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HomeMy WebLinkAbout0340 SCUDDER AVENUE - Health 340 Scudder Avenue Hyannis. A = 288 046 a 1 0 n v u 9 I u 0 d i qw� 9 A- v . V V o � i p gv 8, u OCS m n d u 0 r Flaherty Associates SKETCH ADDENDUM Borrower Kulbersh Michael R. &Janet Cu Property Address 340 Scudder Avenue City Hyannis County Bamstable State MA Lender/Client Cape Cod Five Cents Savings Bank Address Post Office Box 10, Orle: DCGt 184 St. 19 § t: Batts •8 _ Em Pth t0tehen 7 r 216 s1. , e Deck 128 d. 27 _ I Liv'usg ano:n,. Wtcheen - Living Roam 22 31 4 sLmi ats BR t `. First Flom 1203 st LEntry. 20 r � - -' Mrs B th 13 t L BR _:. . € _i BR _ i i �_ �-• Cls - St- f BR cls Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address �► D t7G+ vl(e-5 �L4 vci Cw ner Ow ner's Name information is / Al D�z6 0/required f or every q✓iVI If page. (Ayrrown State Zip Code Date of Inspec ion 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. Mpo out f orms When filling out f A. General Information on the computer, use only the tab 1. Inspector: key to move your �/ 0 /,�Pi/l� v cursor-do not rT use the return �� a 4 key. Name of Inspector �/flm II Company Name Company Address ^� G S City/Town LTO � O'���0 State Zip Code Telephone Nu er License Number tJ� C rs rw� r�r f B. Certification ki �;� I certify" hat I have personally inspected the sewage disposal system at this address and that the C s information:reported below is true, accurate and complete as of the time of the inspection, The inspection c.- was pe firmed based on my training and experience in the proper function and maintenance of on site sewage s: osal systems. I am a DEP approved system inspector pursuant to Section 15.340 of 9 dt. P Y pP Y P O �Title_.5 (a4:0)CM R 15.000). The system: 2 Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority /0/13l' Inspec or'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 T13 TlUe501ficiallrew0wVu �se wageDieposal System•Pege 1 of 17 r Commonwealth of Massachusetts ug Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments/ Property Address Ow ner information is O^ner's Name required for every A✓1vllf / //� doh 0/ page. 3* Town State Zip Code Date of Inspectio B. Certification tlfication (cont. Inspection Summary: Check A,B,C,D or E /a/ways complete all of Section D A) System Passes: ;�l have not found any information which indicates th at at any of the failure criteria de scribed in 310 CMR 15.303 or in 310 CMR 15.304 exist. An failure criteria no indic ated below. y t evaluated are 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 Healt h. *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-3/13 Title 60fflcial ins pecticnForm Subsurface Sowago oisposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Cw ner .Cw ner's Name information is )` required for every `�c v►n r f �// 0�6 0� — page. CityRbwn State Zip Code Date of Inspecti n B. Certification (cunt.) ❑ 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): ❑ 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 mannerwhich will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ns-3113 Tito 5 Official Inspection F orm Subsurface Sewage Disposal System•Page 3 o117 Commonwealth of Massachusetts Title 5 official Inspection Form s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments P' Yo Property Address .0V V,:� Ow ner ON ner's Name information is /'��Q 0���� l0 (� required for every page. Cfty/Town State Zip Code Date of I pecti 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 MJ1 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 ❑ quid depth in cesspool is less than 6" below invert or available volume is less than Ys day flow t5ns 3113 Me50fflciallnspec ton Form Subste ace Sewage Dispose)System-Page 4of17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address / Ow ner Cw ner's Name information is �j� Q�6 0 required for every 4`� �f page. City/Town State Zip Code Date f Inspe tion 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. ❑ 2 Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ Ly' 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. ❑ ld' 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 equal to or less than 5 m of ammonia nitrogen and nitrate nitrogen is pp , 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- 10,00 Og pd. ❑ The system b.11!j. 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 dunking 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. INns 3n3 TItle5Officiallrepeo6onFam Subsulace Sewage Dlspoed System-Page WV Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3 `f 0 Sc, JAW �4ixv_-- Property Address ve Ory ner OH ner's Name e information is a� f ��/ /7 Dal 6 f7� required for every l page, Cityfiown Sfate Zip Code Date of Thspecti n C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes- ❑ mping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ 2 s 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). Number of bedrooms (actual): l/�, DESIGN flow based on 310 CMR 15,203 (for example: 1 Lf 10 gpd x#of bedrooms): " T4 Lt5im13 T10 5 Olflciel Ins pectlm Form Subsurface Sewage Disposal System-Page 0 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address �trw L Cw ner Cw ner's Name information is Al 01 G 01 /0 required for every tiN N/l page. City/Town State Zip Code Date of Inspect' D. System Information Description: � /,..