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HomeMy WebLinkAbout0068 BAY ROAD - Health 68 Say Road Cotuit P A = 007 025 +� 4'=w EYEIAxD H9N0G/IA/M6HSYplYN w�• I I xt i r Ij I _j-I —ice :3a�••.7 _�__\i I �Ir I w l ,\, -=t ICI ct I —I I r zs = i T ^a c T O tm i 1 tz I y °O ,� � J4•_4• •°� cy" C V w " e • a icvrFrcuumxveo�cuwcseswxrco.d - '7V E:s 34'-4-7 44 c �'Aq G�L fa•--' I i � �r •` O 0 �f-8 � � � � , O • �r I s t� s- i v l ems- 'j I 1 a I I i I)l fir; 'Si ioz I i _� ` - -_I_ i - r r0i 1 F Gam- • ii I- I .� � I � �11 —� .n I � , IL ro- c• �� I I � I.g y Ci C � `N pp3�- �a l: 1»o lu: 44 out-4zo-j2U2 COTUIl FIRE DEPT PAGE . 02 I Cotuit Fire Department Fire, Rescue & Emergency Services G��Ul?► 64 High St. - P.O. Box 1632 °u Cotuit, MA 02635 Paul A. Frazier FA -Chief e a nt Phone (508) 428-2210 508 02 TO: Tom McKean, Director of Public Health Town of Bamstabie, Board of Health P.O. Box 534 Hyannis, MA. 02601 FROM: Chief Frazier, Cotuit Fire Department SUBJECT: Tank Removals, et al DATE: September 25, 1997 The following tanks have been removed/abandoned singe my letter dated June 25, 1997. If you need further information, please feel free to call me. Thank you. NAME tAOTES Claussen 20 Oyster Place Rd. 07/23/97 2000 gal. tank removed, Cotult, MA. 02635 no contamination or odor present. Rotsteln eon 68 Bay Rd. 08/25/97 275 gal. tank removed, Cotuit, MA. 02635 no contamination or odor ,6 present. McGeoch �. - P 865 Main St. 09/09I97 27fi/500 gal. tank removed, Cotuit, MA. 02635 no contamination or odor present. Rogers / (95, oY6 908 Old Post Rd. 09/17/97 1000 gal. tank removed, Cotuit, MA. 02635 no contamination or odor present. p�`'OD'�1�1�-� G. Gam✓G�f� � �� J" _743 - t ' N e f - COMMONWEALTH OF AWSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS t d DEPARTMENT OF ENVIRONMENTAL PROTECTION d - R W ' Hq SJe �O TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM F RECEIVED PART A CERTIFICATION MAY 1 0 2002 Property Address:68 Bay Road Cotuit TOWN OF BARNSTABLE Owner's Name:Maurice Rostien HEALTH DEPT. Owner's Address: Same Date of Inspection:4/3/02 . Name of Inspector: Timothy Lovell D Company Name:Accurate Inspections MAP Mailing Address: 550.Willow Street W.Yarmouth;F MA. PARCEL : OZ5 Telephone Number: 508-771-3700 LOT 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: X _Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails g Inspector's Signature: L Date: 4/3/02 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. 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 how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:68 Bay Road Cotuit Owner: Maurice Rostien Date of Inspection: 4/3/02 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _No_I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: _N/A 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. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please explain. N/A 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 infiltration 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. ND explain: N/A 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 P Pe( ) y Pa sP (with approval of Board of Health): Broken pipe(s)are replaced Obstruction is removed Distribution box is leveled or replaced ND explain: N/A_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 Obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:68 Bay Road Cotuit Owner:Maurice Rostien Date of Inspection: 4/3/02 C. Further Evaluation is Required by the Board of Health: _N/A 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: _N/A_Cesspool or privy is within 50 feet of surface water N/A Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 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: _n/a_ 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. _n/a The system has a septic tank and SAS and the SAS is within a Zone i of a public water supply. _n/a The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. n/a_ 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 and volatile organic compounds 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 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 68 Bay Road Cotuit Owner: Maurice Rostien Date of Inspection: 4/3/02 D. System Failure Criteria applicable to all systems: You must 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 _x_Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _x_Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow _x_Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped _x Any portion of the SAS,cesspool or privy is below high ground water elevation. _x_Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _x_Any portion of a cesspool or privy is within a Zone 1 of a public well. _x_Any portion of a cesspool or privy is within 50 feet of a private water supply well. x_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 coliform bacteria and volatile organic compounds 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 