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HomeMy WebLinkAbout0211 SIXTH AVENUE (HYANNIS) - Health A = 245 082 i I a° a �I o 'i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '( 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is W anni P ( Ma 02601 7/18/12 required for every �---�Crt I J page. Cityfrown 2-q5' A / n State Zip Code 'Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When ng out forms A. General Information on l the computer, ( ``\������•(H OF rMgSS''''i use only the tab 1. Inspector: I ,� �����' •'9�y�% 4 key to move your :G cursor-do not DAMES :mc James D Sears =O• use the return Name of Inspector y a key. Ca eWide Enterprises,L.L.C.Company Name *i'•.°F �� 153 Commercial $t � 1 1 N S Company Address Mashpee Ma 02649 Cityfrown State Zip Code 508-477-8877 S1623 Telephone Number License Number Z .. B. Certification 50 I certify that 1 have personally inspected the sewage disposal system at this address and that theme information reported below is true, accurate and complete as of the time of the inspection j—pe inspection was performed based on my training and experience in the proper function and maintenance of OrPsite , sewage disposal systems. I am a DEP approved system inspector pursuant to Section,15.3401of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority s 7/18/12 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to.the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does,not address how the system will perform in the future under the same or different conditions of use. t5ins•11110 "Tide aal Inspection Form Sutuurtaa3$swage oisposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .'y 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. Cityfrown 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): t t5ins-11/10 * Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 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 0 ND(Explain below): El 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 manner which will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water ❑ ` 'Cesspool or privy is within 50 feet of a bordering vegetated wetland or!a salt marsh t5ins•11/10 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 5a°�l 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. Cityf 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 ,y or clogged SAS or cesspool El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins•11110 Title 5 Official Inspection forth:Subsurface Sewage Disposal System•Page 4 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is Hyannis Port Ma 02601 7/18/12 required for every W H y ` page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged6� 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. El ,�'® ,. Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑' ' ® Any portion of a cesspool or privy is less than 100 feet but greater than 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 g ' , 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 4 and chain of custody must be attached to this form.] El ED The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. tl 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 k ,`❑ p the system is within 400 feet of a surface drinking water supply Y ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply t 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. , y x, a .. t5ins^11/10 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System:Page 5 of 17 q Commonwealth of Massachusetts REW Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. CityrFown 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? ® El available 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): 4 a DESIGN flow.based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-11/10. 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 y 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The systen is a 1000 gal precast tank D Box and 5 infiltators Number of current residents: 7 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No ' Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d na . 9 , ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: presentDate Commercial/Industrial Flow Conditions: ` Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ` ❑ Yes ❑ No -Non-sanitary waste discharged.to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins q 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 . � a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: m Source of information:, 2001 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 El 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 a � . Tight tank.Attach a copy of the DEP approval. El Other(describe): t5ins•11110` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. Cityfrown State Zip Code Date of Inspection D.-System Information (cont.) Approximate age of all components, date installed (if known)and source of information: Tank-na new leaching 2001 permit#2001-682 Were sewage odors detected when arriving at the site? ❑ Yes ®' No Building Sewer(locate on site plan): Depth below grade:. 