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HomeMy WebLinkAbout0115 WALTON AVENUE - Health 115 WALTON AVE. , ANNIS A = 310 326 i it II o , fik Certified mail#7008 3230 0002 5178 0288 Town of Barnstable THE r0" Regulatory Services sn5srasr a Thomas F. Geiler,Director 16.59.���� Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 / Fax: 508-790=6364 q May 13, 2011 .. Richard Sullivan 115 Walton Avenue mac, Hyannis, MA 02601 NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE CODE The property owned by you located at 115 Walton Avenue Hyannis, MA was inspected' on May 12, 2011 by Town of Barnstable Health Inspector Timothy B. O'Connell, R.S., because of a complaint. r The following violation of the Town of Barnstable Board Code was observed: 4 353-1 Responsibilities of Owners: A large amount of debris and rubbish was observed strewn about back yard. You are directed to -remove all the debris and rubbish from your property and dispose of it properly within fourteen days (14) days of your receipt of this notice. You may request a hearing before the Board of Health if written petition requesting same is received within ten(10) days after the date,the order is served. Failure to comply with an order will result in a fine of$100.00. Each day's failure to comply with an order shall constitute a separate violation. PER ORDER OY THE BO OF HEALTH omas.A. McKean, R.S., CHO Director of Public Health ` Town_of Barnstable A . Q:\Order 1etters\Refuse\115 walton hyannisdoe I Citizen Web Request Page 1 of 2 86 �i'MEA.4 : e 13AMNSTAGLE, R LSS d Citizen Request Management - Internal Use Request ID: 34614 Created: 5/10/2011 9:59:37 AN O'Connell, Timothy Status: Assigned To Staff Assigned To: Health Office Anonymous: Yes Category: Section 353-1 Garbage and Rubbish E.C. Date: 5/24/2011 Created By: Wadlington, Ellen Citations: Health Office Time Worked: 0 Response Time: 0 Requestor Details: Email: Li Request Location: 115 WALTON AVENUE Hyannis, Ma 02601 Parcel Number: Map: 310 Block: 326 Lot: 000 Request: Storing household trash, garbage and debris on side and in back of house, plied high. Being covered by a blue tarp. Seems to attract rodents, etc. Request Work History: Internal Note History: System entry on 5/10/2011 9:59:37 AM: Assigned to O'Connell,Timothy http://issgl2/internalwrs/WRequestPrint.aspx?ID=34614 5/10/2011 ` COMMONWEALTH OF EXECITTIti-E OFFICE OF ENVIRONMENTAL AFFAIRS ' DEPARTMENT OF ENVIRONMENTAL PROTECTION y' TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM ]PART A CERTIFICATION /, Property Address: J/ W�l�� b/-Q I `~ QIt l red Owner's Name: i� $ (ivan ``'' r-'� v Ca Owner's Address: It a x G{ _ — -�d AA�S Date of Inspection: Name of Inspector:(pl�se print} f-r(w,l �.,ri�tj('/ Ica Company Name: .. N wan Mailing Address:No v .g' c ��t•ais ��fi Sd1 Telephone CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper 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: A Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 1u 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 tIow of 14,404 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address t%ow the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/1 512 0 0 0 page I Page 2 of 11 OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESS SUBSURFACE SEWAGE IHSPOSAL'SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: //� �e 6 tz A-e Owner. S A t%&k Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: V 1 have-not found any information which indicates that any of the failure criteria described in 310 CMR I5.303 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"sec ti eed to be replaced or repaired.The system,upon completion of the replacement or repair,as approved the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the follo . g statements.If`riot determined"please explain. The septic tank is metal and over 20 years old*or th eptic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic 'approved by the Board of Health. *A metal septic tank will pass inspection if it is y sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old' available. ND explain: Observation of sewage bac or break curt or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a bro settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipes)azexeplaced obstructim as removed distribiutiad box is lawled or replaced ND explain: The syst required pumping more than 4 times a year due to broken or obstructed pipes).The system will. pass inspectio if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page Zol 1 I