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] no (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. Large Systems:N/A To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No The system is within 400 feet of a surface drinking water supply _ —The system is within 200 feet of a tributary to a surface drinking water supply The system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. I Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 68 Bay Road Cotuit Owner:Maurice Rostien Date of Inspection: 4/3/02 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _x _Pumping information was provided by the owner occupant,or Board of Health _x Were any of the system components pumped out in the previous two weeks? _x_ _Has the system received normal flows in the previous two-week period? _x Have large volumes of water been introduced to the system recently or as part of this inspection? _x _Were as built plans of the system obtained and examined?(If they were not available note as N/A) _x _Was the facility or dwelling inspected for signs of sewage back up? _x _Was the site inspected for signs of break out? _x _Were all system components,excluding the SAS,located on site? _x_ _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? _x _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: Yes no x _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(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:68 Bay Road Cotuit Owner: Maurice Rostien Date of Inspection: 4/3/02 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_2_Number of bedrooms(actual):_3- DESIGN flow based on 310 CMR 55.203 (for example: 110 gpd x#of bedrooms):_220 Number of current residents: 2 Does residence have a garbage grinder(yes or no):_no_' Is laundry on a separate sewage system(yes or no):_no [if yes separate inspection required] Laundry system inspected(yes or no):_n/a Seasonal use. (yes or no):_no_ Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no):_no_ Last date of occupancy:_Current COMMERCIALANDUSTRIAL Type of establishment:_N/A Design flow(based on 310 CMR 15.203): end Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Owner Was system pumped as part of the inspection(yes or no):_no If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: . TYPE OF SYSTEM _x 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: Repair done in 1991 Were sewage odors detected when arriving at the site(yes or no):_no f - Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: 68 Bay Road Cotuit Owner. Maurice Rostien Date of Inspection: 4/3/02 BUILDING SEWER(locate on site plan) Depth below grade: 1'8" Materials of construction:_cast iron _x_40 PVC_other(explain): Distance from private water supply well or suction line: 75' Comments(on condition of joints,venting,evidence of leakage,etc.): Pie joints look fine,no evidence of leakage SEPTIC TANK:—x (locate on site plan) Depth below grade:_8" Material of construction:_x_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: 1000 Gal Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:_0" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle:_14" How were dimensions determined: Field Measurments Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Tank should be pumped every 2 years,No sign of leakage structurally sound GREASE TRAP: N/A (locate on site plan) Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:68 Bay Road Cotuit Owner:Maurice Rostien Date of Inspection: 4/3/02 TIGHT or HOLDING TANK:_N/A (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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_N/A (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.): PUMP CHAMBER:_N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): f' Page 9 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Bay Road Cotuit Owner:Maurice Rostien Date of Inspection: 4/3/02 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type _x_Leaching pits,number:—I— 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.): 1000 alb leach pit level 2'below invert,no sign of hydraulic failure CESSPOOLS:_N/A_(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 or no): Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:_N/A (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.): Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 68 Bay Road Cotuit Owner: Maurice Rostien Date of Inspection: 4/3/02 SKETCH 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. Right side of home 1000 gal tank ya� 1000 gal pit Town water i Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:68 Bay Road Cotuit Owner: Maurice Rostien Date of Inspection: 4/3/02 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 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 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: U)�ej( stet T w ZS '4± L1✓, of,6_A-IV4 Coo t Ze,44 4 4pi f -k✓AeA-,,A 3 5,d 1A A Rio f" Permit Number: Date: Completed by: !