1 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.): pipeing is 4" pvc sch 40 - 4 Septic Tank(locate on site plan): 4" 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 31' Sludge depth: l5ins•11/10 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 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 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 27" Scum thickness Distance from top of scum to top of outlet tee or baffle 8" - Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? tape asbuilt sludge judge plan Comments(on pumping recommendations, inlet and outlet tee or baffle condition,`structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank at working level tank and covers at 4",in and out let tees no sign of leakage or over loading Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene_ ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date - t5ins•11/10 $ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 211 Sixth Ave Property Address b Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) 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.): 3 *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No !Sins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. City/rown 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.): D Box is 16"x16" 16"below grade ,one line out box is clean and solid no sign of over loading or solid carry over 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.): Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: t5in •11110 Title 5 Official tnspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts Tale 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'y( 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. Cityrrown State Zip Code Date of Inspection D: System Information (cont.) Type: ❑ leaching pits number ® 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.): Leaching is five Infiltatorsw/4'stone 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 r Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ims•11110 ` 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 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 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, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ' f t8ins•11/10 ritle 6 Offitsal k soon Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . y 211 Sixth Ave Property Address Theresa David Owner owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 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. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately de �3 e o ❑ tsina•t 1/10 . Title 5 Offiaal inspection Porte:subsurface sewage Disposal system•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope . ❑ Surface water ® Check cellar ❑ Shallow wells " 126"+ 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 2001 If checked, date of design plan reviewed: Date 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: T.H. on plan no water at 126+" y Before filing this Inspection Report,please see Report Completeness Checklist on next page. Mns•11110 , Tide 5 Official Inspection Form:Subsurface Sewage Dispossi System•Page 16 of 17 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 211 Sixth Ave Property Address Theresa David Owner Owner's Name information is required for every W Hyannis Port Ma 02601 7/18/12 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D(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 tsins•11110 Tina 5 Official Inspection Fomr.Subsurface Sewage Disposal system•Page 17 of 17 Six ff A % 1-4 VI I\ A 1a1 Lj.r�MEDrurlE le�NoUL41111.Penn. 1.. •remP N4Wa N ;k sreae . 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'a � I, I J �- Y. ;lPii{f i tis�l',v. i s9 w• ' , o' e a ti z 1 • TOWN. ,,OF BARNSTABLE LOCATION SEWAGE # 7777-, VILLAGE ASSESSOR'S MAP & LOT IN ✓l � LP INSTALLER'S NAME&PHONE Nd� - SEPTIC TANK CAPACITY 5- LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER.OR OWNER PERMIr DATE: kJ2'5-/0- --COMPL1ANCE DATE: 10 1:31,10 Separation Distance Between the: 'Mixinium,Adjusted.Ground fUac tiing Facilit water Table and Bottom'of - y �� Private Water Supply Well and'Leaching Fac i*' (Uflny:wells exis onsiteorwin within:200 feet of leachirig facility),': Edge"ofWetlad and 1eachingFacil any wetlands exist%.,. Feet -300 feet of leachi facility wi n g Furnished by A Is Da, A 3 -c K- 0 13 �L N- 0 nn TOWN OF BARNSTABLE LOCATION 0 1 SEWAVGEE # VILLAGE t��F6� I (L�l ASSESSOR'S MAPP & LOT INSTALLER'S NAME&PHONE NO'—_ ( cJ �'✓� ��S�l��� SEPTIC TANK CAPACITY( t�liS►c1�-�.. 5,,11,Ac1JT LEACHING FACILTI'Y: (type) 1r_►�N]1&-t(L( OIL (size) q NO. OF BEDROOMS__ BUILDER OR OWNER PERMrrDATE: 0 2157/01 COMPLIANCE-DATE: 10131101 Separation Distance Betweenfthe: Maximum-Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist ` on site or within 200 feet of leaching facility) Feet Edge of Wetland'and Leaching Facilit3�49 any wetlands exist within 300 feet of leachi g facility Feet Furnished by Wl e-- Y NN a a a,' s y . o r f 4 .