HomeMy WebLinkAbout0123 WALTON AVENUE - Health 123 Walton Avenue-
Hyannis
A'= 310, 327-:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
lln-_4 rC t o Fo',plSe(f
Owner Owner's Name
information is fill ci'qn 0a 6 0
required for is
every page. City/Town C71 State Zip Code Date o(Inspeliction
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 filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key /
to move your r)G r-I/ / 9 v/S Pj//j
cursor-do not Name of Inspector
key the return �Ny1fl _ /�G//
Y
VQ
Company Name
Company Address
��S�I,Ph-, 1��� p� 6qJ
City/Town State Zip Code
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 R 15.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspect s Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time;of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
�I
I
t5,ns•09/08 Title 5 Offivai inspection Form:Subsurface Sewage Dillstem•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
`
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
p Y
Property Address
Fvo Se c c,
Owner Owners Name -
information is 9 00/
required for State Zip Code Date of Ins ection
every page. City/Town 74
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/ always complete all of Section D
A) ZePases:s
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:
1
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 ❑ NO (Explain below):
15ins•09r08 Tltie 5 officat Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
IT
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is � I
required For 1�tjo r�rll.S 60 8 �
every page. City/Town (:74 State Zip Code Date df In ection
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•09ioe Title.5 Official inspection Form:Subsurface sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Ins ction Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
O L'i S-cc,
Owner Owner's Name
information is L/�
required for � ����� ''/� OoZ 6 0
every page. Citylrown ( — State Zip Code Dat of 1 pection
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 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 critelria 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
❑ 03 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 5" below invert or available volume is less
than Yz day flow
15ms 09108 Title 5 Okidal Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for /�1-3q✓0 if � ��6 0/
every page. CitylTown State Zip Code Date oftspi6cfion
B. Certification (cont.)
Yes No
❑ Required pumpin,,g 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.
❑ L7 Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ 5j" 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 noiother 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 systlem 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•OYOB
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
UIV
Property Address
O 1�1,SP.�Gt
Owner Owner's Name
information is
required for Gi✓1✓1 f S Oc Z 6 0/
every page. City/Town State Zip Code Date of nsp ction
C. Checklist
Check if the following have been done. You must indicate "yes" or"no"as to each of the following:.
Yes N
❑ 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?
L�' ❑ Was the site inspected for signs of break out?
L�' ❑ Were all system components, excluding the SAS, located on site?
L9' ❑ 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:
LEI Existing information. For example, a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5))
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5rns•09106 TWe 5 Official Inspection Form:Subsurface Sewage Oi500"System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/C� � " 1��,
Property Address
�
Owner Owners �-o�Se C
/� _
information is oa 60/
required for �G✓i�t�
every page. City/Town C7` State Zip Code Date of In pection
D. System Information
Description:
/Soo a 6(//II vim
Number of current residents:
Does residence have a garbage grinder? ❑ Yes 2-'-No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No
Laundry system inspected? ❑ Yes .O'No
Seasonal use? ❑ Yes No
Water meter readings, if available (last 2'years usage (gpd)):
Detail:
Sump pump? ❑ Yes [3o_
Last date of occupancy: Cat✓iPw
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: -- — ------
i5ins-09108 - Titiei 5 Official Inspection Form:Subsurface sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V,
Property Address —
f -o✓�52C�
Owner Owner's Name Pj
information is Ci i y 0 /
required for
every page. City/Town State Zip Code Date o Insp cbon
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 S em:
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):
15ins•09(08 Title official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
MWEim
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form •Not for Voluntary Assessments
'3 "/UV
�
Property Address EO kve- f,- c."
Owner Owner's Name / )
information is f i 0,2 L 0
required for r^ N�l� _
every page. City/Town C71 State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date instal d i(if known) an source of information: 3
Were sewage odors detected when arriving at the site? ❑ Yes No
Building Sewer(locate on site plan):
Depth below grade: feet
7Material onstruction:
cast iron 40 PVC ❑ other!(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: feet
Material onstruction:
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: !�
Sludge depth:
15ins•09/oe Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
kipTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Fo L,►Se c G,
Owner
information is
required for
every page. Cityrrown State Zip Code Date Ins ection
D. System Information (cont.)
Septic Tank (cont.) 3,2?