/,-,,r2 La,,,till HIGH GROUND-WATER LEVEL COMPUTATION Site Location: 468 /9AY �/} p� Lot No. Owner: / /lo 15ILr Address: ` CIA-d Contractor: Xd&v#A �'—.r5 /a2S Address:,f,S.r,1 G4.Affa✓ A Notes: v ' STEP 1 Measure depth to water table to nearest 1/10 ft. .............................................................................. .Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well.................................................... w,�Y OB Water-level range zone .................................................... STEP 3 Using monthly report "Current Water Resources Conditions" determine current depth to water level for index well ........................... 'hf/� L✓�'L `�' 6 month/year STEP 4 Using Table of Water-level Adjustments. for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 213) determine water-level adjustment ...................:. d ..................................................................... STEP 5 Estimate depth to high water, by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ............. . � Figure 13.--Reproducible computation form. 15 TOWN OF BARNSTABLE LOCATION G BAY ROA d SEWAGE # VILLAGE co TU c 1F' ASSESSOR'S MAP & LOT 607-G X-t' INSTALLER'S NAME&PHONE NO. ✓a t,6 C,4A Co 77s-.6L 6 y SEPTIC TANK CAPACITY _A60 9A/ LEACHING FACILITY: (type) 4 P 6006 (size) NO. OF BEDROOMS 3 BUILDER OR OWNER to Its 4-S PERMITDATE: ,/!b-/' T COMPLIANCE DATE: lej-V 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 . ' y ^rt � , � Yi , // TOWN OF BARNSTABLE LOCATION SEWAGE # R - ��l VILLAGE �o�u r 7` ASSESSOR'S MAP 6i LOT INSTALLER'S NAME PHONE NO. A & B CANCO 775-6264 SEPTIC TANK CAPACITY ®O LEACHING FACILITYAtype) /� 100-0 (size) (0,' t® NO.OF BEDROOMS vZ PRIVATE WELL O UBLIC ATER BUILDER OR OWNER Ros- tte DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: C VARIANCE GRANTED: Yes No PC 1 , ! side. Ale.w ' LP to Do - OX � � 4 i Fics.. n:........... THE COMMONWEALTH OF MASSAAH USETT� BOAR® OF HEAL �41(_. , p o v TOWN OF BARNS ­PI,Qt2O1' D a Co App iration for Disposal Works (Tnri r rrmff-ton Application is hereby made for a Permit to Construct ( ) or Repair ( i�an Individu�d isposal System at: a --- A -........... ............................................. ..... ................................................................... ------------------. L.. -Address —or Lot No. Owner It tr Address 1.4 Installer Y Address d Type of Building Size Lot___________________________S q. feet U Dwelling—No. of Bedrooms____�....................____ .Expansion Attic ( ) Garbage Grinder ( ) P`L4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures ------------------------•-----•- W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter-_______-__--_---_ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water--_-_-_______-_--_---__. f3, Test Pit No. 2................minutes per inch Depth of Test Pit...:..............._ Depth to ground water........................ a ---- •---------------------------------------------------------- •------------------ •----------------- ---•----•-----••-•---•-------••.---------------•---_----- 0 Description of Soil....................................................................................................................................................................... W V .........---••••...............••----•-•---•-•---••--------•-••---•-------•---------•-----------•--•-•••••--•-•-•--------••-••---......-------•••-•..................................................... UW ••--------------------------------•-------•-•---•------•------•-•--•--------------•---------....... �• Na ure of Re 'rs or Alter tions—Answer when applicable...: /__._O_tJ._(� -........... a'/....... .................. . .... Agreement. The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State E viron . �ntal Code e undersigned further agrees not to place the system in operation until a Certificate of Co pliant s been is ued y the board of health. © .. Signed ....... ... ....... ... ....................... ............................................... ----�---' �-- ----.- --�--- - Dace Application Approved By .... ° -�,L ,rw.�;a, Cl `J ------------------------------------------------------- Application Disapproved for the following reasons: ....................... -----...----.._................................................................... .Date• ........ ...... ...... ...................... ... ........................................................ .... .......................................................................................... ............. . ...... Dare Permit No. ........_7/------- Issued ' Dace 00 No.. -f_... ::,� Fps..�?0....J....... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ) , pplira#ion for Dhipmtal Mirkii Tnnitrurfiun Vantit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage`Disposal System at: n ................................................ •-•-- _.:.......--•• • ---...------.....---•••------------.....