Passes Ltr\135 Scudder Ave HY 2014.doc J Commonwealth of Massachusetts Title 5 Official Inspection Form - . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Scudder Ave Property Address Suzanne R. Turyn Owner Owner's Name information is required for Hyannis Ma. 02601 7-22-14 every page. Cityrrown 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: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Matthew F. Gilfoy cursor-do not Name of Inspector use the return key. B&B Excavation Company Name 14 Teaberry Lane Company Address Sandwich Ma. _ 02644 Cityrrown State Zip Code . (508)477-0653 S113640 Telephone Number License Number B. Certification t I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to.Section 15.340 of Title 5 (310 CMR 15.000). The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7-22-14 Inspect 's Signature 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. t5ins 3/13 Title 5 Official Inspection For Su rface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts u,pTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 135 Scudder Ave Property Address Suzanne R. Turyn Owner Owner's Name information is required for Hyannis Ma. 02601 7-22-14 every page. Citylrown 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: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. 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-wi 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 d Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments o 135 Scudder Ave Property Address Suzanne R. Turyn Owner Owner's Name information is required for Hyannis Ma. 02601 7-22-14 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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): D-box is in poor condition and must be replaced. ❑ 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): 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 salt marsh t5ins-3/13 Title 5 Official Inspection 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 135 Scudder Ave Property Address Suzanne R. Turyn Owner Owner's Name information is required for Hyannis Ma. 02601 7-22-14 every page. City/Town 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 ❑ 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•3113 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 135 Scudder Ave Property Address Suzanne R. Turyn Owner Owner's Name information is Hyannis Ma. 02601 7 22-14 required for y every page: Cityfrown 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 to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with,no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,.you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA)or a mapped,Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large . system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins 3/13 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 135 Scudder Ave Property Address Suzanne R. Turyn Owner Owner's Name information is required for Hyannis Ma 02601 7-22-14 every page. Cityrrown 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. ❑ ® 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•3/13 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 135 Scudder Ave V Property Address Suzanne R. Turyn Owner Owner's Name - information is Hyannis Ma 62601 7-22-14 required for y every page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection t information in this report.) El Yes No Laundry system inspected? ❑ .Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ .Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310-CM R 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•3/13 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 F-s 135 Scudder Ave Property Address _ Suzanne R. Turyn Owner Owner's Name information is required for Hyannis Ma. 02601 7-22-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): I General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped:- gallons How was quantity pumped determined? Reason for pumping: Type of System: - ® Septic tank, distribution box, soil absorption system Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest - inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 P 9 P Y 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form -Not for Voluntary Assessments 135 Scudder Ave Property Address Suzanne R. Turyn Owner. Owner's Name information is- required for y H annis Ma. 02601 7-22-14 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1983+/- Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2 feet. Material of construction: ® cast iron ❑ 40 PVC ❑other(explain): Distance from private water supply well or suction,line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good working order no sign of leakage. Septic Tank(locate on site plan): Depth below grade: feet Material of construction:. ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No. Dimensions: 1000 gal. 2, Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form:Not for Voluntary Assessments 135 Scudder Ave Property Address Suzanne R. Turyn Owner Owner's Name information is required for Hyannis Ma. 02601 7-22-14 every page. CitylTown 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 34" Scum thickness 1 Distance from top of scum to top of outlet tee or baffle 6„ Distance from bottom of scum to bottom of outlet tee or baffle 16" ` r How were dimensions determined? measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t At time of inspection septic tank appeared to be in working order;Tees present no sign of back- up.Liquid level equal with outlet invert. Tank was last pumped 2-25-13. 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•3/13 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 135 Scudder Ave SV Property Address Suzanne R. Turyn Owner Owner's Name information is required for Hyannis Ma. 02601 7-22-14 every page. Cityrrown 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 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 iii 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Scudder Ave Property Address Suzanne R. Turyn Owner Owner's Name information is Hyannis Ma. 02601 7-22-14 required for y every page. Cityrrown 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 0 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.): At time of inspection d-box in poor condition and must be replaced. 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.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain.why: t5ins•3i13 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 135 Scudder Ave Property Address Suzanne R.Turyn Owner Owner's Name information is required for Hyannis Ma. 02601 7-22-14 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: . , ® leaching pits number: 1 (6,X6,) ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of.soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At time of inspection leaching appears to in working order no sign of hydraulic failure.Water level was 211" below invert at time of inspection. i Cesspools (cesspool must be pumped as part-of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No . t5ins•3/13 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection- Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Scudder Ave Property Address Suzanne R. Turyn Owner Owner's Name information is .required for Hyannis Ma. 02601 7-22-14 every page. Cityrrown 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.): Privy(locate on site plan); Materials of construction: Dimensions Depth of solids - Comments (note condition of soil, sighs of hydraulic failure, level of ponding, condition of vegetation, etc.): r j t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 135 Scudder Ave Property Address Suzanne R. Turyn Owner Owners Name information is r equired for, H annis Ma. 02601 7-22-14 - Y every page. City/Town 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. Loci& where public water supply enters the building. Check one of the boxes below: Z hand=sketch in the area below ❑ drawing attached separately Q 0 Al zg` 0 A3` 3�1' A I - (33 - V - t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 135 Scudder Ave SV Property Address Suzanne R. Turyn Owner Owner's Name .information is Hyannis Ma. 02601 7-22-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: f ® Check Slope j ® I _Surface water i ® Check cellar ® Shallow wells Estimated depth to high ground water: >15'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: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: previous inspection report ❑ Checked with local excavators, installers (attach documentation) ❑ Accessed USGS database-explain: - You must describe how you established the high ground water elevation: see above Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•N13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 v Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 135 Scudder Ave Property Address Suzanne R. Turyn Owner Owner's Name information is required for Hyannis Ma. 02601 7-22-14. every page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection SummaryD (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 �r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 TOWN OFr STABLE Y LOCATION / 5 SEWAGE# VILLAGE ASSESSOR'S MAP&PARCEL INSTALLERS NAME&P NE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) NO. OF BEDROOMS .,3 OWNER M, PERMIT DATE: 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 ling Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY r �/" g.i a W cfi �' No. � _ Fee VU computer:Entered in THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppliCation for Misposal 6pstrm Construction VPrZ%Ll Application for a Permit to Construct( ) Repair 0< Upgrade( ) Abandon( ) ❑Complete System Components Location Address or Lot No. RAyl j J al 60 X Owner's Name,Address,and Tel.No.13 S 6i Assessor's Map/Parcel C,kk 0,. t tom. J �"`.fyi.'f �Ll Installers Name Address,and Te.No. Designer's Name,Address,and Tel.N . v r � 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(min.required) gpd Design flow provided 73C gpd 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) FACE erlC oe ,rtn 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 Certificate of Compliance has been issued by this Board of Health. Si Date 77/ Application Approved by Dateel da Application Disapproved by Date for the following reasons Permit No. )-0 — Date Issued C i F No. O' ` Fee /00 THE COMMONWEALTH OF MASSACHUSETTS, Entered in computer: ✓ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zipplication for Bisposal 6pstem Construction per: Ll it Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Components Location Address or Lot No. �,� J ag9 (9 3®0 a_ Owner's Name,Address,and Tel.No./3 s'4 Assessor's Map/Parcel ,71A.?Z 4 vv �C t1 #Y4 Installer's Name Address,and Tel.No. Designer's Name,Address,and Tel.N'. 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(min.required) gpd Design flow provided 730 gpd 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) 3G,r ��f m c., 7L 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 Certificate of Compliance has been issued by this Board of Health. Si ed Date 7/ P Application Approved by Date i c/ Application Disapproved by Date for the following reasons Permit No. �_0 - ,-q Date Issued (l --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS (�� f BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(l_� Upgraded( ) Abandoned( )by r at J( -6 U,114, 1 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit Noj 0 ated / 1 Installer Designer #bedroomso��i/j Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system wil(l-fu c ion,as designed. Date / �, # Z' Inspector -------------------/-------------J------------------------------------------------------------------------------------------/--------------- No. 0 I�I �J l Fee Ida vJ THE COMMONWEALTH OF MASSACHUSETTS _ PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS disposal *pstem Construction Permit Permission is hereby granted to Construct(/I ) Repaireo Upgrade( ) Abandon System located at (v CV U.pr >� 174 ` and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. =' Provided:Construc 7 mu'be completed within three years'of thetdate of this permit. Date �// l Approved by 14 (s �\ COMMONWEALTH OF KkSSACHt'SETTS r: EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PR �I��TI'O\ ONE WINTER STREET. BOSTON. MA 02106 RECEIVED �W'ILLIAM F WELD OCT 2 � 1997 ag L•DY CO'KE Govcmc t04VIVOFB TABLE ARGEO PALL CELLL'CCI Sc;rctan HEALTH DEPT \'D B.STRUHS Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO a Commission: PART A �► CERTIFICATION Property Address: 13 , Sc�:�� z�{ �,< < `pty�lZ.l>� Address of Owner: 'Itle. la,J•1 , ���-� Date of Inspection: �f,i^ �� (if different) 1-15 0:6 S 1 Name of Inspector: / � �o Ca:yQ-3 ts..►VZd r 1-4 A, (52AoGy I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name:A±/67"4,-a Eft M'r-/'r-j K wt P.A+e`/ Mailing Address: 520 Agnx -0_3�� HAS&e_e9L HI9} © 2s'(_9' Telephone Number: e_5 7f-7 C 9L 2- 14 2—C7 CERTIFICATION STATEMENT I cerii� that I have personall\ inspected the sewage disposal system at this address and tha: the information reported beioN is true, accurate and complete as of the time of rnspec.o-. The inspection was performed based on my training and experience in the proper iunction and maintenance of on-site sewage disposa systems The system:. Passes _ Conc!no^aii\ Passes Neecs Furthe• Eva!uat;on the Local Approving Authorir� QInspector's Signature: C Date: The S\-stem Inspecto• sha!' submit a cope of this inspection report to the Approving Authorin, within them (30, days of completing this inspection. If the system is a shared s\•stem o• has a design