�ao G��l>� � �rc q-.l✓ 0 0 Number of current residents: Does residence have a garbage grinder? ❑ Yes No Is laundry on a separate sewage system? (Include laundry system inspection Yes No information in this report.) El Laundry system inspected? ❑ Yes N�o Seasonal use? ❑ Yes a No Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yet No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 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: t51ns 3113 - Tide 5 Official Ins pection Form Subsulare Sewage Disposal system-Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form $ Subsurface Sewage Disposal System Form Not for Voluntary Assessments 3,C Property Address � tlz:I, L- Cw ner Ow ner's Name information is G J /l dat6 D I required for every page. City/Town State Zip Code Date of Inspe tion D. System Information(cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes 5 No If yes, volume pumped: gallons Howwas quantity pumped determined? Reason for pumping: Type of Sy M 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 (descri be): Ons•3N 3 No 5 0f ficl al Ins pec don Form Su bstrf ace Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 2cfO Property Address ON ner Owner's Name information is �� 0�G0 l0 o1S required iorevery g'wI f page. City rrown 0111 State Zip Cade Date of I spec on D. System Information (cont.) Approximate age of all components, date installed if known) and s7e of-information: Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): / Dept h bel ow g ra de: 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.): Septic Tank(locate on site plan): Depth below grade: feet Material 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) / D Yes ❑ No Dimensions: Cy it Sludge depth: tSns-3/13 Title 5 official Ins pec tion F am Subsurface Sewage Disposal System•Page got 17 C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 3W Property Address Lo v� Cw ner Cw ner's Name - �/J information is7i f //%/¢ required for every page. Cityffown State Zip Code Date of InspectiotY D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 battle cf evl�� /�a How were dimensions determined? o ,-�. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _ G yti f✓ I �-s 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 t51ns•3113 Title 5Officlal InspecUm F orm Su"we Sewage Disposal System•Page 10 of V Commonwealth of Massachusetts a Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 3yo ..Sc WW1,, Property Address / f�/ �✓ Ow ner ON ner's Name information is 4 0NtS ap 6 3 required for every page. Cityffown State Zip Code Date of Ihspectio6 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 tens Vl3 T1050rflclal Inspection Form Subsurface Sewage Disposal System-Page lid 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Cw ner CW ner's Name ' 7 information is required for every G 5i page, frown i State Zip Code Date of I pection D. System Information (cont.) Distribution Box (if present must be opened)(locate on site plant'— Depth of liquid level above outlet invert �- 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,): 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: 15 ris-N13 Title 50fAcial Inspection Form Subsurface Seymoolsposal System-Page 12 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments �v SC Gf Property Address ON ner C v ner's Name information Is f required for every page. City/Town 610 State Zip Code Date of In ectio D. System Infor ion (cost.) Type: leaching pits / number: ❑ beaching 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.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan)rz)l Number and configuration Depth—top of liquid to inlet invert Depth of solids layer f Depth of scum layer Dimensions of cesspool USG Materials of construction -- Indication of groundwater inflow ❑ Ye No t51M•W3 TIUe5010cial tnspeOonForm Subudace Sewage Disposal SyMem•Page 13 d 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address ON ner Cw ner's Name information is / A required forevery page. Cityrrown State Zip Code Date of spectlofi 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, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 501Adal l specton Form Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r Property Address / ON ner Cw ner's Name / ? Information is required for every Gh`'��S page. City[Town State Zip Code Date Insp coon D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least tw ermanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where blic water supply enters the building, Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately Q/7 LlI� a --o2 3 J�• t5m-Y13 TIU50fficial Inspection Form Suburface SewageDispossl System-Page 15of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsu.rface Sewage Disposal System Form -Not for Voluntary Assessments ci 6 C/o k- Property Address L.. Ow ner Owner's NameSt,4 V4 information is / required for every / Av�✓llS /�� Qa6n `� O� _ page. CityNwn State Zip Code Date of►nsp ction E. Report Completeness Checklist Inspection Summary; A, B, C, D, or E checked Inspection Summary D(System Failure Criteria Applicable to All Systems)completed U Sy tem Information— Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file I ins'3113 Tito 5 Official Inspection F orm:Subsulace S"e Disposal System•Page 17of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form • Not for Voluntary Assessments Property address Cw ner Qv ner's Name L information is /�� required for every vl/ Q�-6 0/ l0 page. Citytiown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: / �^ vt d 1 .