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HomeMy WebLinkAbout0027 CEDAR STREET - Health 27 Cedar Street A = 018-040-001 Cotuit --- - - - - - - - - — - - �I I I i t. Commonwealth of Massachusetts copy Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is required for Cotuit MA 02635 April 4, 2012 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any v way. Please see completeness checklist at the end of the form. Important: A. General Information When filling out y 9 forms on the }} computer,use 1. Inspector: `-f- only the tab key to move your Patrick T. Sullivan cursor-do not Name of Inspector use the return key. Ready Rooter, Inc. e.. Company Name ` P.O.Box 371 Company Address Sandwich MA 02563 Cityrrown State Zip Code 508-888-6055 SI 12843 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: L ® Passes ❑ Conditionally Passes ❑ Fails El Needs Further Evaluation by the local Approving Authority ch '— :- April 9, 2012 cam✓ Inspectors Signature Date t— Thesystem 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. ZI i n . Subsurface Sewage Disposal System•Page 1 of 1, Title 5 Official Ins W.o Ys 9 t5ins•11/10• 9 Pos y Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is required for Cotuit MA 02635 April 4, 2012 every page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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. Z Check the box for"yes", "no"or"not determined" (Y, N,,KD)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 infiltra;i'on or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 2 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owner's Name information uired for required Cotuit MA 02635 April 4, 2012 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cunt.): ❑ 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 bro", 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 'r replaced ElY ❑ N ElND (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 b the Board of Health: ❑ Conditions exist which require fu her evaluation by the Board of Health in order to determine if the system is failing to protect blic health, safety or the environment. 1. System will pass unles Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the syst is not functioning in a manner which will protect public health, safety and the environm nt: ❑ Cesspool or privy is within 50 feet of a surface water 4 ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is Cotuit MA 02635 April 4 2012 required for P every page. Cityfrown State Zip Code Date of Inspection B. Certification (cunt.) 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 absq tion 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 d 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 wa r analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent nd the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided t at no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters i due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is,less than day flow t5ins•11/10 Tttle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4 L • ' Commonwealth of Massachusetts ti Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is April Cotuit MA 02635 A 4 2012 required for p � , every page. City/Town State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. / For large systems, you must indicate either"yes"�;: no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ th/eh wit '16 400 feet of a surface drinking water supply ❑ ❑ thithin 200 feet of a tributary to a surface drinking water supply ❑ ❑ thlocated in a nitrogen sensitive area (Interim Wellhead Protection Ar ) or a mapped Zone II of a public water supply well If you have answered "yuestion in Section E the system is considered a significant threat, or answered °yes"in Seve the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Insp ection Forth:Subsurface Sewage Disposal System•Page 5 of 5 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owners Name information is Cotuit MA 02635 April 4 2012 required for p , every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period?. ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage backup? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected.for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® El information the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD t5ins•11/10 Title 5 Official Insp ection Form:Subsurface Sewage Disposal System•Page 6 of 6 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments "t 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is required for Cotuit MA 02635 April 4, 2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): 2010=62 GPD2011= 0 Detail: Little or light use of property over last 10 years. Sump pump? ❑ Yes ® No Last date of occupancy: 10 years 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/pefsons/sgift., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank/pr sent? ElYes ❑ No Non-sanitary waste dischar d to the Title 5 system? El Yes ❑ No 7 Water meter readings, if�ailable: t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is required for p Cotuit MA 02635 April 4 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: No records found Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system Single cesspool El 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 1 El i . Tight tank.Attach a copy of the DEP approval. El Other(describe): t5ins•11/10. ° Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is required for Cotuit MA 02635 April 4, 2012 every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Approximate age of all components, date installed (if known) and source of,information: Original system installed Aug. 3 1979. Leach pit moved for pool install 11/4/91. Certificates of Compliance on file with Board of Health. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 2'7"feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® 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: 8.5'X 4.5'X 4.5' 1000 gallons 2" Sludge depth: tSins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 9 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is required for Cotuit MA 02635 April 4, 2012 every page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 37" Scum thickness 0" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 14" How were dimensions determined? Tape measure and dip tube. Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet PVC tees in place. Liquid level at outlet invert. No sign of leakage. Risers bring covers within 6"of grade. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete El metal /Mfihei glass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of/scum utlet tee or baffle Distance from bottomom of outlet tee or baffle Date of last pumping: Date t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 10 Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '< 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is required for Cotuit MA 02635 April 4, 2012 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or 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 r Date of last pumping: Date Comments(condition ,alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is required for p Cotuit MA 02635 April 4+ 2012 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): One inlet, one outlet. No solids carryover. No high water staining over outlet invert. Riser brings cover within 6"of grade. D-Box very close to tank. Pump Chamber(locate on site plan): Pumps in working order: / ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): r Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: F �V Y t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12 A . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is required for Cotuit MA 02635 April 4, 2012 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6'X6'w/3'of stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of technology: Comments (note condition of soil,signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit was dry at time of inspection. No sign of past hydraulic failure. Clean stone visible through sidewalls of pit. 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 F t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is Cotuit MA 02635 April 4 2012 required for P , every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): i Materials of construction: Dimensions Depth of solids Comments (note condition of s il, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11r10 Me 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14 1 J Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owners Name information for is required for Cotuit MA 02635 April 4,2012 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ' 0 ! i I . f i 40V 1 � t O A y A3 Cy=37` JD qr t5ins•11110 Title 5 OftW Wpeation Rum Subwdaoe Sewage DiSF"System•Page 15 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is Cotuit MA_ 02635 April 4 2012 required for p , every page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: >4feet 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: 06/28/79+ 11/04/1991 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers- (attach documentation) ® Accessed USGS database- explain: ma.water.usgs.gov terraserver-usa.com You must describe how you established the high ground water elevation: Test hole to 12'found no ground water(1997+ 1991). Base of leach pit at 8'+- below grade; elv= 85+-.Accessed local ground water contours and topo mapping. No high ground water in area of system. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16 Commonwealth of Massachusetts m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r< 27 Cedar Street Property Address Robert Conant Owner Owner's Name information is required for Cotuit MA 02635 April 4 2012 every page. City/Town state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file F t5ins-11f10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ` r a 19'4" 20' 32'8" 614 14' s �� Family& Sewer Pipe Dining F Existing Walls 139 3/8" O ih Master Bedroom Frame for 4'shower Existing partition Kitchen not to be changed- 36" Linen Ref Existing partitions not to be changed. Garage. 21 38" 60"Tub 10'9" 36' 94" Den Bath Bedroom e" 38"finished stair opening Hat rack 38" 12'1 3/8" 738"finish dimension Entry Foyer CO Bedroom 48" 24' 4 John Hanewic 5 !� 18' 18, 12' 27 Cedar Stre Cotuit, MA Drawn By, 48 Dan Paianza, De Jan 3, 2013 F TOWN OF BARNSTABLE 4 LOCATION J— SEWAGE# ('>ILLAGE ASSESSOR'S MAP&PARCEL 0 MA'S NAME&PHONE SEPTIC TANK CAPACITY �©oa LEACHING FACILITY:(type) (size) NO.OF BEDROOMS OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Y 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 BYp � � Lp - 3 a � I>k3: 30 3 ASSESSORS MAP NO: d O Y 'D YO—00 No................° J�.� PARCEL NO: 7� Fss�,,�,J /.......... THE COMMONWEALTH OF MASSACHUSETTS / BOAR® OF HEALT - TOWN OF BARNSTA Application is hereby made for a Permit to Construct ( ) or Repair ( Individual Sewage isposal System at: _ f Location- dress or Lot No. ........... .�., ...._.----------- -------------� ---.....--•--------------------------------•---- / O er Address® I / Installer Address dType of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms.............................. .. .....Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building No. of persons............................ Showers — Cafeteria 04 Other fixtures .-••--•-•--••---•-•----••--•-••• . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity./,WM.gallons Length---------------- Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------/_.___ p g q._____. Diameter____ _ _________ Depth below inlet.___.___.__.___ Total leaching area._._........__....s 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........................ .Test Pit No. 2................minutes per inch Depth of.Test Pit...:................ Depth to ground water........................ a ----------------------------------------- ----------------------------------------- ------------------- -....... ••------------------------------ ----- ----- 0 Description of Soil-------------------------------------------------------------------------------•-----------------------•------------•-----------------------............................ x V ---••-••---•--••••••---•------••-•-••----•--•-----•---•-•--•---.......--••-........••.............•----•••••-•-•---••---••••--•-•••--••--••-----•-••--•••----•--•--•••••••...._---•--..........------•-- W ••-•••••-•••-•-----------------------------•----.._..-•--•••----•----•-......__.....•-••-•-•............................................ --- U Nature of RepairsP—A-4 or-Alterations—Answer when pplicable---------,�._ r / ...... . .._ _. _ ......_. ........................ .•- ------------------ -------------- �- ...l�r r ------dLI Agreement: 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 has been issued bythe board of health. Signed ..---- :-- lam( � ------------------- -----�1. _.._ _. /.�----------- ---- ---_..._....__ pate CT //-� Application Approved BY - _ . ................ ..:------..---------------------.....---- ----------_----- Application Disapproved for the following reasons- --------------------------------------------............................................................. ----------------------- ...................... -- --- ---- -- ---------- --- ---------------------------------------------------------------------------- -......................................................... -------------------- ------------------------------ --------. ............-------- -- Dare Permit No. �r-- �� P'---------------------- Issued ----....-- 4 0/Y.-o Y6-do / No...9 - .��...�4 Fps l..��... ....' THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ,4 06 Appliration for Dispaial Works Tonstrudibn ami# �� Y Application is hereby made for a Permit to Construct ( ) or Repair 'an Individual Sewage Disposal System at: Location-A dress or Lot No. .................... ��..,...._ - _...;� ._ :..