floe of 10,000 gpd or greater, the inspector and the system owner shall submit the repo to the appropriate regional office of the Department of Environmental Protection. The orig!na! should be sent to the systern owner and copes sent to the buyer, if applicable, and the approving authority INSPECTION SUMMARY: Check A, B, C, or U AI SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS. BI SYSTEM CONDITIONALLY PASSES: One or more system components as described in the "Conditional Pass' section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y, N, or ND,. Describe basis of determination in all instances. If 'not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (artachedi indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (rov:oad 04/25/97) Pago 1 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM 1NSPECT10% FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection:.. e) SYSTEM CONDITIONALLY,PASSES tcontini-d .jSewage-backup or breakout or high static water level observed " the distribution box is due to broken or obstructed apipets),or due to a.broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health;: ,Describe observations: .� broken pipe(s) are replaced q t „ obstruction is removed distribution box is levelled or replac The system required pumping more than four times a ear due to broken or�aructed pipe(s).. The system will pass inspection if(with approval of the Board of Health): broken prpe�s? are replaced obstruction is removed CJ FURTHER EVALUATION IS REQUIRED BY THE BOARD ON HEALTH: Conditions exist which reauire further evaluation by Fie Board of Health in order to determine if the system is failing to protect the public health, safery and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HFALT DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH ND SAFETY AND THE ENVIRONMENT: Cesspool or prn-, is within 50 iee: of surface water Cesspool or priv, is within 50 fee: of,f bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MA."'ER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: / The m c e s�_te has a septic tank any so I absorption ,_ � system (SAS) and the SAS,is within 100 fee, to a surface water supply or trrbutary to a surface water supply. The systern has a septic tank anrd soil absorption system and the SAS is within a Zone I of a public water supn'v well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank/nd soil absorption system and the SAS is less thar^ 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance 4pproziiiiiiation not valid). 3) OTHER 1 (revised 04;25/9") page 2 of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORP.1 PART A CERTIFICATION' (continued) Properh Address: Owner: Date of Inspection: D) SYSTEM FAILS: You must indicate either "Yes" or "No' as to each of the following: I have determined that the system violates one or more of the f lowing failure criteria as defined ,n 310 CMR 15.303. The basis for this determination is identified below. The Board of Healt should be contacted to determine what will be necessar• to correct the failure Yes No Backup of sewage into facil,hy or system compon nt due to an overloaded or clogged SAS or cesspool. Discharge or pond,ng of effluent to the surface f the ground or surface waters due to an overloaded or clogged SAS or cesspool. Sta:,c hou,d level ,n the d;stribut,on•box abo a outlet invert due to in overloaded or clogged SAS or cesspool L,eu,d depth ,n cesspool ,s less than 6" bel w invert or available volume is less than 1/2 day floe. Recurred pumping more than 4 times in a last year NOT due to clogged or obstructed pipe's . Nimper o`times pumped _. An, pon;on o'the So!! Absorption Svst m, cesspool or privy is below the high groundwater eievat,on Any por::on o:a cesspool or privy ,s ;thin, 100 feet of a surface water supply or tributar to a surface water supply. And por;,on of a cesspoo' or pro.), \A ithm a Zone I of a public well. An-• pc^jc-. c"a cesspoo! or prig ;s w,th,n 50 feet of a private water supply wel! Am po^.or. o-a cesspool or pri -�• is less than 100 feet but greater than 50 feet from a private Nate, supply weli with no a:ceo;abie Nate, qual,t% anal\s s. If the well has been analyzed to be acceptable. anach cope o;well water analvs,s for conform,, bac-,er;a volatile orga ;c compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate e:ne, "Yes` or "No" as to a ch of the following: The ioi:oN:r•.g crate,;a app;\, to large ystems in addition to the criteria above: The syste-: serves a facilm with a 'esign flow of 10,000 god or greater (large System: and