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HomeMy WebLinkAbout0040 BAY ROAD - Health �+r Road Cotuit ` r -- F d' Commonwealth of assachusetts Title 5 Official Inspection Form - = Not for Voluntar y Assessments Subsurface Sewage disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information a Important: When filling out 1. Property Information: forms on the computer,use 40 BAY RD. COTUIT 02635 only the tab key Property Address to move your BARBARA POOLE cursor-do not use the return Owner's Name key. PO BOX 731 Owner's Address VQ COTUIT MA 02635 Cdyfrown State Zip Code Date of Ins 4/10/07 Inspection: Date .2. Inspector. PAUL C. MARTIN Name of Inspector D.J. BURNIE&SONS bluewater holding core Company Name , 105 FERNDOC ST UN T A Company Address HYANNIS !i MAY`02601 Cdy/Town State S^Zip Code - 508-775-0139 t-'s Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address,a d that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on training and experience in the proper function and maintenance of on site sewage disposal systems. am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). the system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Eva uation by the Local Approving Authority 4/10/07 Inspector's Signature Date The system inspector shall submit a Pe copy of this Inspection report to the Approving Authority(Board of Health or DEP)withiA130 days of completing this inspection. If the system is a shared system or has a design flow of 10J000 gpd or greater, the inspector and the system owner shall submit the report to the approphati 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 desc bes conditions at the time of i;spection and under the conditions of use at that time.This ins on does not address how a system will perform in the future under the same or different conditions of use. POOLE T-5.doc 0312006 Tale 5 Official Inspection Form:Subsurface Sewage Disposal system Page 1 of 16 Commonwealth of N assachusetts Title 5 Off Jcial Inspection Form Not for Voluntary A essments. r Subsurface Sewage isposal System Form b B. Cerfificafion ( nt.) 40 BAY RD. COTUIT IAA 02635 Property Address COTUIT MA 02635 City(rown State Zip Code BARBARA POOLE 4/10/07 Owner's Name Date of Inspection Inspection Summary: 0 heck A,B,C,D or E/ o all complete always f Section D A) System Passes: ❑ I have not found a y information which indicates that any of the failure criteria described in 310 CMR 15.30 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System ConditiodallY Passes: ® One or more systen components as described in the"Conditional Pass"section need to be replaced or repaire .The system, upon completion of the replacement or repair, as approved by the Board of Heal ,will pass. Answer yes, no or not c etermined (Y, N, ND)in the ❑for the following statements. If"not determined,"please explain. El The septic tank is rf etal 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 ta k 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. ND Explain: POOLE T-5.doc•03/2006 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System- aj� � Page 2 of 16 Commonwealth of assachusetts Title 5 Official Inspection p tion Form . Not for Voluntary A essments Subsurface Sewage Disposal System Form B. Certification (cbnt.) 40 BAY RD. COTUIT 1 02635 Property Address COTUIT MA 02635 City/Town State Zip Code BARBARA POOLE 4/10/07 Owner's Name Date of Inspection B) System Conditioly Passes(cont.):al ❑ 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 ith approval of Board of Health): ❑ broken pipe(s)are replaced . ❑ obstructi or, is removed distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass in pection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ obstruction is removed ND Explain: 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 failind to protect public health, safety.or the environment. 1. System will pad$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 emJf,ironment: ❑ Cesspool of privy is within 50 feet of a surface water ❑ Cesspool of privy is within 50 feet of a bordering vegetated wetland or a salt marsh POOLE T-5.doc•03/2006 . Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 3 of 16 Commonwealth of . assachusetts Title 5 Official Inspection Fo rm Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (c Ibnt.) 40 BAY RD. COTUIT MA 02635 Property Address COTUIT MA 02635 City/Town State Zip Code BARBARA POOLE 4/10/07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health(cont.): 2. System will fai 1 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 aseptic 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 privat I water supply well". Method used to determine distance: '*This system y m passes If the well water analyses, 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. POOLE T-5.