-� C OG Before filing this Inspection Report, please see Report Completeness Checklist on next page. t51ns•3113 TO5plAciel Inspection Form Subsuiace Sewage Disposal System-Page 16of 17 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 21pprication for Migaaf *pgtem Construction Permit Application for a Permit to Construct( )Repair O Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No.340 Seas"" a^e- Owner's Nine,Address d Tel.No. ��a�rit5,t'►'l.o. ��1 Ro bR.s"1"b V v Assessor's Map/Parcel ,�2� "3�O 6 �L D Installer's Name,Address and Tel No. Designer's Name,Address and Tel.No. -Pp.�o k Lo 1p O2.(a �. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or terations(Answer when applicable) ()fn I info ey'n tp_f, 9?w�cc. 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 issue b t is BoArd of Health. Signe ° r2= Date © Loq _ Application Approved by Date Application Disapproved for the following reas Permit No. 3 Date Issued t , No. Fee • THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Application for �Biopogaf *p.5tem Conotruction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 544 UJ e Owner's N Address and Tel.No. Assessor's Map/Parcel ? Installe 's Name,Address;and Tel.No. J Designer's Name,Address and Tel.No. �:15, n tcos�Lne� awl Son,�1�G IL Cs�l � �v 1�c ,1 � • Type of Building: Dwelling . No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank. Type of S.A.S. Description of Soil I. Nature o Repairs or Alterations(Answer when applicable) i 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 iss ed b this Boat of Health. " J ` 0 / Signe i _ _/rrU Date i I I� ( t ' Application Approved b / �� - O Date PP PP Y _ Application Disapproved for the following reas n r Permit No. OVV7 Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS f (Certificate of Compliance THIS IS TO CERTIFY, that the On-siie Sewage Disposal System Constructed( )Repaired ( 'l)Upgraded( ) Abandoned )by .:'Jl 0 [u0���bU Cj'td rbc,� 1xic at 3t10 �` �- ' �t/CtA'L115 0 0k constructed in accordance •M with the provisions of l'tle 5 and.the for Disposal System Construction Permit N ., dated Installer Designer Designer,-- N The issuance of this permit shall not be construed as a guarantee that the system illti a ction as designed: Date "Z Inspector -�� No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE., MASSACHUSETTS Digp,00af 6potem conotruction Permit Permission is hereby granted to Cons ruct( )Repai O Upgrade( „ Abandon( ) System located at �atlo jC�Jr . V �Vxt�1/ '__ f 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:Constr 77770 � )ompleted within three years of the date of thi berm t.. t Date: Approved b � _ Y PP TOWN OF BARNSTABLE LOCATION 05C Od011fl- �//� SEWAGE # i VILLAGE - y ��j >` ASSESSOR'S MAP dz LOT INSTALLER'S NAME 6z PHONE NO. \J. SEPTIC TANK CAPACITY J,6-bo ,g�C LEACHING FACILITY:(type) % f / (size) ON 9 6 L NO. OF BEDROOMS--2�L PRIVA�T/E WELL OR PUBLIC WATER BUILDER OR OWNER ".DATE PERMIT ISSUED: COMPLIANCE ISSUED: =SCE GRANTED: Yes No N - iINI r A P P R O V E D THE COMMONWEALTH OF MASSACHUSETTS Barnstable Conservation CommissiaOARD OF HEALTH � " O N [OF BARNSTABLE Signed D to Applirtt ilIn for lliipniial Work.5 Tomitrurtion rumit Application is hereby made for a Permit to Construct ( �) or Repair ( 1-<an Individual Sewage Disposal System at ..J.4 ���c � ...1444e......... r . -------------------------------------------•---••••-.... -•-.•--•Location-Address -- - --- - --- ---•--..----_-or Lot No. .._. c ...................•• ..... 7— ........ Address sm.......................... ................................... ........................................... Installer Address Type of Building `/' Size Lot............................Sq. feet U Dwelling�No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) `4 Other—Type T e of Building ............... No. of ersons--...--..................... Showers p., YP g ------------- P ( ) — Cafeteria ( ) Other fixtures ...--------••----••-••---------- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons 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 ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a 14 Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........---...--........ P� Test Pit No. 2................minutes per inch Depth of.Test Pit.-- ................ Depth to ground water..--................---. P4 -------------------------------------------••-•---------•-•- --- ----- --------•- ------ -------------------------- ------------------------------- 0 Description of Soil.............................. .................. ------------------------------------------------------------.._......----- W ---------•---------------•------------------------- x -----------------------------------•------------•------------------------------•------------.....