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle U
Distance from bottom of scum to bottom of outlet tee or baffle I
//-501le �Q c4 vice�
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
silf2 r0 "e?D t),e-e clel
ch T ,
/Oftn N q c^ C s' /4 fry l v�c' ✓ 1.
b LeG 41r.
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
t&ns•09i08 Title 5 Official inspection Form:Subsur(ace Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
�S�C
Owner Owners Name �]/J
information is
required for
every page. City/Town State Zip Code Dat of I spection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Dace
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract.(required). Is copy attached? ❑ Yes ❑ No.
t5ins•09I08 Titie 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
02
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is9 /�(1 Op-6 0
required for Gi N I t i_�
every page. Citylrown State Zip Code Date Ins ection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
'� c C/-
A/0
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 .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal) System Form -Not for Voluntary Assessments
/C�_�
Property Address
Owner Owner's Name
information is /��,�,q/
required for 4-7 ci 0 k7,f ?y 60
every page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Type: J f/ �ig4io� �p
❑ 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.):
�'a GrnC� 01 e�✓) ate, Cam✓
�/l� C� Sj ✓tl' p T �a� ��� �� /!i1/L i i
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
15ins•09/08 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
UV
Property Address
Owner Owner's Name
information is AW D�60 �8
required for '��If
every page. Cityr town State Zip Code Date of fnspe6tion
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
J
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.):
r
t5,ns•OQIU Title 5 Official inspection form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address —
Owner Owner's Name
information is6 i�"if, Dot 6 0
required for � `�`�f f
every page. Cityfrown State Zip Code Date/of In pection
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:
❑ and-sketch in the area below
drawing attached separately
15'ns•09/08 Title 5 omcial Inspection Form: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
/0�
Property Address
f o�sec�
Owner Owner's Name
information is G v1/f 0,; 6 0
required for
every page. CityfTown State Zip Code Date of In coon
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells / d LC
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health - explain:
/06�1 s -�- T-e5/ 140 les
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
C� s- 4
�r l c 4100 �-✓�
� �i✓�epv p� f-r
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15�ns•09108 Tate 5 Official inspection Form:Subsurface Sewage Disposal System-Page 16 0 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
/�J (,✓;/-/-0
Property Address Foo
Owner Owners Name
information is �1 Q,-� 6 D
required for --�
every page. City/Town State Zip Code Date f 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
m Information — Estimated depth to high groundwater
y
VSketch of Sewage Disposal System either drawn on page 15 or attached in separate file
15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of'17
/1
TOWN OF BARNSTABLE y
LOCATION .12,3 QQ 1AQ n Ct O e. SEWAGE # 03
VILLAGE -1 Q Z LA ASSESSOR'S MAP & LOT 3/0 -32 7
INSTALLER'S NAME&PHONE NO. & Q p_ 62 CC12- r-0 t?,C V 1 S e- —
SEPTIC TANK CAPACITY
LEACHING FACI=: (type) -'0 t PQ k o C S (size)
NO.OF BEDROOMS
BUILDER OR O � IG)
PERMTTDATE: / /7 0 COMPLIANCE DATE: 1 191
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
3CA
a
10
I
TOWN OF BA.RNSTABLE
LOCATION 123 0011,00 cc cJ 4-- SEWAGE #
VELLAG ASSESSOR'S MAP & LOT 3/0 -327
INSTALLER'S NAME&PHONE NO. .0 Q_ 1. 2 id A-1ntf,e21A y =
SEPTIC TANK CAPACITY g ra!/o tl.S
LEACHING FACILITY: (type) Jq—jE(19i l t Pa JoC-1; (size) 36`L A
NO.OF BEDROOMS
BUILDER OR 0 R &O ICA i
PER.MrrDATE: / /� L'S� COMPLIANCE DATE: / / D.S'
Separation Distance Between the: '
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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,No. g5 �Q ' Fee `60 —
THE COMMONWEALTH OF MASSACHUSETTS Entered in compute
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Ziopooa.Y *pgtem Con!5tructiun Permit
Application for a Permit to Construct( )Repair( )Upgrade(Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. /2 3 i1 f ;,, a og Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 3 `0 /3 �- i4 c, /z 3 AInz
1 d i t
Installer's Name,Address,�}d Tel No. Designer's Name,Address and Tel.No.
