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Home My WebLink About0276 COTUIT BAY DRIVE - Health 2 F6 COTUIT BAY DR 1 V No. �`� f �� I Fee BOARD OF HEALTH TOWN OF BARNSTABLE 01ppYtcattou jor Yell (Con0tructtott Permtt Application is hereby made for a permit to Construct( Alter( ), or Repair( ) an individual well at: a 74 Co 7 r'T /Iky or Location-Address Assessors Map and Parcel Owner Y Address /JE�s JCo>'v•ue l/ /o$- Deefd'w Rd M4947,,oet �� Installer-Driller Address Type of Building Dwelling Other-Type of Building No. of Persons Type of Well. y 4 a C, Capacity Purpose of Well I�P y gTor,) Agreement: The undersigned agrees to install the afore described individual well in accordance with the provisions of the Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the well in operation until a Certificate of Compl' nce as been issued by the Board of Health. Signed Date Application Approved By 13to ate Application Disapproved for the following reasons: `, I 1 Date `�v Permit No. - �1 Issued Date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well Constructed(tom Altered( ), or Repaired( ) by Scat.N nj e 1/ Installer. . at )76 Cg 7~ 13aX p/ has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private WeV Pr tection Regulation as described in the application for Well Construction Permit No. Dated 7 3 L THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector No. Vv ! Duo Fee r BOARD OF HEALTH 4 y'. TOWN OF BARNSTABLE r: 2pplic4tiou •J-f or Yell Cow6truction Permit Application is hereby made for a permit to Construct Alter( ), or Repair O ari indlvldual:well at: ' a 7� cp7u T /3a __Location Address Assessors Map and Paroet Owner t �.,: �,, +� p Address �✓-f / YS SCOI'U'y2 (/ ��O DP�e/GSS /`� M4 SCl�e 4 M Installer-Driller Address - Type�of Building .. Dwelling Other-Type of Building No. of Persons f Type of Well y f yC Capacity Purpose of Well i q aTo") Agreement: 7 The u�dersigned agreesao.install the afore described mdlvidual well accordance with the provisions of the Town of Barnsable Board of Health Private Well Protection Regulation-The.undersign d further agrees not to place the well in operation until a Certificate'of Compliance has been issued by the Board.ofiHealth. Signed Date Application tAk proved By Date Application Disapproved-for hey following reasons: ate ..... _... .. . Permit No. Issued Date ------------------------------------------------------------------------------------------------------- BOARD OF HEALTH TOWN OF BARNSTABLE Certificate of Compliance THIS IS TO CERTIFY,that the individual well .Constructed(a);' Altered( ), . or Repaired( ) by SCa /0/1-e Installer Jm at J 76 C67`u r 7` l3a}r, p has been installed in accordance with the provisions�of�t�lie Town of-Barnstable Board of Health Private Well Protection Regulation as described in the application for Well Co�nstruction�N' it No. \ ' -0 9` ( Dated 3 Z THE ISSUANCE;OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORILY. Date Inspector BOARD OF HEALTH TOWN OF BARNSTABLE Yell Con5truction Permit No. 'V\J1a k bkA Fee Permission is hereby granted to 0 SCCiry Installer s to Construct Alter( ), or Repair O an individual.well at: No. P76 r Street �a as shown on the application for Well Construction Permit No. r Dated f: Date \ Z Approved By 00e !tom SQ i 7(p CaTuIT NY ---------------------------------------------------------- C oTu 136 y71 0 i ----------------------------------------------------------------------- TTL-- - �i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 276 Cotuit Bay Drive r Property Address Alan Peterson Owner Owner's Name - information is required for every Cotuit Ma a 02635 >. 5/2/11 page. City/Town State°_ Zip Code : Date of Inspection Inspection results must be submitted,on this form:Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information,' filling out forms on the computer, I use only the tab 1'° Inspector , key to move your cursor-do not Ricky L.-Wright , use the return : Name of Inspector , key, B& B Excavation, Inc: rab Company,Name 14 Teaberry Lane Company Address Sandwich MA 02563 City/Town State Zip Code 508-477-0653 " S14595 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: ;..., C) ® Passes ❑ Conditionally Passes ❑ Faits ❑ 'Needs Further Evaluation by the Local Approving Authority a �' 71 5/2/11, ' Inspector's Signature ` Date M 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'd.esign 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurf4Sewagel System• age 1 of Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name ' information is required for every Cotuit Ma 02635 5/2/11 page. CitylTown 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. Check the box for"yes", "no".or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain.The septic tank is,metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. - "A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635 5/2/11 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed- ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 i I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments �M 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is required for every Cotuit Ma' 02635 5/2/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. . ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. El The system has aseptic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: '* This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or - less than 5 ppm, provided that no other failure 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 Ej ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or°cesspool ❑ ° E 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 '/2 day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635 5/2/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply E-1 ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone'll 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 276 Cotuit Bay Drive �M , Property Address Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635 5/2/11 page. City/Town 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 El ® 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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was thesite inspected for signs of break out? H . ❑ 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 ® -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: ® ❑ 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 t5ins•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635 5/2/11 page. Citylrown 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d n/a 9 ( Y 9 (gp ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: August 2010 Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is Cotuit Ma 02635 5/2/11 required for every , page. Citylrown 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: 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 ❑ 'Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the PEP approval. ❑ Other(describe): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 276 Cotuit Bay Drive Property Address ` Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635 5oi i page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.)' Approximate age of all components, date installed (if known)and source of information:` . 15-20 years est. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: f e0 t Comments (on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer appeared to be in good shape no signs of leakage or blockage. Septic Tank(locate on site plan): r Depth below grade: 3 feet . Material of construction: . ® concrete ❑ metal ❑ fiberglass ❑ polyethylene '❑ other(explain) F If tank is metal, list age` years Is age confirmed by a Certificate of Compliance? (attach,a copy of certificate) ❑ Yes ❑ No Dimensions: 5.2x5.2x8.6 Sludge depth: no sludge t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635 5/2/11 page. Citylrown State Zip Code Date of Inspection D. System Information (coat.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle no sludge Scum thickness no scum Distance from top of scum to top of outlet tee or baffle no scum Distance from bottom of scum to bottom of outlet tee or baffle no scum How were dimensions determined? scour stick Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection tank appeared to be in good shape tees present no sign of back up.Recomend installing riser to bring cover within 6" of grade. Grease Trap(locate on site plan): ' Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635 5/2/11 page. Cityrrown 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 r Holding g o g Tank a k(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal - ❑ fiberglass ❑polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day.. Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is eve required for Cotuit Ma.` 02635 5/2/11 every page. Cityrrown 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 no d-box 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(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS.not located, explain why: 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° 276 Cotuit Bay Drive �y Property Address - Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635. 5/2/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type. ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: µ ❑ 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.): „ At time of inspection leaching appeared to be in good shape no sign of staining or hydraulic failure.Leaching was dry at time of inspection.Recomend installing riser to bring cover within 6"of grade. 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 t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635 5/2/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments M 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635 5/2/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) . Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below - ❑ drawing attached separately A RE�`� A2= ; 00L B3 33 ' 6'I t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635 5/2/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells >12 . Estimated depth to high ground water: feet . Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑. Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand augered hole through dry leach pit. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form Not for Voluntary Assessments 276 Cotuit Bay Drive Property Address Alan Peterson Owner Owner's Name information is required for every Cotuit Ma 02635 5/2/11 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 s t t5ins•09168 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 II I jg�QNE LINE M NOW 00 c � RIGHT NORTH ELEVATON ADDrMN ID N ELEVATIONS 2 LEFT SOUTH ELEVATION 3 REAR WEST ELEVATION Al QOIE B�1IIB FINE LINE LA i 0 a ® OF N FOOTF NT ' POOTPRINT e L�Q . - ADDITION O PLANS FIRST FLOOR PLAN �0 has A2 J13 n Aar W1E 931/�B FINE LINE --' I o .» , .. I m rwres: O pX19nH6 64RA6E m �g N FOUNDATION PLAN 2 FIRST FLOOR FRAMING PLAN ROOF FRAMING PLAN AMMON :G Y STRUCTURAL A3 4 FOUNDATION DETAIL (I ) - wre eame S: i ! I ww c�nae coo fSI o 0U� ' /' Lu mr�men e.i..°B.vm zIST... Sam, Doom roR I'.• ( � I �p � .a a w�,^1.�j rmc�n i uci�iu � 1 it i I I \ , z Cr1@So!1E_GAs.4G° TZ( I II _ i _.. �.. EXISTING FIRST FLOOR PLAN auyE.va°.r-o• i ...,.....,..'--.......... i ..__..... ' EXI5T1 4 i•I•RB7 F100A.P7:.4N.-7.7 saw•+r— '� r uo; `TQYLOR DES[GiN LLC � " . 7.1 It " 6oc.2'tap�'-3'Al I sO - _ _..,. . �.. . Cam•-ruc,�wt� �-_ 2r44. ps��:. �. ._�_ _�.__._. - ___ �.s .. _ tIr�e ,,r--� �q: L..+ �a 5 -kr , + ..::. :[�a :tea tPs _.�t1•+9. I�s _,. (=.00► G1 t r•? C-7VID TAI'tOR`�ESlGN LCC; gar_ � p�� :CkEMEC:'eY DATE Ar t -t_jqL , r9 v „ . �o �r 3 - JA Ldc. : , Wee j i. 1� r r SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPEteT1ON FORM PART C SYSTEM INFORMATION(continued) i �►opeay Address 276 Catuit Bay : , Cotuit owner.: Peterson Data ofanspeetion .'lB_,L f.� V—/✓ SKETCH OF SEWAGE DISPOSAL SYSTEM: i I tndudities to at least two permanent reference landmarks or benchmarks }' beate all wells within.100'(Locate where public water supply comes into house) i i r� i• � li. s is i. I'. L 1.i -evi sec 9 2[y�. Page 10 of 11 + • 1 � 1. ii(: _ CO'.%31OX%EALTH OF MASSACHI;SETTS _ G EhECliTE OFFICE OF E'.N-moxN1E\TAL AFF.AJRS _ -- DEPARTMENT OF ENVIRONMENTAL PROTECTION OXE WL%TER STREE'.BOS OO\) A 0210t r61'j 292-550t,I�' TRH DI' COXZ Secre:a_r% ARGEO PAtiL CELLliCCI D VID B STP-HS • Governor CotnLntiss:one- SUBSURFACE SEWAGE DISPOSAL SYSTEM NOPECTWN FORM PART A CERTIWCATION Proper"Add:ess: 276 Cotuit Bayer ,, NanwafOwner Alan Peterson - Cotuit Address of Owner- Date of inspection: /6 — Name of Inspector.(Please Print Wm. E. Robinson Sr.. 1 am a DEP approved s aril inspector to Section 15-W of Title 51310 CMR 16.000) ComparryName:Wm. E . Robinson �eptic Service MaSrngAddress: PO Box 0 9. Centerville MA Teiq*wrm Number:77-�5 7 2� CERTIFICATION STATEMENT I certify that 1 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 inspection. The inspection was performed based on my training and-experience in the proper function and maintenance of on •sitZa, seage disposal systems. The system: es Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: L U Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of competing 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 Department of Environmental Protection. The original should be sent to 1?te system owner and copies sent to the buyer, if applicable. and the approving authority. NOTES AND COMMENTS t, 101 a P . 4. OCT 2 0 ►�'0 '"ev:seQ 9/2/98 t) Pape lofll V-� -^mud o^Recv6rd Pane t' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (condnued) Nop"Address: 276_ Cotuit Bay�Y: , Cotuit .)` ner: Peterson Date of Inspection (?^11� INSPECTION SUMMARY: Check 01 C, or D: A. 71h ..PASSES: v not found any information which indicates that'any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: c B. SYSTEM CONDITIONALLY PASSES: \ n One or more system components as described in the "Conditional Pass"section need to be replaced or repaired. The system. upon co L pletion of the replacement or repair,as approved by the Board of Health,will pass. f Indicate yes,no, or not determined(Y. N. or ND). Describe basis of determination in all instances. If "not determined',explain why not. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection: or the septic tank, whether or not metal,is cracked,structurally unsound. shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection If the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets) or due to a broken, settled or uneven distribution box. The system will pass inspection if Iwith approval of the Board of Health). broken pipe(s)are replaced obstruction is removed rq distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets)- The system will pass inspection if twtth approval of the Board of Health): broken pipets)are replaced obstruction is removed r e Q 1 i `_ev1Se 9/2/56 Page 2of11 0 } r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 276 Cotuit Bay ®�, , Cotuit : Own of Inspecneterson4 /�-f l o--v C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE WITH 310 CMR 15.363(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ Cesspobt or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSITEM WILL FAIL UNLESS THE BOARD OF HEALTH IAND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. T The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid). 3) OTHER I _'e _Se,., PxRc3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 276 Cotuit Bay : r Cotuit Owner: Peterson Date of Inspection: /b J``r,jL_,U D. SYSTEM FAILS: You must indicate either -Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the faiiure. Yes No Backup of sewage into facility-or system component due to an overloaded crelogged SAS or cesspool. rDischarge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. _ I Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: B 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: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes I 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 I 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) The owner)r operator of any such system shall upgrade the system in accordance with 10 MR 1 Y Pg Y 3 C 5.304(2). Please consult the local regional office of the Department for further information. Cj 2/5t PaRr4ofII L. • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART B CHECKLIST Property Address: 276 Cotuit Bay r<', Cotuit Owner: Date of In4,)%-t,@rson Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No Pumping information was provided by the owner,occupant, or Board of Health. _ None of the system components have been pumped for at least two weeks and'the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NfA. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: Existing information. For example, Plan at B.O.H. Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) _ The facility owner (and occupants.if differeru from owner) were provided with information on the propermaintanaarj�.cf SubSurface Disposal Systems. -e. used 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 'roperty Address: 276 Cotuit BayA'1., Cotuit Owner: Peterson *"• Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow:31,Q g.p.d./bedroom. Number of bedrooms (design): Number of bedrooms (actual):,' Total DESIGN flow 3G 6 Number of current residentsi--�L— Garbage grinder(yes or no): A-0 Laundry(separate system) (yes or no)/�6: If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no1: lr—s Water meter readings, if available (last two year's usage(gpd): 1999 1 01 nno rra 1 Sump Pump(yes or no)-A,0 1 998 1 00, 000 gal Lest date of occupancy:,1. COMMERCIALANDUSTRIAL: Typof establishment: Desi n flow: gpd ( Based on 15.203) Basis�Of design flow Greasy 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 -ate of occupancy: OTHER:(Describe) Last-d te of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: )yes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE 0 YSTEM 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) VA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: '�•� Sewage odors detected when arriving at the site: (yes or no)A0 reviseC Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icononued) *rop"Address: 276 Cotuit BayCotuit own er: Date of Ins "rson BUILDING SEWER: llocaie on site plan) Depth b low grade:_ Materia of construction:_cast iron_40 PVC_ other lexplainl Dist:ice from private water supply well or suction line Diameter Comm tints: (condition of joints, venting, evidence of leakage,-etc.) i SEPTIC TANK.1-' (locate on site plan) I Depth below grade:., Material of construction:_Zoncrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ ls.age confirmed by Certificate of Compliance_ (Yes/No) V 6 6 Dimensions: h, (.