--•--•----...........----•- Locatior1- Address or Lot No. ....... .. ._. n!.....15........J r'.AS C-.�- -------•-•-------- ..........--.............................................................................._..... Owner Address •.....-•------•.............---• - - ---------•-•..------••---.......-- v --•- Installer Address C Q Type of Building Size Lot............................Sq. feet ... .......:..................Dwelling—No. of Bedrooms... � Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g -------••----------•-------- P ( ) — Cafeteria ( ) Otherfixtures ------------------------- -----------------------------••----•-•--•------•-----•--•---....--••-•••-•-•-•--.._..-•-•-••--••----•----•............------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length-___-_-_____.. Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No_____________________ Diameter.................--- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by........................... Date Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 04 ----------------------------------------- •...... ..---------------- ..-------------------------------- -•...... •--------------------- ....-------------•---..--•- 0 Description of Soil......................................................................................-----------------------------•------------------------------------------------... x U ...--••-••---•-•----••-••-••-••-•••-------------•••--------•-••----------•-•----------•...---•-•----•----------•--•••---•--••----•-----------•--•-----••••-••-•--••--...•••••------...---•••-----..---••- W ----••-----•------•----••---------••--••---•----•-•-------- -•-•--••••-•-•-------•--------••-••-------. �, e =- " t U Nature of Repairs or Alterations—Answer when applicable � c P PP tom! ------------------------------�)--- .;F Agreement: ! 1 The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code=The undersigned further agrees not to place the system in operation until a Certificate of Compliance as been issued by the board of health. V 1 Date Application Approved BY ----------------- \\---------------------------- _. ----------------- -----;s!'- d- `-- - �~'- Date Application Disapproved for the following reasons• ----- ---------------------------------------------------------............................................................ ----------------------------- ----------- --- --------------- - ------- --- ---------------.............................------------------------------ ----- ------- -- ------------------ ........................................ L Permit No. -...-.-.��------/--�r ......--.::.. - Issued ........-- ------- ------ ----------- --------- -to------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�ertiftcate of C�outylia cce THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by---------------!' 1 --..:. ? ------------.................................................................................----------- ------- Installer at --..--(.....'..............-F .>......... �-.`% .:. ... �' --Tl�...r..`T."'.................................. -has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .... f..-....ff'a.,�---_--_---- dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CO R S A GUARANTEE THAT THE SYSTEM WIL U CTION SATISFACTORY. DATE.....1.. .... .......................................................... Inspect .._.. --------- _-Ia.-...:..:........ -.:..-.... (( r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH a No.... TOWN OF BARNSTABLE . U FEE. !�....-- 3.v.: � r- .:"....... I Diiipas t1 Works Tome r Uan amit Permission is hereby granted...... _. .! ..._r' Q.? _ :)................................... to Construct ( ) or Repair ( j,,)*an Individual Sewage Disposal System at No.......f .._... ..<:- .......2 .,.•... r f`'?'t t Y Street as shown on the application for Disposal Works Construction Permit No.. . ::.,�_`_J/.. Dated.......................................... ........................•-•--... -1 -------------------------•- DATE. Board of Health FORM 38E08 HOBBS h WARREN.INC..PUBLISHERS l y� �� TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION � QAM jOOW,N��ER AND INSTALLER INFORMATfI�ONADDRESS: I/-)C) i f l MAP~NO./_J -""PARCEL NO. 1/ OWNER NAME: �IV et r lL �� VILLAGE: INSTALLATION DATE: ( / A9 0 /171 BY: t '+ ' a W 1V ^ ADDRESS: _ CERT. NO. F _• '� TANK INFORMATION 2J t Y LOCATION OF TANK: t J CAPAC I TY TYPE AGE FUEL/CHEM I CAL 1 �s'el, 0 • i s TESTING CERTIFICATION C ] PASS C ] FAIL DATE { !t LEAK DETECTION C ] CHECK IF N/A TYPE/BRAND } ZONE OF CONTRIBUTION C ] YES C ] NO DATE TO BE REMOVED' f FIRE DEPT. PERMIT ISSUED C ] YES C.�] NO,-----DATE-. ^� CONSERVA i ION C JEI CHECK IF N/A� ! � r BOARD OF HEALTH TAG NO. 1 ]C ]C ]C ] DATE fio ! PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON,,-,RiE BACK OF THIS CARD o� o � Read S M EAD BEEPING YOU ORGANIZED No.103U 2-153L HORDE III USA GET 0RGMV.ED AT SMEAMCOM