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 0 Page 4 of 16 `� Commonwealth of assachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Cert ficatlon (c( nt.) 40 BAY RD. COTUIT A 02635 Property Address COTUIT MA 02635 Cityrrown State ZipCode BARBARA POOLE 4/10/07 Owner's Name Date of Inspection 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 ❑ ® gogged SAS or cesspool ischarge or ponding of effluent to the surface of the ground or surface waters ue to an overloaded or clogged SAS or cesspool ❑ ® tatic liquid level in the distribution box above outlet invert.due to an overloaded clogged SAS or cesspool ❑ ® L quid depth in cesspool is less than 6" below invert or available volume is less t II ian Y2 day flow ❑ ® F equired 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. El ® Ait butary to a surface water supply. y 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 s stem passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence o ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, p vided that no other failure criteria are triggered.A copy of the analysis o>�chain of custody must be attached to this form.] ® The system is a cesspool serving a facility with a design flow of 2000gpd- 1 ,000gpd. Yes No ❑ I 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 n ssary to correct the failure. POOLE T-5.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 Commonwealth of assachusetts e , Title 5 Official Inspection Form Not for Voluntary Assessments m (Subsurface Sewage Disposal System Form B. Certicat�on (cent.) 40 BAY RD. COTUIT IWA 02635 Property Address COTUIT I MA 02635 city/Town State Zip Code BARBARA POOLE 4/10/07 Owner's Name Date of Inspection 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, yo must indicate either"yes"or"no"to each of the following, in addition to the questions in Section DI YES NO ❑ ❑ t ie 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 11 of a public water supply well If you have answered"lyes"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. POOLE T-5.doc-0312006 Title 5 Official Inspection Form:Subsurface.Sewage Disposal System- Page 6 of 16 6 Commonwealth of assachusetts Title 5 Official Inspection Form Not for Voluntary As,sessments r` Subsurface Sewage Disposal System Form C. Checklist 40 BAY RD. COTUIT IVIA 02635 Property Address COTUIT MA 02635 Cityrrown State Zip Code BARBARA POOLE 4/10/07 Owner's Name Date of Inspection Check if the following have been done.You must indicate"yes"or"no"as to each of the following: YES NO ® ❑ PLimping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ H,-is the system received normal flows in the previous two week period? p ❑ ® Have large volumes of water been introduced to the system recently or as part of thiis inspection? ® ❑ Were as.built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ W s the facility or dwelling inspected for signs of sewage back up? ® ❑ W s the site inspected for signs of break out? FR74Caol ® ❑ W re all system components, e�the SAS, located on site? ® ❑ W�re the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, diriensions, depth of liquid, depth of sludge and depth of scum? ® ❑ W4is 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 ben determined based on: ® ❑ Ex sting 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)] POOLE T-5.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of assachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form { D. System Information 40 BAY RD.COTUIT MA 02635 Property Address COTUIT MA 02635 Cityrrown State Zip Code BARBARA POOLE 4/10/07 Owner's Name I� Date of Inspection Residential Flow Conditions: Number of bedrooms design): 3 Number of bedrooms(actual): 2 DESIGN how based oil 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 678 Number of current resiJents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separae 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)): 2005 63GPD, 2006 52 GPD Sump pump? ❑ Yes ® No Last date of occupancy- CURRENT Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow( ats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holdin tank present? ElYes ❑ No Non-sanitary waste di harged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last.date of occupancyjuse: Date Other(describe): POOLE T-5.doc•03/2006 Title Official Inspection Form:Subsurface Sewage Disposal System- Page 8 of 16 Commonwealth of assachusetts Title 5 Official Inspection Form Not for Voluntary Assessments y Subsurface Sewage Disposal System Form D. System Inform tion (cont.) 40 BAY RD. COTUIT A 02635 Property Address COTUIT MA 02635 Cityrrown ! state Zip Code BARBARA POOLE !! 