« . • /•r- `� (✓�+ ` J " •�ni....w'• • 0 No. Fee�V THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZLpprication for �Mi000ar 6potem Congtruction Permit Application for a Permit to Construct( )Repair(-11U,,"pgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No.271 1 ;X+-h V"GV L-- Owne�ame,Address and Tel..No. �L�1 U Assessor's Map/Parcel ` 1� Inst s a ne,,e�ddress d Te.`NTo. Designer's Name,Address and Tel.No. . Qox. ` �� tI.()Q Leah a,nn isF A O�l�,O I CG j , )'1 ° 0249 Type of B •ding: Dwelling No.-of Bedrooms -3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3 sp gallons per day. Calculated daily flow gallons. Plan Date S O I Number of sheets Revision ate Title Size of Septic Tank 5 1 Type of S.A.S. Description of Soil 0&/V 42 I Nature of epairs or Alterations(Answer when applicable) JAJIV Jv4IS4 70 /6 S 54&-K an s,cis vi eL Date last inspected: DESIGNING ENGINEER MUST SUPERV;SE Agreement: INSTALLATION AND CERTI THIS SY FY IN WRITING The undersigned agrees io ensure the construction and maintenance of the; RTE i$�°ol'fsystem in accordance with the provisio s of Title 5 of the Environmental Code and not to place the system-m eration until a Certifi- cate of Compliance has been is ed by is Boar o H alth. Signed Date' O Application Approved by Date S / Application Disapproved for the following reasons Permit No. a— Date Issued C� S NI.. -ArFee, Entereddn-computer: VfTHE'COMMONWEALTH-OF,MASSACHUSETTS -Yes Pudik HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS. Zip ilication for 3Di5p0 Oat *Vf0g,m-'Congruction Permit p V ?.'(, - I c ")4-, 11 , Application for a Permit to Construct(' ) r( ,Components Repair grade ykb,2�`do-'11`,( )" EiComplete System El Individual A Location Address or Lot No. 1)(+-h Ave— Owner s Name,Address and Tel No. 4j -r--f- 4­IP( Assessor's Map/Parce J j: 04!5 �i - Installe's Name,Address and le 0. Designer's Name,Address and Tel.No. _ff t3 X 6d&vjv 10 9ecl, (NA_702ta 3 1), Type 'of Buiidinj: 1 — Dwelling , 'No Lot Size sq.ft.of Bedrooms Garbage Grinder Type Showers( .Cafeteria( oOther of Building No.of Persons *;L,es Other Fixtur. Design Flow ----,g#j10ns per day. Calculated daily flow gallons. 'Plan Date Set)-kl.M)Ge r <01-Number of sheets Revision l5ate? _file 5. Size of Septic Tank 16Y) q,Cd -�.,A� -h snc,,-.-4—TYpeofS.A.S. YC4 < 74: Description of Soil t-7,o k-", C) LA'S Nature'ofRepaits or Alterations(Answer when applicable) jA_1A1 ,V,/S Im Date last inspected: Agreement: s \k The undersigned agrees to ensure the construction and maintenance e of the afore described on-site sewage disposal system in accordance with the provisions''f Title 5 of the Environmental Code ad not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar o H'a-1th. Signed �Sfm_LU, D Application Approved by Date,� S/6�s c Application Disapproved for the following reasons Permit No CY, Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-sioSewage Disposd Syste Con tru .d, Rep )Upgraded Abandoned (bPy at 21 WTV90 r-M5 11/1 / 1i has been constructed ip,accordance with the provisions,of Title 5 an fispos al System Construction Permit No.Q --)ft I-U)J� dated' �C) L)) thq or D installer UAA. Designer The issuance of t permit shall not be construed as a guarantee that the sy in will 42X function as designed.. f Inspector- q,�j —————————————— — ——————— NO. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Diopoal *pglem Courtruction Permit Permission is hereby grmd tQ Ccpstr`44 Repair �pgrade`� bandon System located at21 W4r at UL- UA uC and as described in the above Application for Disposal System Constructiomyermit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provide i Construction must be completed within three years of the date of�this'p'r' mit. Date. rD<�-I Approved by f` •a: ' GRASS hr�. tj PC rz TEST Co 1.1 D�c r�n o►J L " � _ , , _ _ - � �� `�' � \ NE T� A Sandy Loam � �2� L S 2001 (3`l � j32tA.rJ `� — _ � GRA1Gvtt,t.E C3 E.AcN RD /0 yR /i _ 12"L()-TCEC.1 A . vJ tT(JESSE-r) �Y, b ► Lows ' G LEr n1�1 FI /� (Z 1;1 N c,'r D� � Bw Sand Loam � '4: yJ [JRtV CALCULAltQ5 : y 1!� I 3 2 (2\(a,s,33 0i, ) _ 57 Sandy oam fill C > ) _ (f�1 � �xt T � 5'� 14122� o S irJG � i ) �$� I 20 . ., , 3,�� S - TANK Pu 02 Q `� o T 7a0 AB Sandy Loam J ��1G �`5 �� CQ �,.:— \\' u'�1 =- 15 .50 (11) (� �{- Z5) = 3'7b . 75LA Vv ° SYS i��l . O -_ TOTAt,. BB Loamy Sand , TF4oNAS MAt2c.ELLO Io 3 t3"T tjoo0 L.PJ Pt Cl — Sand �e y � , SEPTIC SYSTEM REPAIR PLAN ¢ FOR I 211 SIXTH AVE II �of i MAP 245 -PARCEL 82 USE xtS T tnlG l ;-�� i o a o G Arc, TAt,)►K, ,� i H o M NEW SAS) nna ��o \_ s� OWNER: STEPHEN T. DAVID fee t'� Nth No. 24421 d 211 SIXTH AVE 10 .gee i�'ST Tao X o CISj HYANNISPORT p Lo c c • f . o - ono 10 � .. I USE FI\ F—(S) INPtLTAT02S 1. 5 (� ' � �2uS�f�D SANE Ff f f r SCALE: in feet (, CRvSNE� f S,oNE 16 @ S� at5 /AND , S ` o t C R O 5 S WA o 20 40 ao C2u-%fcj) S-roNc � ENOS � I inch = 20 feet No T To SGALE TA-OLE { Ahydrocad\skdgn Sep. 18.2001 07:53:24 .