the system is a significant threat to public he;`tn and safety and the a .v,ronment because one or more of the following conditions exist: 'Yes No . the system is within 4 feet of a surface drinking water supply the system is within 00 feet of a tributary to a surface drinking water supply the system is locat in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a public water supp well) The owner or operator of and such ystem shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 an 6.00. Please consult the local regional office of the Department for further information. (revioad 0,/ZS/S7i Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: Owner, � ` �\ Date of Inspection: Check if the following have been done: You must indicate either Yes" or "No"as to each of the following: Yes No Pumping information was provided by the owner, occupant, or.Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recentl,, or as pan of this inspection As built plans have been obta:ned and examined. Note if theY are not available with NIA. The fac:ltt\ or 6%eliing %%as inspected for signs o°sewage back-up. The system does not receive non-sanitan• or industrial waste flow. _ The site .,as inspected for signs of breakout. _ A!I s\sterr components. excluding the Sod .ADsorption System, have been located on the site. _ The septic tank manholes "ere uncovered. opened. and the interior of the septic tank was inspected for condition of barfies or tePs, materia± o• co s,ruct�o . dimensions, deptn of liquid,.de th of sludge, depth of scum. The size and locat,on of the Soi' Absorption Sv5iem on the site has been determined based on The facdit� ovine, ;ano occupants. if difteren: from owner were provided with information on the proper maintenance of �^ Sub-Surface Disposal Svstem. �pt Existing information. Ea. Plan at B.O.H. _ Determined in the field :n am of the failure criteria related to Pan C is at issue, approximation of distance is uhacceatabie (15.302.3; b`? (revised 04/25/5?i Page 4 of 10 i f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR..M PART C SYSTEM INFORMATION Propem Address: V51S QQ� Owner: Po �'V,KW— Date of Inspe�ion- FLOW CONDITIONS RESIDENTIAL: Design floN J.jv e.o-d-bedroom for S.kS Number of bedrooms Number o'current residents Garbage g', der (yes or no,—.0 Laundry co--ected to system (,yes or not�! Seasonal use ryes or no,. P�l c Water meter readings, if available (last two i2 year usage tgpo): tV Sump Pump Ives or not Las; date o'occupancy Mir i'a �. YT-Yi �+�►5 �„ �,�v..�t( CONAMERCIA111•'NDUSTRIAL• Type of establishmen: Design fro%% _fa!ionscia\ Crease trap present rues or no Industria! \'taste Holding Tani; Dresent ves or no 'Non-sanitary %kasie d,scnargec to the T!t,e 5 system nes or no_ \%ater meter readings if a,ailabie Las:Fate o: o .6;arc. OTHER: .Describe lase pate of occ.:�anc. GENERAL INFORMATION PUMPING RECORDS and source of m r. formatio ® l $^ i(L ruu kz' ii-ISC se -t .N System pumper as par, of inspection: rues or no.tit If yes, volume pumped vallons Reason for pumping TYPE,OF SYSTEM _ Seot-c tank'd,stribuuon box.soil abscrption system Single cesspool Overflow cesspool Prig)' Shared system (yes or no; (if yes, attach previous inspection records, if any) I/A Technologv etc. Copy of up to date contract? Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site. (yes or no) , fzwiaad 0�/2S/9�> Page 5 of 10 SLBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMAT10% (continued) Property Address: i 3 Owner: ^��n(V�� Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade. Material of construction: _cast iron _40 PVC_other (explain( Distance from private water supply well or suction li-t Diameter Comments: (condition of)oints, venting, evidence of leakage. etc.) SEPTIC TANK: yl (locate on site pia. J Depth beloN grade Material of construction: 4concre:e _mete _Fioe•g4ss _Polyethylene _othertexplarn If tank is meta. Ins: age _ Is age confirmec o% Cen•ficate of Compuance _(Yes'no _.. Dimensions I W� T& Sludge depth t Dtsiance from top o: sludge to bonorn of out;e: tee o• ba-"ie-N� Scum-thickness CS- s,( Distance from top of scum to top of outlet tee or ba-,e _ ►t Distance irom bottom of scarn to bo-o;-- o� outle: tee c• bane How dimensions mere determined A;,J Cl,' Li Comments trecomniendation for pumping :condition of role, and o-jttet tees or baffles, depth of liquid level in relation to outlet invert, structural 11 integrity, evidence of leakage. e:c.t \ ' N l -% i GREASE TRAP: (locate on site plan; Depth below grade: 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 