OFFICIAL INSPECT ION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: it � � e Owner:—j65AU i VatK Date of Inspection:C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in er 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 ith 310 CMR 15.303(l)(b)that the system is not functioning in a manner which will protect public alth,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 vegeta d wetland or a salt marsh 2. System will fail unless the Board of Health(an ublic Water Supplier,if any)determines that the System is functioning in a manner that protects t public health,safety and environment: The system has a septic tank and soil ab rption system(SAS)and the SAS is within I00 feet of a surface water supply or tributary to a surfa water supply. _ The system has a septic tank and AS and the SAS is within a Zone I of a public water supply. The system has a septic tank d SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". ethod used to determine distance *"This system passes if well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile or is compounds indicates that the well is free from pollution from that facility and the presence of ammo a nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are Qered.A copy of the analysis must be attached to this form. 3. Other: 3 f Page 4 of I I OFFICIAL INSPECTION FOR I—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DIRPOSAI SYSTEM INSPECTION FORM PART..A CERTIFICATION(continued) Property Address: //.S k14AbH u tie n Owner. sAft Vt i a Date of Inspection: 8( t Z.(p Z_ D. System Failure Criteria applicable to all systems: You most indicate"yes"or-`no"to each of the following for All inspections: Yes No x Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool x' 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'/day flow _y, 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. _0( Any portion of a cesspool or privy is within a Zone I of a public well. d Any portion of a cesspool or privy is within 50 feet of a private water supply well. Qf 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.mjThls system passes if the well water analysis, performed at a DEP certified laboratory;for cvfifww bacteria and volatile organic_compa ds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal:to or less than S ppm,provided that no other failure criteria ,,�� are triggered.A copy of the analysis must be attached to this forma N1 (Yes,'No)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 esign flow of 10,000 gpd to 15,000 You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to criteria above) Yes no — the system is within 400 feet of a s drinking water supply — the system is within 200 feet o tributary to a surface drinking water supply — — the system is located in a trogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public supply well If you have answered"yes" o any question in Section E the system is considered a significant threat,or answered "yes"in Section D abov a large system has failed.The owner or operator of any large system considered a. significant threat and Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system wner should contact the appropriate regional office of the Department. 4 Page 5 of I I OMCIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B / CHECKLIST Property Address- / a,l Owner: 5 aN 1 dqvN Date of Inspection:�=A,( &5— Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No �C _ Pumping information was provided by the owner,occupant,or Board of Health d 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? _ 1! 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 o 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 m intenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no = Existing information.For example,a 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 CUR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM IN-FORMATION Property Address: /( Owner: Date of Inspection: b&' FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 13 Number of bedrooms(actual): r� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): A30 Number of current residents: c2 Does residence have a garbage grinder(yes or no): /W Is laundry on a separate sewage system(yes of no):f4O [if yes separate inspection required] Laundry system inspected(yes or no). Seasonal use:(yes or no):40 _ Water meter readings,if available(Iast 2 years usage(gpd)): Sump pump(yes or no): 00 Last date of occupancy: Gu/4r COMMERCIA LtINDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): and