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HomeMy WebLinkAbout0016 THACH LANE - Health 16 THACH LANE, HYANNIS i A r' i• 0 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System /Form-Not for Voluntary Assessments °< 16 Thach Lane -ova n� Property Address HSBC-931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 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 the I �� computer, r,use 1. Inspector: only the tab key to move your Joseph R. Smith cursor-do not Name of Inspector use the return key. E. Stevens Construction, Inc. Company Name P.O. Box 71 Company Address Marstons Mills MA 02648 Cityrrown State Zip Code 508-776-9054 SI 4994 Telephone Number License Number B. Certification 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, w,,3 ❑ Needs Furt er Evaluation by the Local Approving Authority ;^t o r~� -n 1-26-2010 _.o%%�R'specwrs Signature Date - W (11) The system inspector shall submit a copy of this inspection report to the Approving Authority(Poard of Health or DEP)within 30 days,of completing this inspection. If the system is a sharedEsystembr 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. D t5ins 09/08 .Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °t 16 Thach Lane Property Address HSBC -931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cost.) 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: The title V system at this residence passes; meaning none of the failure criteria existed during the time in which the title V inspection was conducted. During the inspection a significant amount of solids carryover was found in the d-box; however, the leaching field area did not exhibit any signs of being hydraulically overloaded. 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-09/08 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 16 Thach Lane Property Address HSBC-931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every page. City/Town 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 ❑ 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 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-09/08 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 "< 16 Thach Lane Property Address HSBC -931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cost.) 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 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 1/2 day flow t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts ll Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thach Lane Property Address HSBC -931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every 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 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•09/08 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 16 Thach Lane Property Address HSBC -931 Corporate Center Drive Owner Owner's Name information is Pomona CA 91768 1-23-2010 required for 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-09/08 Title 5 Official fnspedion Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "t 16 Thach Lane Property Address HSBC -931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every page. CityrTown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 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 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 9-1-2009 Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments JAY 16 Thach Lane Property Address HSBC -931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every page. CitylTown State Zip Code Date of Inspection 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 ® 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-09= 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 16 Thach Lane Property Address HSBC- 931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 4-24-2000 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2.0 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 150' + feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints and veniting are all in good shape, no evidence of leakage found during inspection. Septic Tank(locate on site plan): Depth below grade: 1.5' feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) 1,500 gallon septic tank If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'6" L x 5'8"W x 68" D Sludge depth: 6" t5ins•09/08 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 16 Thach Lane Property Address HSBC-931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every page. Cityrrown 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 30" Scum thickness 3" 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 12" How were dimensions determined? Tape Measure, Sludge Judge, and Probe Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping Recommed every 2-4 years as it is needed, Both inlet and Outlet Tee's are in good working condition, and the liquid levels as related to both inlet and outlet Tee's are at a normal operating height. No evidence of leakage discovered during inspection. 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 I Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thach Lane Property Address HSBC -931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 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 Bolding 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-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 16 Thach Lane Property Address HSBC -931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every page. City/Town 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 level and distributing flow equally to infiltrator leaching field. No evidence of leakage into or out of d-box found during inspection. The d-box showed signs of significant solids carryover from the septic tank. 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: t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "f 16 Thach Lane Property Address HSBC -931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (coot.) Type: ❑ leaching pits number: ® leaching chambers number: 4 Infiltrators ❑ 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.): The leaching field is comprised of 4 High Capacity Infiltrators within a 11'x 25' leashing field area. The soil properties that were found during the inspection were found to be primarily dry, and no signs of hydraulic failure were found. No ponding within the leaching field area was encountered, and the vegetation over the leaching field area and surrounding landscapes were grassed lawn. 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 i Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thach Lane Property Address HSBC-931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 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, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5ins•09/08, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thach Lane Property Address HSBC -931 Corporate Center Drive Owner Owner's Name information is Pomona CA 91768 1-23-2010 required for every page. CitylTown State Zip Code Date of Inspection D. System Information (cunt.) 