4/10/07 Owner's Name Date of Inspection General Information Pumping Records: Source of information: BOH 11/6/00 GALS. N/A, 10/10/03 GALS. N/A Was system pumped is 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 ❑ Overfl w cesspool ❑ Privy ❑ Sharec system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innova ive/Alternative technology.Attach a copy of the current operation and maintel ance contract(to be obtained from system owner) ❑ Tight tenk. Attach a copy of the DEP approval. ❑ Other�jdescribe): Approximate age of all components, date installed if 9 I po ( known)and source of information: 26 YEARS PER PLAN DATED 5/20/1981 Were sewage odors de ected when arriving at the site? ❑ Yes ® No POOLE T-5.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of assachusetts Title 5. Off1cial Inspection Form 0 Not for Voluntary A sessments Subsurface Sewage 6isposal System Form D. System Information (cunt.) 40 BAY RD. COTUIT MA 02635 Property Address COTUIT MA 02635 City/Town I State Zip Code BARBARA POOLE 4/10/07 Owner's Name ` Date of Inspection Building Sewer(locals on site plan): Depth below grade: 36" feet Material of constructio ❑cast iron 40 PVC ❑other(explain): ex : Distance from private .kater supply well or suction line: feet Comments(on conditi f n of joints,venting, evidence of leakage, etc.): Septic Tank(locate onsite plan): Depth below grade: 29"feet Material of constructio : ®concrete metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal list a gee` year Is age confirmed by a dertificate of Compliance?(attach a copy of certificate) El Yes ❑ No ---------- ------------------------------------------------------------------------------------------ Dimensions: 1500 Sludge depth: 8" Distance from top of sl dge to bottom of outlet tee or baffle Scum thickness 1" Distance from top of sc im to top of outlet tee or baffle Distance from bottom o scum to bottom of outlet tee or baffle How were dimensions etermined? SLUDGE JUDGE POOLE T-5.doc•03/2006 Title 5�Official Inspection Form:Subsurface Sewage Disposal System- Page 10 of 16 Commonwealth of N assachusetts J Title 5 Official Inspection Form Not for Voluntar y Assessments Subsurface Sewage Disposal System Form i D. System Information (cunt.) 40 BAY RD. COTUIT MA 02635 Property Address COTUIT MA 02635 City[Town state Zip Code BARBARA POOLE 4/10/07 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): SEPTIC TANK IS MIST SING THE OUTLET TEE. Grease Trap(locate of site plan Depth below grade: feet Material of constructio ❑concrete metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of um to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumpin 3 recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related io outlet invert,evidence of leakage,etc.): Tight or Holding Tan tank must be pumped at time of inspection) locate on site I ( P P pact )( e plan): Depth below grade: Material of construction ❑ concrete metal ❑fiberglass ❑ polyethylene ❑other(explain): POOLE T-5.doc•OW2006 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of assachu setts Title 5 OMcial Inspection Fo rm orm Not for Voluntary A sessments Subsurface Sewage isposal .System Form D. System Information (cont.) 40 BAY RD. COTUIT 10A 02635 Property Address , COTUIT MA 02636 Cityrrown State Zip Code BARBARA POOLE 4/10/07 Owners Name Date of Inspection Tight or Holding Tan (cunt.) Dimensions: Capacity: gallons Design Flow: gallons per day I 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 cop y attached?. El Yes ❑ No Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level a ve 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.): BOX IS IN POOR CONDITION AND DETERIORATED. NEEDS REPLACING Pump Chamber(lcat on site plan): Pumps in working orde�: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No POOLE T-5.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of assachusetts Title 5 Official Inspection Form II � p Not for Voluntary Assessfnents Subsurface Sewage Disposal System Form D. System Inform tion (cunt.) 40 BAY RD. COTUIT A 02635 Property Address COTUIT MA 02635 City/Town State Zip Code BARBARA POOLE 4/10/07 Owner s Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption Sys m(SAS)(locate on site plan, excavation not required): If SAS not located, exdlain why: Type: ® leachinC pits number: 1 6X6 ❑ leachinc chambers number: ❑ leachin galleries number: ❑ leachin trenches number, length: ❑ leachin fields; number, dimensions: ❑ overflo cesspool number: ❑ innovati a/alternative system Type/name of technology: Comments(note cond' ion of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)-. LIQUID LVL IN LEACH NG VERIFIED BY SEWER CAMERA 11"OF WATER IN LEACHING POOLE T-5.