^..-. ............... ............ �._- .a. .k::. 'i.+., .^........_.................---...__......... :...:............ ........ O�ner Address ✓-.... J....................... Installer Address Type of Building Size Lot............................Sq. feet V Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aa Other—T e of Building No. of persons............................ Showers YP g ---------------------------- P ( )..— Cafeteria ( ) dOther fixtures ---------------------------------------•--------------••-----------------•--•••-••---------•-----•--•-•-•-....•..... -------_.. W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.;1�?l�?.gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No-------7/---------- Diameter....: ......... Depth below inlet.......Zk......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit---.............--.. Depth to ground water......................... �rq Test Pit No. 2................minutes per inch Depth of Test Pit....--.............. Depth to ground water..--.--................. P4 -••-•---••--------------------------•--------------------•-•-•-....-------•-•............-•••------•................................... •'--------------.----- 0 Description of Soil....................................................................................................----------------------------------------••-••-•'••--............... x U -----------------------•---------•-•---.....-•-......------•-----------•----•-•---•---•--•--------------•--•-•----------•----------------•-•-------•-------••.....••-••••...........•-----.............. W -------------------------------------------------------------------------------- -••----••------•----------------------------------•--------------••-------------- x � ---------------•--e-----•--- U Nature of Repairs or,Alterations—Answer when applicable...........�---- P p •-- . �`', - /'tU-f ..............? ... /1 `_:t— fir+. ' °j Ir/��1 -- v ---------------•--- Agreement: ✓ - The undersiggn64 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 unt11 a Certificate of Compliance has been issued by the board of health. --.� - Signed ........... ...v--- G`,'` ---= A lication Approved B --- / . PP PP Y - �� Dte Application Disapproved for the following reasons: --------------------------------------------------------------------------------------............................ ---------- .............................................. ... ... ............................................... .......................... .................................................................. ....... ................... ....... J / Date Permit No. _ � �"'....�� ---------------- ---- Issued /..... 1.-r' --------- - Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE C�er#tft�ctt#e of C�oz�c�lttt�crE THIS S TO CERTIFY T t t13e Individual ewage Disposal System constructed ( or Repaired Y ----------------------------------------------------------------------------------------- ---------................................. ��� —Installer at ....... ._ .. . ....................... ...r......................................................... -------------------- - - ----------- ---------------------- has been installed in accordance with the provisions of TITLE of The State Environmental Code as described in the application for Disposal Works Construction Permit No. �. .. o>r......... dated ....../.f''...��� .1~ THE ISSUANCE OF THIS CERTIFICATE SHAH NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE........................................... -117 '7 Inspector ...J . -, ----- ------------------------------ -------------- - ,...-- , t THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No......................... FEE........................ Elisp asttl Works Tonstr Wit ami# Permission is hereby granted........A"A1 k......�...�-.. to Construct ( ) yor Re air ( �'a Individual SeA ge Disposal System --------------------------•-------•------------•--•--•-------...... Street Ij as shown on the application for Disposal Works Construction Permit—No.....�/.��pDated.....//I `..• p� Board of Health r DATE / y......••; (f. FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS Fss.............. ..... LTH OF THEBOARD AGF-HEALTH Ts oy{" ----------OF......6? . �. _ •---------------------------------- Applira#ion for Mipaa al Workii Tonstrnrtiun ranfit �j Application is hereby made for a Permit to Construct �) or Repair ( ) an Individual Sewage Disposal 'Qr System at: �ts��� ............ lc'�cz S► ---•- -t- ...._... ................................... ...._� ..