'74!0�/G.4 2caJrt e le lSC) CUT—SoilC-K
,r V 3lr�,Oc -7 � ,TY� ..; ale . iGs F11�4c;�5 C s�.
Type of Building:
Dwelling No.of Bedrooms Lot Size 0 �6 sq.ft. Garbage Grinder( )
Other Type of Building 5 (1 No.of Persons _3 Showers( ) Cafeteria( )
Other Fixtures
Design Flower gallons per day. Calculated daily flow 3 4 A gallons.
Plan Date J11 Z In - Number of sheets Revision Date
Title /2�� i/,)Al h5iA A -<
Size of Septic Tank /SDQ Type of S.A.S. _�-4�jY%410
Description of Soil A 14,A►M) S ig-nd to t j& P. tab 2 S/q.-t.4
Nature of Repairs or Alterations(Answer when applicable) 9So t` Ced StD¢*-- 77"n4L — J—X o x
S. 4 - S .
Date last inspected: L�� C-1 I `Z c cry
Agreement:
The undersigned agrees to ensure,the construction and maintenance of the afore described on-site sewage disposal system
in accordance with,the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this oard of Health. .
Sign Date " 19 'Z-
Application Approved by Date q
105
Application Disapproved for the following reasons
Permit No. dooc:� --p 3 q Date Issued �S
. 5
/00
(00
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for 30igpogal *pgtem Congtruction Permit
Application for a Permit to Construct( . )Repair( )Upgrade V<Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. /2 3 tvn/t-o-1 Owner's Name,Address and Tel.No.
'(ZiG�r4.icQ GoIQ ✓LiCI� 75'D-/SI�S�
Assessor's Map/Parcel 3 p 3 oZ +iyc�•�M+`� ►a 3 A /Tc+.-, A vE
/ �M it I�'•7 R9• ��G,o�
Installer's Name,Address, d Tel.No. Designer's Name,Address and Tel.No.
60IF6/ l< ��nc�r�.��, Sb�-SI!(�-�j23/
p o. 3tK -7 b3 Ce�,T-1 ,.�
� tit8 yaz.B oz1�3L Mph Ir �s /"1✓a 013��
Type of Building:
Dwelling No.of Bedrooms Lot Size 11r 3 6S sq.ft. Garbage Grinder( )
Other Type of Building50,n 4 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow .33 n _ gallons per day. Calculated daily flow 3 3 gallons."
Plan Date Number of sheets Revision Date
Title 2_74 1 W A
Size of Septic Tank /SOCK Type of S.A.S. 5'1_0e _
Description of Soil A - Loa,,►., Sp+nd /o t jiZ A Login i S11-d /0 Yfr
Nature of Repairs or Alterations(Answer when applicable) 13 c 7;�n4 -X V X
Date last inspected: O �-b a`t' ```• �'"
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with.the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by thi oard of Health.
Sign d C Date t'' /Cf `Z
Application Approved by Date 1 q 0 5
Application Disapproved for the following reasons
Permit No. c --c Date Issued 105
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Se•:,age Disposal System Constructed ( )Repaired ( . )Upgrzded(h/ )
Abandoned(- )by___...�_.A0R-J-P 0j kfT1•sf5 LL <-
at_f 1? Lr%A I SbYN 4x-e )4, v4,I has been constructed in accordance
with the provisions of Title\5 and the for Disposal System Construction Permit No. dated
Installer 4eAA)A.- Eh _J"JL Designer 14m eS e4..Ij YL n.,T 73 4c�.