•-•-----------------•----------•--------------•-. --- -- V Nature of Repairs or Alterations—Answer when applicable- -- -•----------------------------------------------•----------•---•--•-----------------•-••-••••-••-••--------•••--- ..................................................... Agreement: Agreement: The undersigned agrees to.install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant has been issu b e board o health - j Signed ----- . .. e .: /............. Dace Application Approved BY '..... ......... ...... .....M ---- -- ----- Application Disapproved for the following reasons- ................................................................---------------------------------------------------------------------- ------------------------------------------------ --------------------............................................----- ------ --------------------------------------------------------------------------- -----............................. Dace PermitNo. --......./. '-.. �.9�------_--------- Issued --------------------------------------------------- Dace F�s.....:�........... �. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ `*OWN OF BARNSTABLE 5 Appliration for Eligpniia1 Prkii Tonarurtuart Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( �an Individual Sewage Disposal System at: .�. `1)... .... ...- ref........f�1�' !vfl��s ...............••------•-•--....-•--• ----..............------.......................------. . .. Location:Address or Lot No. .. 1 •....• -• ---.......................................... 4 �(/ Address e a ..................................................... - Installer Address UType of Building,(� /f' Size Lot............................Sq. feet t-, Dwelling-LXNo. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g ---------------•--•--------- P ( )--- Cafeteria.(..._)_ Otherfixtures ------------------------------------•-----------------••-•------•------------•--••-••-•----••-------•--•----------. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter-----------.:--- Depth................ Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No- --------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Otherr Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by. --- ---------------------------------•------------------- Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit......--............ Depth to ground water.......--.....---....... f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water..--.................... 4 ------------------------------•--••-•----------___---- ---------....----------.---------------------------------•-.-•---•---------•--------- 0 Description of/'Soil-------••--•-------------•... ------------------ -.- - --- U -------------••----•--•...--•-•-------....------------....... •--- - W --------------------------------------------------------------------................................................ ----•-------------....--••-----•-•-------••----•-----•••••-•----................. V Nature of Repairs or Alterations—Answer when applicable--------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further a rees ncit-to place the system in operation until a Certificate of Compliant has been issue- b the,'board-o•health Signed ... ................................................... /. ......... .. ... �^.. `. Date q Application Approved BY .. . . -- 1 ..'.. -------------------- = -= -----��`--�� { Date Application Disapproved for the following reasons- ---- ------------ - ------------------------------------- ---------------------- -- ---------- ------------------------- ---------------- -- ------------------- -------- ----------------------- --- -- --- --------- -- ---------------- ------------------------------------ -------------------............. ......................----------------- Date PermitNo. .. ......... --?/.--.....--- Issued .................................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH `"` r TOWN OF BARNSTABLEGertifirate of Taraylianre THIS IS RTIFY, T t th ndividual Sewage Disposal System constructed ( ) or Repaired ( S Y b .- --------------------------------------------------------------------------------------------------------------------------- ------------ -- alter �� at -----......�JG�r�------------ ................... ----------- G ^GZ ' �............ _ _ has been installed in accordance with the provisions of IT 5 ofTh�e State Environmental Code as described in v` the application for Disposal Works Construction Permit No. -------- .dated ................................................ THE ISSUANCE OF/THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL,FUNCTION SATISFACTORY. l InspectorV ' �..........................DATE................... //I -------------------------------------------------------- -------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �� �� TOWN OF BARNSTABLE No.. ............. .. FEE........................ Permission is hereby ranted... ..'. '---'i.. ...................... ------`-------------------------------------------- .......... ..... .... to Construg ,(, ) or epair ( Ind iv' ual Sewage • ' posal System Gf at No................0...... -- -... ........•-- ...............................--- = J Street as shown on the application for Disposal Works Construction Permit No________��________� Dated.......................................... f DATE_ v Board of Health FORM 36508 HOBBS 6 WARREN.INC.,PUBLISHERS