`...... _. » Location r -ess - - or Lot N . •-••• ' ..................... ..-.. ____ .......... ------_-- •••-- - Owner Addressr— ............................. r.!r'...t1.,` (4:: - `� Installer Address Type of Building Size Lot__ ....Sq. feet Dwelling—No. of Bedrooms___......._13___________________________Expansion Attic ( ) Garbage Grinder ( ) '4 Other—T e of Building _........_ Showers — Cafeteria a yp g _.��_Yl2__.__----- No. of persons._--_----- - (I ) ( ) � Other fixtures --------------------------------------------•--•------------------------=---------------....----•----------------------------------•--.....--------• W Design Flow............................................gallons per person per day. Total daily flow..__.._.....�._�Q..................gallons. WSeptic Tank—Liquid capacity/P®Q_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.�9.4.. ....sq. ft. Z Other Distribution box ( ) Dosing tank ( )� ~' Percolation Test Results Performed by------------ .[�_ __G'---....C��=._.____._.-.-•_ Date....._. - �. ..... Test Pit No., 1 Gt'SS...minutes per inch Depth of Test it..f'.:;�:.......... Depth to ground water ____ Test Pit No. 2_ minutes per inch Depth of Test Pit....rZ.�_..... Depth to ground water. _.._...®. ------------- ---------------------------------------------------------------------------------------------------- 0 Description of Soil.......b•:n..Z./....•--ZAo.n,..... ....... t Suf ------------- =----------•••--------•--. x '- ---------------------•--•-•---•-•---•---•-•. r -.....----- .u-�1 me'` µ = 0 W •-•---•----•------------------------------••--••••-----••-•--•-----••--•---•-------•-•-•---•-••-•-•----•--....------•--------------••-•---••--•---.................................................... U Nature 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 iITLZ- 5 of the State Sanitary C de— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee is ued by the health. Sign .._. a:... •.......•. ......... ............................................ -•••-•-••--•--.... ....... Da e Application Approved By---•• Date ram . .. ••-•-•-•_------ ^ .. mil f�. Application Disapproved for the following reasons---------------------•-•---------------------•--------------------------------------------------••---.......••-•- •-•-•-.....•-----••-•--......-•-•----•--•-•-•-••-•--••--••-•••••---•-•--••----••--•---•----•-•----••-•--•--••-••----•---•--••--•--•--•--•••---•--••--••--•-••-•---•----•------••-••-•--•--•-•-•••--..... Date ti Permit No......................................................... Issued----...__.._ Z _. �-------...-•-------•-------- Date J' FEz THE COMMONWEALTH OF MASSACHUSETTS BOARD OF, H f LTH ............. `"--..........OF.- -•----............................ App iration for Dhipas al Marks Toustrurtiun Prrutit Application is hereby 'made.for a Per it to Construct ( ) or Repair ( ) an Individual Sewage Disposal Syst3�1 _�Y _ Lotktion-A ess C�rye��a t No. e VVV Ad ress W = r -�................. -----------------------------------------...------.............------•-----------------------..... Installer Address dType of Buildin Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms.___..__.._ Expansion Attic ( ) Garbage Grinder ( ) a►� — Other,;--Type of Building ............................ No. of persons............................ Showers ( ) Cafeteria ( ) Q' Other fixt es�. ... d �. gallons per person per da Total daily flow.._...... _ lons. W Design Flow g P P P Y Y WSeptic Tank—Liquid'capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '~ Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-__-•-_-:-•-••-•---•-_.- fi Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ------------------------------------ -................-....................................................................................................... 0 Description of Soil........................................................................................................................................................................ x rJ .......••-•••••••......---•---•--•-•-••--••---•-•---•-•---•••---•-•-•-----•-•-•-•-------•................•--•--•-- 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 TIT1Z 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign, d ......................................... ................................ Application Approved By........ j !s ..._..._.. Date i Application Disapproved for the following reasons-------------•-•-•-------.._..--•----•------------------•---------------------.................................. --................................................................................................................................................................ Date Permit No......................................................... Issued-.................... .....