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 13 of 16 Commonwealth of assachusetts Title 5 Official Inspection Form . p Not for Voluntary Assessments y Subsurface Sewage Disposa'I System Form ------------------------------------------ D. System Information (cont.) 40 BAY RD. COTUIT MA 02635 Property Address COTUIT ( MA 02635 Cityrrown State Zip Code BARBARA POOLE 4110/07 Owners Name Date of Inspection Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid td inlet invert Depth of solids layer Depth of scum layer Dimensions of cess I Materials of construction Indication of groundwa er inflow ❑ Yes ❑ No Comments(note condi ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): _ I Privy(locate on site pl n): Materials of constructs n: Dimensions %i Depth of solids Comments(note condil ion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): POOLE T-5.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage disposal System Form D. System Inform�Iation (cont.) 40 BAY RD. COTUIT WA 02635 Property Address COTUIT MA 02635 City/Town State Zip Code BARBARA POOLE 4/10/07 Owner's Name Date of Inspection Sketch Of Sewage Dis osal 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 w,ter supply enters the building. �s s'c 14-F: . J=ioAf o �' C •f Are of t 1' Silva t-5.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 16 Commonwealth of Massachusetts Title 5 Official :Inspection Form essments Not for VoluntaryAds ~ Subsurface Sewage Disposal System Form V• D. System Information (cunt.) 40 BAY RD. COTUIT A 02635 Property Address COTUIT MA 02635 City/Town State Zip Code BARBARA POOLE I! 4/10/07 Owners Name Date of Inspection Site Exam: Slope f4 e e/� Surface water 41'0 Check cellar gl y Shallow wells y0 r Estimated depth to groundwater: 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: 5/20/81 Date ❑ Observed�ite(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) Accessed JSGS database-explain: WELL#MI N 29,ZONE A 0-2, LEVEL 8.6,ADJUSTMENT 1.9' You must describe ho you established the high ground water elevation.- SEE ATTACHED POOLS T-5.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 j I R S t. . �I c�, i o w No. 5 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZippYtcation for �Digonl *proem Con5tructton Verna Application for a Permit to Construct O Repair A) Upgrade O Abandon O ❑Complete System ❑Individual Components Location Address or Lot No. 4V i5� . �`I V y' mA Owner's Name,Address,and Tel.No. 6v7 OqO fv �/ ice. C-4,'�d�� Assessor's Map/Parcel ` Installer's Name,Address,and Tel.No.�l �y `"rf Designer's Name,Address and Tel.No. 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) --G-,ns•�e,-X1 aaa ze ' 6/,i,l��✓�[z� ka •L &Idl Gob--o-r t?A v Date last inspected: Agreement: The undersigned agrees to ensure the construction n ain ena ce t fo d scribed on-site sewage disposal system in accordance with the provisions of Title 5 of the Environ e 1 C a d o I t operation until a Certificate of Compliance has been issued by this Board of Health. Signed 'G ig/ J Date -�/// F/d Application Approved by Date g' ©7 Application Disapproved by: Date for the following reasons Permit No. 7— 1 S Date Issued L/_r 8-07 _ •J+t .� �C� .G�J f 'No. . �oV 5�! 1 l aFee / { THE COMMONWEALTH OF MASSACHUSETTS Entere in computer: s PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for �izpo'Sal *p.5tem Con5truCtion Permit Application for a Permit to Construct( ) Repair�k) Upgrade( ) Abandon( ❑ Complete System El Individual Components j r. Location Address or Lot No.4U P3 C,.y i¢ 6L(A Owner's Name,Address,and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No� Ve Law4-.-AL,111, Designer's Name,Address and Tel.No. IUS�IC�r�9J, A:1 A oA OaGol 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(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. ' 4. Description of Soil tit ,. 