� �✓ Sludge depth: — /I Distance from top of sludge to bottom of outlet tee or baffle: i 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: How dimensions were determined: �/✓� a-d�'�� ;omments: (recommendation for pumping,,condition of inlet and outlet tees or baffles, dilpth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) 16-IS �� I'� r/`A' d � GREAS TTRAP: (locate onrsite plan) Depth belo�grade:_ Material of construction:_concrete _metal_Fiberglass _Polyethylene_othe►lexplain) Dimensions:d Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance fyom bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Commej4s: - (reco ,Mendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage,etc.) YE 71S-ed 9%2 90 Page 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Icondnued) 'rop"Address: 276 -Cotuit Bay �: , Cotuit Owner: p Date of Inspet8t kerson TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (Iota\te on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: M gallons Design flow— gallons day Alarm present Alarm level Alarm in working order: Yes_ No_ Date of pre ious pumping: Comments. (conditio of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTIONI BOX:_ (locate on site Y Ian) Depth of liquid level above outlet invert: Comments: (note if level apd distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:{, (locate on site plan) Pumps in working Ader: (Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) NI N re.ViseC4- 5/2 /98 Page 8of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) 'rop"Address: 276 Cotuit Bay DW-v, _Cotuit Owner: Peterson- Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: leaching chambers,number:_ leaching galleries, number:_ leaching trenches. number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Altemative system: Name of Technology: Comments: (note condition of soil, signs of'hy ra/ulic failure, level of ponding, damp soil„c�ondi 'on of v`egeta ion, etc.l /J � 6 S I•%r» y. CESSPO LS:_ (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer. Depth of scum layer: Dimensions offcesspool: Materials of construction: Indication of groundwater: inflow�(cesspool must be pumped as part of inspections M Comments: (note condition of soil, signs of hydraulic failure, level of ponding. condition of vegetation, etc.) � N PRIVY:_ (locate on site plan Materials of construction: Depth of solids: l Dimensions: Comments: (note condition 71.oil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) M Pair 9 of 11 �r s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Irop"Address:276 COtuit Bay Dr. , Cotuit owner: Peterson Date of Inspection: /6 d 61.. �}�L SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Y I a. 4d Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART C SYSTEM INFORMATION(con*NJedl ►openyAd&"s: 276 Cotuit Bay , Cotuit owner: pper} ersen Date of Inspat'tfolt- NRCS Report name Soil Type_ Typical depth to groundwater uSGS Date website visited Observation Wells checked Deep Groundwater depth: Shallow- Moderate SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater 2.0Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed Site(Abutting property, observation hole. basement sump etc.) Determined from local conditions -hecked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data A Describe how you,established the High Groundwater,Elevation. (Must be completed)ted) _ rev=se.: 9/2/95 Page 11ofII clz;) LOtC T I S,.EWAGE MIT NO. VILLAGE INSTf LLER'S NAME & A D D R S BUILDER OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED �� + 33 ; y eJ ll No....... l-...... Fas....� ................. THE COMMONWEALTH F TS� TRD - ��ALTH OF .. ..6 5v ---- ...................................................................... D ApPration -fur Riivoiiallftrks C omitrurtintt Vrrtuft Application is hereby`made for a Permit to Construct Disposal or Repair an Individual Sewage Dis ( ) P ( ) a P Syst� at � �....--- ......----•----- --- . --------------------------- L-o N ---------------------------------------- 1 +ex—Add ress 'ale i - E.� % L 55 ............./ � � A �� .Gl�l�......... . ------......-- t l rInsa ess UType of Building 3 Size Lot...10/- Q ____-Sq. feet -, Dwelling—No. of Bedrooms------------------------- -._-.--__-Expansion Attic ( ) Garbage Grinder aOther—Type of Building ............................ No. of persons:.�-�a_.._........._...____. Showers ( ) — Cafeteria ( ) Other fixtures W Design Flow........ ...............-.{{__..___._gallons per person per day. Total daily flow.._..__s�0--_-----____--_----.-.---.-_. Mons. WSeptic Tank—Liquid capaci�v�.e�__--gallons Length---f!......... Width................ Diameter................ Depth... Disposal Trench—No......... ... . Width.................... Total Length-------------------- Total leaching area..-.-.--__..........sq. ft. Seepage Pit No.L_DDO pia_, •--- P g area----------------_sq. ft. �` IStameter............... Depth below inlet....;. Total leachiu Z Other Distribution box ( ) Dosing tank ( ) -- d�, 1 C�� -- /6 -5�-7 a Percolation Test Results Performed bY,----•- ------------------------------------' --- Date....................................... Test Pit No. 1----------------minutes per inch Depth of "Pest Pit................._. Depth to ground water..._____._____.__....... ,(,q Test Pit No. 2................minutes per inch Depth of Test Pit-----------_-------- Depth t ground water... -...__.___.