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles. depth of liquid level in relation to outlet invert, structural rntegricy, evidence of leakage, etc.,, (revpvad 04!15:97) Page 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propem Address:k Date of Inspection: L•v TIGHT OR HOLDING TANK: ti(J -Tank must be pumped prior to, or at time, of inspection: (locate on site plan, Depth below grade Material of construction _concrete _metal _Fiberglass _Polyethylene _,other(explain) Dimensions. Capacm, gallons Design floes galions.da, Alarm level A:arm in „orkme order_ Yes. _ No Date of previous pumping Comments (condition of inlet tee. condi;ion o• a'a,rn and float switches. etc.) DISTRIBUTION BOX: docz;e on sue p a-. Dept^ o` licuid le%e aoo,.e outie: m�e' �il;tL��'•i�G:;`�� Comments tnve i le e' and d:sr c_:or, is eau ' ev1dence o� ljds carrvover, a •idence of le a into or out of box, etc.) ot PUMP CHAMBER: (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.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspe onn-: � SOIL ABSORPTION SYSTEM (1): 7 (locate on site.plan, if possible, exca,.atjon not required. but may be approximated by non-intrusive methodsi If not determined to be present, explain: Type. leaching pits. number.Aletrp leaching chambers, number:_ leaching galleries, number: leaching trenches. number.)ength: leaching fields, number, dimension ovei4iow cesspool, numbe, Alternative system Name of Tecnnoicip Comments. (note condition of soli, signs of hydraulic failure, level of pond.ng. condition of vegetation, et ) r �li � .� C (? i CESSPOOLS: "(.; (locate on site play Number and config;;ra:.or. Depth-top of liquid to inlet Inver. Depth of solids lave- Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwate- inflow tcesspool must De pumpeC as par, of inspection`- Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 04/25/97) Page a of 10 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continuedi Property Address: Owner: Nk3c,;�=�� Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 (locate where public water supply comes into house) v 3i� Z- 3i (revise'_ 04!25!9') Dag• 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ' Property ddress: Date of Inspection: Depth to Groundwater 4. Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observation o' Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions CnecK %yrth local Board o• nea'tr Chec'K FE.NAA N1aos Check pumping records Check local eacavato,s ins;alle,s lase `crc Da-.a Desc,ibe in vou, ow,- \•.o,as no,.% \o.. es:apLs�)ed the 6nigi-, Grou.n.dNater Elevation. (Must be completed, tzw.sed 041!25'9 Page 20 o1 10 ` LOCATION -SEWAGE PERMIT 1110. VILLAGE I N S T�. R'S N A a 0 ADDRESS r GUILDER 0R W ER DATE PERMIT ISSrU E_0 DATE COMPLIANCE ISSUED L 3 f h, No ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD 'OF HE I�T Aff 1�2 0�5_00 HE V� Appratiota for Uiipniital Works Towitrurtiou Prrutit Application is hereby made for a Permit to Construe or Repair ( ) an Individual Sewage Disposal System at:. .. ... . -• . ............. ........... Loc dres or Lot No. -. .. ...... ......... ..... .-.--------- ..--....: _.. ............................................................. Ovine )/'Address ............... ..... ------- -------------------------------•. ••-- • ......_... �.(�........... ...._. Installer Address Q Type ding Size Lot------ - _Vp-.Sq. feet ' T e o uil U Dwelling—No. of Bedrooms............. .......................Expansio Attic Garbage Grinder Other' 'Type of Buildill p� g ............................ No. of persons..... ------------------ Showers Cafeteria ( ) Other fixtures_--.. W Design Flow........ allons per person per day. Total daily flow...... .3-,O......................gallons. WSeptic Tank—Liquid capaciti, allons 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 to ►� a Percolation Test Results Performed by......_.. :....................... ....................... Date....r�."_.r�^._....__....._.... Test Pit No. 1..:.............minutes per inch Depth of Test Pi .,/............ Depth to ground water_. �..._- �Zq Test Pit No. 2................minutes per inch Depth of Test Pit......... Depth to ground water........................ :..............•-........................................................ ZY ODescription of Soil----•----•---...6.F `_......... �0 _ � ,------•----------------------------------------------------------------------•• -------------------.............................L.. ---------------------------------------------------------------...-.._.--.----•---------.