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 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 16 Thach Lane Property Address HSBC-931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every page. Cityrrown 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: 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: 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: Accessed USGS Site and obtained mean sea level datum You must describe how you established the high ground water elevation: Accessed USGS Site and obtained mean sea level datum, and also accessed Town of Barnstable GIS site and cross referenced the elevation in relation to the estimated groundwater depth of the property in which the title V inspection was conducted on. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ° 16 Thach Lane Property Address HSBC-931 Corporate Center Drive Owner Owner's Name information is required for Pomona CA 91768 1-23-2010 every page. C4frown 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 t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 F ''. TOWN OF BARNSTABLE Y'?� ' LOCATION SEWAGE # . VILLAGE_; ASSESSOR'S MAP& LOT -= ti INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY s �/ LEACHING FACILITY: (type) (size) NO.OF BEDROOMS- IQMDER OR OWNER 44 PERMITDATE:. -- —Z�ZMPLIANCE DATE Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or wi&jn 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of le chine facilityl Feet Furnished b ��-'� ICK CA 2 s , 2 � a . 0 t/-32 ..21 1 TOWN OF BARNSTABLE LOCAjrIQN /fie Thdr� SEWAGE # .6g � ASSESSOR'S MAP& LOTi1� .tG. LNSTALLER'S NAME&PHONE NO. ,C SEPTIC TANK CAPACITY o d LEACHING FACILITY: (type) 4/;2r74FS (size) _ NO.OF BEDROOMS 9ftPER OR OWNER_ ,6A,44 PERMITDATE: LIANCE DATE:_ "'� � Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility _Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or wit,`hiin 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist .within 300 feet of le ching facility) Feet Furnished by a ! f e `' N a C ea J �0No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zi pplication for Digpo5ar *ps�tem Construction Permit Application for a Permit to Construct( )Repair O Upgrade( )Abandon( ) X-Complete System ❑Individual Components Location Address or Lot No. �, �' �� �y�f� Owner's Name,Address and Tell.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms S Lot Size sq.ft. Garbage Grinder( ) % Other Type of Building No.of Persons Showers( Cafeteria( ) '.`. Other Fixtures t,. 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. C_k l)4.0 t '7FVX i Description of Soil 0P-e-(2_ co (V_&-e Nature of Repairs r Alteration�s..(Answer when Answerwhen applicable) i vs�L— YTw f V _fb �'- y�✓"'-�." � OG�. (/!jam✓ 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 ssued by this o 7"' Signed Date 7 Application Approved by Date Application Disapproved for the following reaso _ Permit No. ` Date Issued No. 1✓� Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Z(pp'lication for �Diopogaf *pgtem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) complete System '�❑Individual Components Location Address or Lot No. '� GtC C,�.Q Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No, Designer's Name,Address and Tel.No. WA 0-�. � �t Type of Building: Dwelling No.of Bedrooms ?J 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. cc, pe cL-- Description of Soil ov-f� co n CE 6 Nature of Repair r AlterationkLAnswer w en ap licable) �'�' gs�p St �i- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-sire sewage disposal system in accordance with the provisions o Title 5 of the Environmental Code and not to place the system in operation until a Certifr- cate of Compliance has een.i ued by this Board`o eal t r Signed 1 p 8 Date Application Approved by i Date - Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (certificate of (Compliance THIS IS TO CERTIYA,that the On-site Sewage isposal System Constructed( ) Repaired( )Upgraded V ) Abandoned( )bye at k G kk L t vo_- _. ha been constructed in ceord ce with the provisions of Title 5 and the for Disposal System Construction Permit No. dated W Installer Designer. f The issuance�o this e _ s all not-be construed as a guarantee that the s to will function as°cles. rred. Date �T 'p' � '� � Inspector - ' F: No. V©�r %�� -----------------------Fee F . 1r THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Miopogal *p!5tem Construction Permit Permission is hereby granted to Construct( )Repair( Upgrade bandon( ) ,.• System located at " and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to 'e:- comply with Title 5 and the following local provisions or special conditions. Provided:Construction u be cmeted win three years of the date of 1 Date: <O Approved by Air' h°4 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed =_ Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I �✓ �� '� hereby certify that the application for disposal works construction permit signed by me dated `'4—���"D , concerning the property located at �;� ��� ` �_ y meets all of the following criteria: This failed system is connected to a residential dwelling only. There are no commercial or.business uses associated with the dwelling. • The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. There are no wetlands within 100 feet of the proposed septic system There are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed There are no variances requested or needed. die bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table asing the Frimptor method when applicable] • If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) �0 B) G.W.Elevation —)&9''�J+the MAX. High G.W.Adjustment.3 DIFFERENCE BETWEE A and Br U'� SIGNED :7 DATE: [Please Sketch proposed plan of system on back]. NOTICE Based upon the above information,a repair permit will be issued for bedrooms maximum. No additional bedrooms are authorized in the future without engineered septic system plans. q:health folder:cert �� � ;- � C� r f TOWN OF BARNSTABLE LOCATION SEWAGE # �N .S'� VII.LAGE_,j �,�/! ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �r A t/ T iLEACHING FACILITY: (type) (size) NO.OF BEDROOMS IQ=DER OR OWNER_=_L�� PERMTTDATE: �PLIANCE DATE: �' �� Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet j Private Water Supply Well and Leaching Facility (If any wells exist on site or within_200 feet of leaching facility). Feet. Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feehof le Ching facility) eet Furnished by . e3�� `G L. ��✓C.�CiLT-�__ v -°7z� , �y r Z b