Basis of design flow(seats/persons/ c.): Grease trap present(yes or no): Industrial waste holding tank ent(yes or no):— Non-sanitary waste disch d to the Title 5 system(yes or no):, Water meter readings,i vailable: Last date of occ /use: OTHER(desc e): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM _Q(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) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: � 04 Were sewage odors detected when arriving at the site(yes or no):#U6 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -04¢� Owner: . r�J Date of Inspection: BUILDING SEWER(locate on site plan) . Depth below grade: 07 S Materials of construction:_cast iron Of 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:A' (locate on site plan) Depth below grade: (,O u Material of construciiio—w— r concrete metal fiberglass_polyethylene _other(explain) _ If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions:_ /S zoo 5a Sludge depth:: Z Distance from top of sludge to bottom of outlet tee or baffle: 30 ~ Scum thickness: .7 w_____ Distance from top of scum to top of outlet tee or baffle: Q 41 Distance from bottom,of scum to bottom f outlet tee r baffle: /07 d How were dimensions determined: Syr� Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leak(a4e,etc.) 1 'etc a CAG GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal rberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to to outlet tee or baffle: Distance from bottom of stir to bottom of outlet tee or baffle: Date of last pumping: Comments(on pump' recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet ert,evidence of leakage,etc.): 7 Page 8 of H OFFICIAL INSPECTION EOM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Ilot r'� Owner- Date of Inspection: TIGHT or HOLDING TANK: (tank must be pumpe at time of inspection)(Iocate on site plan) Depth below grade: Material of construction: concrete me fiberglass____polyethylene other(explaia): Dimensions: Capacity: gallo Design Flow: g on day Alarm present(yes or no): Alarm level: Alarm ' working order(yes or no): Date of last pumping: Comments(condition alarm and float switches,etc.): DISTRIBUTION BOIL: < (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: evew Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage mito or out of box,etc.): ,/ P (a c /� 11 w A MILL s cS[4 d5T jr it o d q PUMP CHAMBER: (locate on site Ian) Pumps in working order(yes or no Alarms in working order(yes or o): Comments(note condition o ump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFAC]SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: / 116.t af{ Owner: So 16,v4 A �N Date of inspection: SOIL ABSORPTION SYSTEM(SAS): JC (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number:_ _..0t_leaching chambers,number.4 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.): %� ,(��r' rs sour% dis (104 54eftj CESSPOOLS: (cesspool must be pumped as part of pection)(locate on site plan) Number and configuration:. Depth—tap of liquid tXinvert Depth of solids laver: Depth of scum layer: Dimensions of cesspo Materials of construct Indication of groundwo):Comments(note condf hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 page 10 of 11 OFFICIAL,INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: It k wQ Owner, 4 t.4ttU . •�. Date of Inspection: g(3 8S SK ETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. C(� V� a3 -e_0,r ` Page l l of l l OFFICIAL INSPECTION FORM—NOTFOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: lr Owner: JOL Date of Inspection: $ ;? O S— SITE EXAM Slope NO. Surface water PO Check cellar Vf i Shallow wells 00 Estimated depth to ground water 6 4 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: Observed site(abutting property/observation hole within 1.50 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 establis ed the high ground wate elevation: s 115 IYL�S a c,� e �e o O J Y 11 A 1 TOWN OF BARNSTABLEo�° LOCATION rl Y �e, 17`,,)01 A ee SEWAGE # � VliLAGE w Ic ASSESSOR'S MAP & LOTc�/ INSTALLER'S NAME&PHONE NO. I� SEPTIC TANK CAPACITY `Sd O LEACHING FACILITY: ZP,�Te Ye. ' (size) 7 ZZ. NO.OF BEDROOMS BUILDER OR OWNE PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 3,00 feet of leaching facility) Feet Furnished by � , G.) �� � , 1 �' �., E ci' l7 � �,.� � �'��f� � { :.•� ° t1i - '-�, ,',., � F �, J ,. . 1..► •,� `�t •.� ;.