The issuance of this peymit shall not be construed as a guarantee that the systeLfi'will unction as designed. l
t Date 1 5 Inspector---k�.�. --...�
No. :)MS—03 c( Fee 160
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
&5paaf *pgtem Congtruction permit
Permission is hereby granted to Construct( )Repair( . )Upgrade(V/)Abandon( )
System located at 113 Wd I T?i� ►4,1�2 l� ���`l_ /t�t� 02 t-o I
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 condittiio-nnss..
Provided:Construction must be completed within three years of the da e2 of this perm
Date:_ I3''.�0_ Approved' -fi�
TOWN OF BARNSTABLE
LOCATION
�.e t�.�^ C:ci SEWAGE # �fl��03Y
VILLAGE
'� ASSESSOR'S MAP &LOT LId -°3'27
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type)���'--. r1 ra (size)
`31LL1(I`,0..3
NO.OF BEDROOMS_
BUILDER OR 0 R
PERMTTDATE:
I IIS___\COMPLIANCE DATE:,
Separation Distance Between the: Feet .
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility
Private Water Supply Well and Leaching Facility (If any wells exist Feet
on site.or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by
ea
I66 � �
ToWI n of Barnstable
vO�1HE, 'L Regulatory Services
P 1
Nam. O
• .,..,.,, � Thomas F.Geiler,Director
RAMs�itrr$rnsLt, •
. Public Health Division
ib39. �0
£D �` Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Fotn
Date: Q
Designer: C.S PR\J Ll , r Installer: ��e [�, CIA c�l�C C�ie�►1q>�
Address: l (P ECA I GPOVG:_ Address:
On I �_' _ C�pF i,�C1C .v `h�1 cap was issued a permit to install a
(date) (installer)
septic system at 3 NA N A based on a design drawn by
(address)
dated 1jjq jb5—
`/ (designer)
V I certify that-the septic stem referenced above was.p Y installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with Stater& Local Regulations. Plan'revision or
certified as-built by designer to follow.
SN of Mgssq°ti .
,LAMES A. G�
o PAVLIK in(Installers Signature) CIVIL C
No.36488
GIST
/DNA L E�
t(Designerer's Signature) (Affix Designer's Stamp Here)
RETURN TO BARNSTABLE PUBLIC H&ALTH.DDISION. CERTIFICATE
OF COMPLIANCE WILT, NOT BE ISSUED UNTIL ]go-T-W THIS FORM'.AND AS-
BUILT CARD ARE RECEDED BY THE BARNSI'ABLE
THANK P LIC HEALTH DIVISION
Q:Health/Septic/Designer Certification Form
BENCH MARK: TOP OF FND. (SAS) SHALL BE
' ELE'_ ED,
:25' LONGMANHOLE COVERS TO EXTEND TO O r WICWITHIN 6' OF FINISH GRADE DEEP
1 Q
BAFFLE REQ'D 3 �
�' DEL=. 47•$
•7 elD D.B.
2x - - -- _ -_ -- 2' PEASTONE TOPPING
'' 47, °B ?.�� - - __ ENDS. GENERAL NOTES:
14 K •� I c• �' �°Z3 _- -_ _ -__ - 3140 DOUBLE WASHED — ELEVATIONS SHOWN BASED ON U.S.G.S. DATUM.
EL=. I � STONE ALL AROUND SYSTEM PIPE SHALL. BE EITHER C.I. OR
SCHEDULE 40 P.V.C.
cam" C RubtEEO — THE BOARD OF HEALTH SHALL BE NOTIFIED
20 1 S�v'�€ 1.5 3125' .5 PRIOR TO BACKFILLING OF SEPTIC SYSTEM.