------ 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 TI'i 1E 5 of the State Sanitary Code—The under • ned further agrees not to place the system in operation until a Certificate of Compliance has been isX191y the 1)6arj of health. gned -- ------------ -•--------------------- / � e D Application Approved B z fY L ...._.._._.. Date Application Disap ov f o the following reasons:-------•-------------------------------------------------------------------------------------------------------- ._ ••---......... Date ........................................... Date 1 I e --No.�-z� ................ THE COMMONWEALTH OF MASSACHUSETTS BOA R®�O H E LET14 H .........OF...............:'tt .!_.. .. ......................... AVVftra ion for llhipoii al Workii Tow3trnrtinn Vrrantt Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal System at: ep ......1.............. ... ..4q, .... .... ..................... ...........-..- .... LotNo. ---- ----...._....-•--•-•-------....................... Owne� .1,��lddress y� ff . ..........................................................•------------ F� J Installer Address dType of(Building Size Lot...... ._.; . ._Sq. feet U .......................Ex ansio Attic (/(/�}f✓°r Garbage Grinder Dwelling—No. of Bedrooms............. ...:. p Other—Type of Building ............... No. of persons.....(,-i................. Showers — Cafeteria al Other fixtures ........ --------------------- Q / W Design Flow.....-. .....gallons per person per day. Total daily flow. .... ..6e�__.__........_........gallons. WSeptic Tank—Liquid capacity/0 allons Length................ Width................ Diameter................ Depth................ x 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 (/ j _ ~' yr Percolation Test Results Performed by._.......ie'_Z...................... ........................ Date.... , __- _.._.._... tea Test Pit No. I................minutes per inch Depth of Test Pit._..._._ ..._._. Depth to ground water---1"F_ ��,..... f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................... e., -------,..i--------------------------------•-•-•-------------------------.------------ O Description of Soil................��,--- -----•---..�✓T.t..�y✓k'`_�_.�..�.'.e���-�-'�-�'=--------------------------------------•----------------------•------•-•---- 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 TIT iZ 5 of the State Sanitary Code—The under i ned further agrees not to place the system in operation until a Certificate of Compliance has been issuelby the ar of health. SignedJ ...... �............... /� ._. .... . ✓� �- Application Approved By Is -----•-------•---------------- /ls' -/ate Application DisapV the following reasons--------------------------------------------------------------------------------- ---•--....Date----.....__ ....................................;;;�-.....-•......_...............•-•••-----••.........._.._.......•------•--•--•---•---•-•••-••---------•--------------••--•••----••- ............................. Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARDZPF HEA TFrI X ....... ..OF.... "...... ...... ..... .............................. UTrrtifiratr of TompliFanrr THIS IS T RTIFY, That t4p Individual rage Disposal System constructed *' �or Repaired ( ) by-•...... �- �� ..... �` .. . ...... ...........•--•--....... '....----------------------......---......-----...------••--•-•--•••••......._ �,9 f Installer , ' at = `! �" .ae.e l f ✓e_• sue° _ _f_ t�" ------------------•-----•----------------------.........---•------------ has been installed in accordance with the provisions of TIi � of The State Sanitary Code asfd�scribed in the application for Disposal Works Construction Permit No.__°-`--"*•.2:6............... dated---/�:��:/..: ­..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector................................................................................... r. THE COMMONWEALTH OF MASSACHUSETTS BOARD,.,,,,• HEAL � - ... ..........OF.......•1�., _ ......!/. ����................... .� ' FEE..-.... No.............'� .... ........... t aT orkv Ton Milan , rntt# Permission is hereby granted....... ............. to Construct (X or Repair ( ) an Individual Sewage Disposal System at No................................................................................................................................................................... .f ......... Street—, as shown on the ap lication for Disposal Works Construction Per ndN?0.