- Date j THE COMMONWEALTH OF MASSACHUSETTS ° i BOARD OF HEALTH j.........OF..........9 . ... -�.... ........................ Trrtifiratr of Tomplitturr THI,VIX TO CE FY, That.the Individual Sewage Disposal System constructed ( �r Repaired ( ) by-•-_.: .........V4t1*� . = - at. `� .. �Zr _ _ _ •.. .`... .... .......�.. S'�` has been installed in accordance with the provisions of TIT�q` bf Thy State Sanitary Cede as descri ed in the applicationfor Disposal :W-orks Construction Permit No..' _ -- t.r. _..__. da.ted.r(,E,k. ..t._ - t_ ►........ 'THE",ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSUMED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY DATE... j�•-----k ---••... ........... Insp&t'or..:._ a Ti 'E COMMONWEALTH OF MASSACHUSETTS BOARD O HEALT, 1 No... .. 1." ... r ... . FEE.. G/........... �` �i���a�tt1 nrk� a�utrttrtilan rrutit • PermiPermission hereby grant ssion --•------- •. . -- ............. ...................... to Coristruc ( gor.,Repair ( ) an Indivi al .wa e Disp System atNo... ------- -•------ --•--... ---------------------------- aStreet as shown on the application for Disposal Works Construction P it JN�C� Dated___ ______ __ ___�.�.. u Board of Health FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS c Ta! �fiC y S{ t �` A 509, a -� t t r / "f- s -. o .r't +rt s Lc, lr,l r jlt v, i krb .'�k t ; - f - h'� ¢ ,� s' + - .,. f =�:' i �'-{Jr 't!t sd.,. 4- 'NI Ii! Rq,'k` j 19 V I 4 i { ,- 4 -k," S K4�'�y t7�_'Y} f x s, ,P� a.1 bva n. ,tr4 1, ,a �� r ;y t p �fi r 1,, Wit, �«. + i j 4 , _t,. i .t S rr-.— 2 tlt- t,- ,N 4 4 f °%,. a , ;1 i'I .>. ( : rmYh -, 4,.�� iY`C ,>r ,t'4b2 f 1, Y ` r. d1 .e ,, , , � r r 4 i i.K t€ fir F . "I �' ��>g ,, r 1� 3,• l /6 �/1�I '°� i� '' J�/ �.1 f ✓ -a.� � ��r d a7 t,. }, i .¢p t. 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T > y �S,�` 'CON,TOUR 0 � r x yu _ 4A #ht9'�S:i EU '.SPQ:T ELEVATION "'0.'0 t _ n, . � r`'� a�v > V d�f}` f d ,.. , :ty''r It f, t;�r1 a f 1'° }. 6 1 �,?•' X f - a..� iLL'...� 5:'� ...i sy'r. 1 p � '?..a�. 1 i jaiIvD1:,SOARD0F :HEALTH 3 F S Ali t4Flaj,�Ayn�..tt , kSgqx h ,a,3 �{ Ada ski ; " dte .� �Y1�®V' 0�,�® e ff Sy'� 4 :}- k�S. 7 F`' l} A ,N J .. c 1 ! ,E 3'� ,e ' ,' AGENTry ,I,. SCALE: 12 /G �'"DATE117 ��,,F � ''`1 � aA 4 '` 7h id �',,fi-' ENCi/IVEERI�OG' ,CO. !N , CLIEN _ - RTIF THAT ".` €f� F-�UW �.� ' aA. _'. ` nta<' —. `� I CI: YT . HE PR®IP,O'1E . t , � I .TER 1 ; 6T�, rS E REGISTERED �Q® N0.'7`"G� �_ BUILDING SHOWN 0'N ,T9i� P�� r ' �� ; V ti fVIL ra r+u , ,LAND, �� CONFORMS TO THE ZONING � LA6�IS�,, 4 DR. BY _� 4 �K IidGlAl--. ,, 4— SURVEYOR -- — OF SARNSTABL , ' MASS 4^ f,ar��Z. h + i > ,i , t � I � ,{VIAiIV ST .t' + �t:;= 712 :AAAIN':ST . 1)1 a ,w 7� , DSO 'I ylQGTH' MASS ,HYANNIS MASS. �r= , '4 . #�' � SHEET— OF ____ DATE . 6?EG. LAND SURVEYOR t , r gX a t: r 1 I ' ri ' a:,. ,.l,J,"kt,.. .1a ,.I a "`.� ,a d '. _ �', w WIL W.A.-'W.'�'Y wmv, 6 4 4;: :`*_ :,,:-�1""��'� : ''. ::t -,-,. A �'� �=`'. ?`�`-yr' ° Isr � � �` `��r!% � - fw4'm 4:! v, l?, e CON,ll jar co A iczrAiv sAwo. -7 I-EgF4, 4wi-AYER AS Go o'b Awl IN.APPI WA SM",I�NC epr/c 7ANX Pox a WA 0 mr a :0. PMSCAS r SEEPAGEOle jw J�CD 0 0 0 -0 o. 0 a 'a 0 -0411 V i P17 OR C /Alk'ZAPT 4ff4EVA7'140N5 7 • -7, 0 xr/NYZjR7- A-r wau.Dlma 9 L -.Ek 7;%&/"7 -0140 , 6 .Y IN4E-r SCA'rle 7,4,VK 14 S&P?/C 7-ANH 6 3 Pr IN4,ET 4015MI&OTION BOX 96 .0 JM'7 GROUND WATER TABLE WA6H -APAS.~,, A, A`17- Fr -�P.IMAA4$10N A 3 AC$hSA( CM 72M 1A 3 04ROAGEPISPOSA1.1/,Vor A Sol 1. *'-4rrfA%4reD jmd.O*V 3 3 s.41./,6A r 7407A MIA10ER Ovc 404CMIN& CP/73L mori 0 �m//,< -S , 5-41 Aa4CHIM6 -PER P/r ' aorro)w 7 F W COA A7YON 'AA 70 CH, -ro7,044 J.44CHIAI& AREA -2,66 SO. F7."- 11-7746*,A4�rff t9'T v '�'Qo'swmmff Zm4eNnv6 AREA Z 6 sip. FT ROSERT, ��\ :i T.. v t '' F ti L �- 01 p 4�a 4L tv 20 No 22M2 ro -I N- ,9pg •w,-- V "N N Z 51 o �-c We �0, 2 5W(1� eta L�J� � 44 C 7 1 r ovj el to 7T YI\ 0.)l 6 �n r � S 0oW°�� W L��Dj 1�'IR(8�555 n S dull �c,qtse 1 new �,H Oct 5 � I � . � i J TOWN OF BARNSTABLE LOCATION ` r SEWAGE # I VILLAGE ,(419 . ASSESSOR'S MAP & LOT �oo' INSTALLER'S NAME PHONE NO. J SEPTIC TANK CAPACITY 1 � LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER !� DATE PER MIT ISSUED: r DATE COMPLIANCE ISSUED: Lq,I VARIANCE GRANTED: Yes No �� � y � ,� ��r6 �,. . � . � � � �� ����� ,� � � �® � � � .. � � � � � -��- L 0 C A T ON 17��� �7 / SEWAGE PERMIT NO. Z 2- i8l3 _ Ced a`. VILLAGE c IM - Old 0V0 -ool I N S T A LLER'S NAME i ADDRESS -7R 44 1-/d,!i UILDER R OWNER DA T E PERMIT ISSUED DATE COMPLIANCE ISSUED -7 63� 9B �