� ��, .s;,' - - TOWN OF BARNSTABLE ' LOCATION //�-S— 641216 A Ze SEWAGE # ' Q' VII LAGE �i.! ASSESSOR'S MAP S&LOT! INSTALLERS NAME&PHONE NO.1r SEPTIC TANK CAPACITY /Sd O j LEACHING FACILITY: SPA Te (size) 7 f; NO.G1 BEDROOMS 4 . BUILDER OR OWNER © I PERMTTDATE: COMPLIANCE DATE: , . Separation Distance Between.the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist _ Feet y on site or within 200 feet of leaching facility) ,Edge of Wetland and Leaching Facility(If any wetlands exist ' -. Feet !In 300 feet of leaching facility) . Furnished by = _.. L� I n � I �'41 P i zW .i VZ1 r No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Mis spool bpe;tem Construction Permit Application for a Permit to Construct( )Repair( )Upgrade( /Abandon( ) 1KComplete System ❑Individual Components Location Address or Lot No. Os- L1_/A��C�tl! Owner's Name,Address and Tel.No. Assessor's Map/Parcel 3`Q Installer's Name,Address,and Tel.No,, Designer's Name,Address and Tel.No. VW o-(_"r7: 5(5pT\C- 4'- lUj.s S,, 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 `��C7 - gallons per day. Calculated daily flow 3 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank t n Type of S.A.S. - Lin Cs.dk.c°J� Description of Soil OL-e a I C0 YZ,)--_ S w� Nature of Repairs or Alterations(Answer when applicable) _.J �l� \�w S�✓1 ��- � � �� '�aX n;LrA d yL �-\n t`u rnG�c-�'S'�l,'�y�ica C.�Td'G.c'�3 JL C,�,.li I L-1 t 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 beeiffissued by this Signed Date 5 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued Fee " THE COMMONWEALTH OF MASSACHUSETTS Entered in=computer: T.. Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 2pplication for Miopooal 6potem Construction Permit Application for a Permit to Constnuct( )Repair( )Upgrade( /andon( ) tKEomplete System ❑Individual Components 1 Location Address or Lot No. p k—Noki NrCmac. Owner's Name,Address and Tel.No. Assessor's Map/Parcel 3`Q ( UG�� Installer's Name,Address,and Tel.Not Designer's Name,Address and Tel.No. VIWh p''_(_4W S c Q� Type dBuilding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow —33 3 C gallons per day. Calculated daily flow k� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1-Sn� Type of S.A.S. Description of Soil V�'�-' & VZ J C-. h�� t Nature of Repairs or Alterations(Answer when applicable) 1 J Cy d t G. -1�040� ✓L 0'4 `n Cum JI c �- v�t� (Tr(c-�i 0 dl C, vt-� I t �TG�. �l�✓c�..,� Q _# Ova Sr roc 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 provis' Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this o Signed Date s Y` Application Approved by Date i Application Disapproved for the following reasons Permit No. Date Issued ---------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(� Abandoned( )by //(��'"C14 p6 S C C_ at \ \S lti 1 A� o N Ay-e— t S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. — dated r Installer Designer -� 0 ,..-, The issuance of this pe m't-gh�all not a construed as a guarantee that the systy�in ill function as s'gned� �f , �f p �� Date �2 Inspector � (� x`j 1, — --- ...+�.//� ./ ---------------------- No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 'Wi5po0al *pgtetn ongtruction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located attai 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:Constructt ust be�omyp�leted within three years of the date of this Date: Approved by r 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) hereby certify that the application for disposal works construction permit signed by me dated —� --0� , concerning the property located at ` s V� �`��JV� ���,r meets all of the following criteria: L� This failed system is connected to a residential dwelling only. There are no commercial or business es 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. (.f There are no wetlands within 100 feet of the proposed septic system .,o 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 , •/here are no variances requested or needed. _.? The 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 using 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) �J ' B) G.W.Elevation 10+the MAX.High G.W.Adjustment.3 _ DIFFERENCE BETWEEN A and B SIGNED : DATE: [Please Sketch p posed plan of s em n 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 I� ~ `� L ` ., �. ■ �' G 6 TOWN OF BARNSTABLE LOCATION rd L'xm A ed - SEWAGE # VILLAGE— s w ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /Sd O LEACHING FACILITY: Te IC (size) �f � NO.OF BEDROOMS nn BUILDER OR OWNE PERMITDATE: I DATE: kgo_ Separation Distance Between.the: Maximum Adjusted Groundwater Table and Bottom of Leaching.Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i?`,l y s" - - G T 1 -------------