'Nature of Repairs or Alterations(Answer when applicable)--I-Ark Date last last inspected:. Agreement: The undersigned agrees to"ensure the constructio am Hai.tenancee f afo scribed on-site sewage disposal system in ~w accordance with the provisions of Title 5 of the Environ a al de an PI terra-in operation until a Certificate of Compliance has been issued by this Board of Health. Signed �"`�r Date r✓/,l7 Application Approved by \�- Date g' 07 Application Disapproved by: Date for-the following reasons . w Permit No. CY07 157 1 Date Issued id- ( U-07 �., m. •-- -Y - ->- oto�J\ _ .THE�COIGIM ONWEAIETH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On site Sewage Disposal System Constructed ( ) Repaired (x ) Upgraded ( ) Abann/d//oned( )by 93Lit Aj i (_ 1(<e LJA+5 C , at T� /�/l 6 r has been constructed in accordance i with the provision4f Title 5 and the for Disposal System Construction Permit No. 90r3-7— 15 f dated �` --o7 Installer Designer #bedrooms Approved design flow / gpd The issuance of this permit shall not be construed as a guarantee that the system w'tl fu ction as desiignned. Date /mot J 1!n�j4; Inspectors' .,�iC r 1 I ' (— rt"t! Y j Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS wtqpoar *pgtem Construction Permit >n Permission is hereby anted to Construct ( ) Repair K) Upgrade ( ) Abandon ( ) System located at U 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 conditions. Provided fConstruction must be completed within three years of the date of tlli_s�e flit. 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Appliration for Uiipnial Workii Tnnitrnrtinn Prrmit Application is hereby made for a Permit to Construct (*4) or Repair ( ) an Individual Sewage Disposal System at:........................ BA-,�, ..P L4_��-:......6 T - Z. .s /0 ... .. .-- cation-Address ggr�Lot No. n r dress W .........................../ 4.. ........_.......... ............................. Installer Address Type of Building Size Lot.. feet U Dwelling—No. of Bedrooms.................3......................Expansion Attic ( ) Garbage Grinder (d/� . `4 Other—T e of Building No. of persons............................ Showers — Cafeteria Other fixtures --------------- --------------------------------- W Design Flow...................S1.5........_._ ----gallons per person per day. Total daily flow.____._...................` ....gallons. WSeptic Tank—Liquid capacity� g g g 7........_ Diameter________________ Depth................ Disposal Trench—No.-----.----_--•._.. Width.... ns Lent Total Length .T Total leaching area:...................sq. ft. xp I---------- - Seepage Pit No.___-.-•_-I_______: Diameter.................... Depth below inlet.... ........... Total leaching area...... 51--sq. ft. Other Distribution box ( ) Dosingtank ( ) ^ i n Z Percolation Test Results Performed .......Ft.`.�!��.__r _. Date...... .. '.......... Test Pit No.'1_..:7�-_-_-minutes per inch Depth of Test Pit.......17._.._. Depth to ground water------------------------ (i Test Pit No. 2.......... ._._minutes per inch Depth of Test Pit........1 ^.... Depth to ground water._...._` R4 ----•-•-••-•-------------------------------•----....------..................................-••••---........................................................ 0 Description o.. Soil .Lum......--..�A_ - - - - - - - x ----------•-. V W •-•------•-----------------•--------------•-------.................................................................------------------•-----•-•--------•---•---•---------•--•----••---------•-•------- UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----------------------------------------------•-------------------------•-----------•---•-------------------------------------------•------....._.__...--------------------------------......__....-••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TI`11 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has"enissued_b, the boar of heal r ! Date�� Application Approved By---- -- � it� '-------- 'Date Application Disapproved for the following reasons-- -----------------------------------------------------------------------------------------•-••--•-•--•-•-•-•- .....................•-----•------•------------.....-----.....---•--------...----•-......----------------......-----•---•-----••---------••••---•--------------•--•--.................................. Date PermitNo......................................................... Issued....................................................... Date :!.......... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , l Q ..................OF...... .t,J. �a �' .........._............... Appliration fur t,Diopoottl Works Tandrurtion ratuff Application is hereby made for a Permit to Construct K) or Repair ( ) an .Individual Sewage Disposal System at ................__....� :....-----.-- ...._p6m)�T- - �- c-- Location-Address �t �,f t— r Lot No. .... nFr Address a '." V §5..---•--•--•_________ --------------------------------A. ............... Installer Address U Type of Building Size Lot...94,t�%���q. feet Dwelling—No. of Bedrooms........................._.._...._---_-_--_-Expansion Attic ( ) Garbage Grinder a�_l Other—Type of Building No. of persons............................ Showers YP g -------------------------•-• p ( , ) — Cafeteria ( ) Otherfix ures -------------------------------•---•--------------.........------------------------•-----.._...-•-•---••--------------------....------.._........._... W Design Flow................ ............;,.-------gallons per person per day. Total daily flow.........................�ct.`A.....gallons. WSeptic Tank—Liquid capacityL_1Wq.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width....i.. _--__--_ Total Length.......-.__t-___....Total leaching area....................sq. ft. Seepage Pit No.........l----------- Diameter....._.._..... Depth below inlet... ............ Total leaching area.....a-�--__+.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ( I `" Percolation Test Results Performed by_=?°)_6Li__�;15....._. .:_�!- ..............' Date._.._5__Z`' L- ].......... W Test Pit No. 1....�...__.minutes per inch Depth of Test Pit......-Z ..... Depth to ground water---_-__--------------- Test " (i Pit No. 2.._._..I ....minutes per inch Depth of Test Pit------- _... Depth to ground water........................ ............................................................................................................................................................. DDescription of Soil-•....•........ ...........------------------------ ..... ------------------------------- _......................................................... W UNature of Repairs or Alterations—Answer when applicable............................................................................................... -----------------------------------------••-•-•----•--------------------•----•-•------------------------•---....---------------------------•--••------------...-----•--.....--•-._......._..._..__-_.... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i;'%. 5 of the State Sanitary Code- The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha een issued thl boar, of heal, 1. i f .... -•-•--... Date Application Approved B .. '` � �°✓ PP PP Y = Date Application Disapproved for the following reasons:-------•------------------------------------------------------------------------•-------------............... ----------------------------•--...------....--•-••••-----•----------------•...---.....--•-----.........-------•---------•-----------------------------------------------•---- --------------------- Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD- OF HEALTH u ........T .................�OF....... ........................... ........................... (9rdifiratr of Tomplianrr THIS IS TO CERTIFY, That the Individual Sewage/Dispos ystem constructed ( ") or Repaired ( ) by------------------------------------- ! _._...- ....... (........:7.��........I...............................................................•--- Inst ll has been installed in accordance with the provisions of TI^ F c of The State Sanitary Code as described in the application for Disposal Works Construction Permit Nq .t'� d ------------------ dated_-..._---_--_-.------_----_--__----_------_----_ THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. G- DATE................................... ......................... Inspector..................... liU .. THE COMMONWEALTH OF MASSACHUSETTS BOAR© OF HEALTH ,�J 1- (; �-� try A r r��Ty�6(, N eig FEE.. ............. Disposal Norko wonstruction Vamit . � = ` r Permission is ereby granted.---------- '__>_--�_-r�,�;�_��_-_ t.�,,..,..........�_..--......==`�===�`=='--,'---:....----•............................ to Construct ( ) or Repair ( ) an Individual Sewa Disposal System at No... '� Z. Irn � ' ...... ...---------------------------------- Street as shown on the application for Disposal Works Construction Permit No................................ Dated---- ............................. ff Board ea h DATE............................ 2" •. FORM `1255 HOBBS & WARREN, INC., PUBLISHERS Zvi 2�=11 �% �'L�i ✓' � LOCATION SEWAGE PERMIT N0. VILLAGE AA - 6o"7 I-NSTA LLER'S NAME ,� AD-DRESS l e lU IU L D E R OR OWN ER DAT E P ERMIT I S S U E D DAT E COMPLIANCE ISSUED cf/LL� L For ;f �z .A I 1 V x 1 , ter.', IV -�-+ _. ���A v���� � • pdc.: ..ram. �.r- u 5C , r a r '. ..,......fir' ....._... ..,- ._ .•• 'l?..�Co r S.�T}"!� ram` 762 3�-_ -. •.._. �� 'I"'" .'-.. � ,H 1}r ,1,�-::,�.: � ; r,s'"` r�ii 1)f- t f A N SSJJ i �± _r r �C+NAI EN �.j t r _ 1 42 If 4 % / 1 r Add rzo\\ �16•�.� -FA Tod'' ct= � � � ,., � -� ` �� \ pAf� ( c=Lou -�t+= >ot1,00 � CLlov C�=D Pp J� ?'• ` 06E. I SoU GOAL, i fo f - o \ �...._ �,� ..._• Nt\ �;� gyp. � � I l3 � ic� 113 �►� SLnpE s -. 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