__...... ...... Dated.P_' __.. Ai................. Board of Health DATE-- ,f " r FORM 1255 HOBBS & WARREN, INC., PUBLISHERS ' - L L t e�i :ram — — ---• ,.ram �.l _ ,. STX. s L07 2 L.orr,5 4' �0 09 ! �� m r o iy1:. �0 R r Q M ToP of " Stk. is �c Q ELEV. 100,, c Lor 1 + 32 4. 99x 3 o e .ED 0, '� 9 CN No 01 9y x 5o 1"f - .( yc y t - t �KbI m 3 7•'z x� O I 7—�r f99 O F 9 OF M r. 5cu g � is h 4Q' Tov./►, .. .WA i� .p 29874 STE �A LEGEND rt F CERTIFIED PLOT pLaO . EXISTING SPOT ELEVATION Ox0 ��NV, _^��s CERT > ' EXISTING `CONTOUR ----_ ® � _ r a c � o ALBF 'FINI3FIED' SPOT ELEVATION ( �p-r 2 SGuDra�R AVE�u� ryA�vrv�S # FINISHED ._CON.TOUR 0 C3 SE. - No.10951 O IN- APPROVED , BOARD OF HEALTH S/0MA DATE AGENT. vv ..:SCALE 30, DATE NOV 29 '82 fLDREDGE ENGINEERING CQ IN CLIENT: y D� ) CERTIFY THAT THE PROPOSED EOdSTEFdE REOIST�IEO JO®.AI® is BUILDING SHOWN . OId THIS PLAN CIVIL ' LAND ;` CONFORMS TO THE ZONINt3 lA1f'dS DR.�►Y ENGINEER , SURVEY R ,. OF. BARNSTAB E WJASS 712 MAI N.S7REET CH. 8Y� E , l`I 1q. - x H YA N N I , M ASS, SHEET.L. OF 3 A E LAND SURVEYOR w a v � .coal � � � •� rL_ D' IPA e. d. JA to 61 mi"' �, I (il 0 D rJ V x IrZ tk :C y • �) y * " a • mow �" 0 • "�� � �1I lb . . . , . 3 y � co14 rn b C�' ego ` � N, � oayy F H dtA Iv p lip t r s.y,. 7777777 �A r t _. H I Gii GRUUND=WATER lVEI CUMF'UTAT I ON, Y,. �u..�.-�—�1 _ $ �ocallron �CuGDi �?�` �P. �• a�t.a.i� �C. Lot No I t r te; I.-1.I.4-,I-.,-.,.�,.I_.,�..,�..II-.-I..�.��,�.1 A.I.�_�'t�.I 1I,..I_,­,,�III,'.,"'�o.I...,I.,.;.�."­V. I. �.[I I_—I..1�.:�:,.,�I..�I,.- �'` Ow1►er.: f It=r r->f �\r ►cxSD Address H`IAt-i'l$ r�: — F: Address , E�1 - '--r1L.�� Contractor ,.(�v 1G'a (�...:.)IC 1�a� eo r� '; ' ^ k Jl C n pl 1 l UUIyC� ,). e 4% Noyes: ..C�, G .[�� �' ` F�c~. ... Pr—T: of'- APE at.sc �' �,; s . - t } L , a A 1 STEP 1 Measure depth t_o water fabler . .. 3 _ :4 Z to-.nearest, l/l.0 ft — - /�.r /8'i �� �; date— #Ip 1 '1 t j 3 P rr{ i_ STEP: 2 Us r ng 1Jater Level Range Z,one . « t and Index rWel 1 :Map locake f 7 ♦ r , e r },. >< ) b k 'Vz A y 1 s r to `and determine ,t` ; , TSVJ F ,�; f;. r 7`yG r r } (}.�{ _ r . ; i 1 A) Appropriate indexawe 1 .,, t .. z '., ,s 3- x A, r .? i s. B. Water level range zone �,3t� ., " " STEP . 3, Using monthly report:"CurrentFy,p ' { , =p Water Resources_ Cond'�t ions' ,�i � t' R � 1,1 a r4, 'k' rf; 1. determine_.curl , depth �tq w l 12 4i ` water�•'level for;. �ndex 'we),rl ," , q'/82 . . X �g , n F4 t �' � , ��- ' mQ Yr �k Y, z s n. , i # i STEP 'Us i ng, Table of :Water level { €i 'y f { i ; Adjustments fors}in. we'} 1 "'S � ' ti-, , STEP:, 2F1 , current d�pt� ta a J° water-" level for: index well ; ` (STEP and water }eve} °�°� , f+ zone.-(STEP 2B) ;determines i t -� r' ;- t .. { water-level ad j:ustmcnt ,z>° : " • • • - ' ' . yy ;. 5 P r( ,.�, STEP;. 5 Estivate depth to hiVghwateE�g { by subtracting,ahe.`water ,tji i, 1 l STEP 4f)° ` ,, eve adjustment ( �?,- from measured depth to;'watet'Y � : - lever, at .site '(STEP 1) �-. 'I " . . . ' / W14''MQ e '-7ps�µ, TAT DA(E. 1=PT 'Lr r`1 ci'L r ,11 tE� 9c Q '. -I t4c,L.E 'ELEVAIIc=t . - 9 s. . .5, WA= �2. � :2 r s 2 8.2 , 4 + o,ss' sE P P y )A r __ <..... z 4 t, �r f't1C►1 y 'P WA 1LR`_E L ryFC�, T..h 4.r•r ht'A 1t.:1 y..•1 0 C� f `i : a t '4 '' ('..o- r r>,v► i✓�-t' fir �-_ T!7LLL `:/ 1 i. s 4, �b 4 i -h- 4 I t _ fir, V {,3 yrt}hn sf tY '{ •�, a }' k t ,� - ;, i w , y ` H I LH. GROUND-WATER-LEVEL..' COMPUl.AT 1 OIJ' C�D~E� � G-a(�. �1 .i: © yG� i�- Lot _ j t o Location'. --C<-' Owi►cr �( It:'r( �( \r ►cinD Address Gpntrac.tor I A� C.) co Ad dress Notes' G G _ ry t STEP 1 Meas.ure 'depth to water table` ft W ' to. nearest 1/1.0 - •, ' date }; Water Level Ran a Zone STEP 2 Using g and Index Wel1 'Map locate site -an`d de'terini ne A) Appropriate i ndexJ we) l} B) Water-h 9 zone . eve 1 -:ran a i STEP 3 Using .monthIy report"Current i = 1 Water: Resources= Conditions" h ' % ' determine current depth to 1A water level .foc index well mo ,Y STEP 4 Using Table of 'Water level €° Adjustments for." index we:).l A ,:• A TSTEP 2A � . current "Ao water`level far i ndex ,we;t . (STEP_ 3) , and water zone (STEP 2B). .det.ermine water-leve) adjustment" 3* �' . . . . . . . . . . . . . . . . - STEP 5 Estivate depth Rto high water 00 by.,subt.ract.ing_ .the water,- x ' level adjustmept. (.STEP ) from .measured depth- to watel' -: level at s'i to . . _ . t�1pl�' ITT T DAIS �E PT. t e �'o '4 E F -r t�o�r E •i��n©F -r r WATER 'El ,Fc rhl.N Wf\i i l�M, F 1' ('t Ti-T.LE 1 G1'i0�11 o F T' ri' LOCATION �- -. / S E W A G E PERMIT N0 e . VILLAGE IpST RCS , pAM i ADDRESS l l IDUILDE0 OR qlN FR I D A T � l E P EIt III IT ISSU E_0 9' DATE COMPLIANCE ISSUED /0 2- i M J