20' MIN. — SEPTIC SYSTEM STRUCTURAL.COMPONENTS
USE`FIVE (5) INFILTRATORS SHALL BE CAPABLE OF WITHSI�WDING A
WITH 4-0' of STONE 0 SIDLE H-10 LOADING. UNLESS SPECIFIED OTHERWISE
so1L TEST LOG PROPOSED SEPTIC SYSTEM
1.5' OF STONE O ENDS — SEPTIC SYSTEM UNDER DRIVEWAYS SHALL
PERC RATE-< 2 MIN/INCH NO SCALE NO STONE AT BOTTOM , COMPLY WITH A H-20 LOADING.
—THE DESIGN AND COMPONENTS OF THE SEPTIC
DEPTH EI EV•
= c�p, a p SYSTEM SHALL BE IN COMPLIANCE WITH THE
O� A �� sANo � M� STATE OF MASSACHUSETfS SANITARY CODE
3 2,, _ TITLE V. AND SHALL BE IN COMPLIANCE WITH
9 sA�o 1
47,53 �1��.�/f/.+►� �" 3 of, 7 O THE LOCAL BOARD OF HEALTH RULES AND
j3o�ro1� - -� REGULATIONS.
MEOW — THE CONTRACTOR SHALL BE RESPONSIBLE FOR
Cl sArru N 0 Jt) A,Tt-A 0 13 S ekveo LOCATION OF ALL UNDERGROUND UTILITIES AND
SHALL NOTIFY DIG - SAFE PRIOR TO
'J (0 — NO GARBAGE GRINDER
3y ; 31%A P A V L-I l v� ' + LoT 32�
�A� o3sER v�� � {�,, � So• 30 _ _ � DESIGN CRITERIA:
00
S� = � DESIGN FLOW
LEGEND: 3 BEDROOMS AT 110 G.P.B. / DAY 330 G.P.D.
EXISTING CONTOUR — —— —— t� �7 0.20 ' REQUIRED SEPTIC TANK:
Ep
WATER SERVICE W—W— !�, S r S
TEST HOLE \ 5 SEPTIC TANK PROVIDED
F DESIGN PERC RATE <2 MIN/INCH
GAS SERVICE G—G \BENCH MARK tdBM � cY _ / / SIZE OF REQ'D. (SAS) AREA = 330/0.74 = 446 S.F.
CESspooc <�� G o
o SIDEWALLj2)%83)(34.25)+(2)(0-83p.(l1)= 75.12 S.F
)PoTLLcV5j0.(0 rVBOTTOM 11 4.25) = 376.75 S.
NOTE: 'i w,q y ' SIZE OF LEACHING FACILITY PROVIDED:
PRIOR TO INSTALLNG THE NEW (SAS) THE »£' , :tr�i` ``� ::.. 376.75 S.F. + 75.12 S.F. = 451.87 S.F.
CONTRACTOR SHALL PUMPOUT /ILL LEJ>GNPiTS l'V
AND BACK FILL WITH CLEAN MEDIUM SAND -, ` > �L' { �� = 334.4 GP
IF L EAcA f%15 ARE ENCOUNTERED IN THE v p ...,(SAS) AREA THEY SHALL BE REMOVED
` ,0 �p ��o.!0 ` EFFECTIVE DEPTH: 10"
Ey > EFFECTIVE ,LENGTH: 34.25,
EFFECTIVE WIDTH: 11.0
c4:
P�SHOF,ygs Sd ; O OU98ACK ENGINEERING
1faS EAST GROVE STREET
JAME A.K G \ /7_ ' MIDDLEBORO. MA 02346
PAVLI (508) 946-9231
CIVIL PROJECT: SEPTIC SYSTEM REPAIR
No.364Sg I FOR
12.3 W A t,Tv rJ A Q E ,
� sio �E G � �L,�-� �4. it �: AS !SHowN l�Y�e.1NL°'°s 1 i o S MAP 310/ LOT 3 V7 �ft.
OWNER: (Z<«i aRD C,aco2i��c
k ANr.I � MA O (mob