____.... W _. _ Yt' _'- .. _.. e ------- --• _ ---_ -. ---- -- •-- < x Description of Soil ( l " ------ ! --•-•--- ----- --•/10--'------------- w � -� .. I----------- x ------------- ------------------------- ------------------------------------------------------------------------------------- -------_---------- --------------------------------------------------- V 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been)ssuedbythe boy of health. ------ /D /. 7e - ---------------------------------------- -----_.... Date Application Approved B .............. Date Application Disapproved for the following reasons:...................................... .._..._._..___.___._._....._._________..._._._.•__________ ----------------------- -------------------------------------------------------------•--•----------.......-----------------------------------------------------------------------------------....._-•---- Date PermitNo......................................................... Issued-----------------------------.......................... _ �� ---Date---------------------------- , THE FOLLOWING IS/ARE THE BEST i IMAGES FROM POOR QUALITY ORIGINALS) I M A�C( l DATA No.............Y.. 1�............... . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Aplifiratimn -fair Di.spumttl Works Towitrnrtinn Vrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an individual Sewage Disposal Syst at / i f Location-Address % or"Lot No. /'l tl/ - /� Owner it Address r Installer Address Q Type of Building Size ^ ........Sq. feet U Dwelling No. of Bedrooms..._...`...................... . .Expansion Attic Garbage Grinder p4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) P I Other fixtures ---------------------------------- W Design Flow.............. .............................gallons per person per day. Total daily flow......::` _....._....._..._...._..__.gallons. WSeptic Tank—Liquid capacitv'__--.--_-gallons Length__..r........... Width._._f......._.. Diameter___._...._..___ Deptlt_..f�_._.._.... x Disposal Trench—No..................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit ......... Diameter.................... Depth below inlet_____-__3--------_.1Total 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.._--_._--__-..--._.__.- f14 Test Pit No. 2................minutes per inch Depth of Test P...................... Depthft ground water. ---_--------------- ----------------------------------------------------------- j !- /.....--------------------------- ---•••-- ' � / ` ___ ,l {� `, f 1 r� I Description of Soil--------- ------ � ��r ' =`=( ' - �` '" {�'� = " .s. .ts- � =�------------------------ U -------------------------- - �= i G_��. <`='7"= <` ---------------------------------------- W _____________________ ----------------------------------------------------------------------------------------------------- U P PP 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 Article XI 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. igned �' r / ,ram j' , _ . � /^ �/ J Date Application Approved BY :! '':=ra_:: `� ---- ----:.r.. ----_7� / �1s�/T _:�". / Date Application Disapproved for the following reasons:--•-----------------------------•- ----•-------•-------•-----_-------•-•---------------•------------------------ .....--•-•- ••...............................•------------------.......------------•---•--•-••-------...........---...-•--•-------•--•--•-•-•---•--•---------------------•-•......---•---------•------•-- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH- . 0F. ............. %Urrtifiratr of 0,11mpliaurr THIS-IS TO/CE(TI.FY, That the Individual Sewage Disposal System constructed or Repaired ( ) by ........................... ---- ........................... ----------------•--•------------------- f f I ----- • - J' has been installed in accordance with the provisions of Arti 1-(-. I of The State Sanitary Code as described in the application for Disposal Works Construction Permit No:.._('-='-____- ---------- dated_.._ __ ______ THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W L FUNCTION SATISFACTORY. DATE.------.. ! -'/...................................... Inspector........................------------•---•-•--•-•-•-•.............................. THE COMMONWEALTH OF MASSACHUSETTS b76 BOARD 07 HEALTH �= ,/ f -- 1..................OF.......v.�s��.,�-� �f�a. ............... / No. •-{-•7•• .......... FEE. ��trnrtia�$a �rrmtit Permissio is hereby granted___( _-�___-_/�__ __ .. - - - ` r^........................ to Construct.a or Repair ( �)/an ndividual/ ew ge D spos�l Systerrl� Street' _ as shown on the application for Disposal Works Construction Pei 2rt No_ / PP P f��.-- '-- Dated-�/,1-- -------------....... �! % f� // / ................•---•------........... Board of Health f DATE-----�`----_..L_:3-^--��_----- � FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS C O 2 D 1ti/p p p - �=96¢. ,o L _ 2 04 moo. oo.. N L07- 90 I ` I V) rl 92. I C -/bock Line <- 5 39 ZG'- /Z'" 70.00 " g�. 2j .32o Op C® TU/ T BAY DR � �� : . / hereby - certify that the T PL AN l Foundation is located as shown L ®r qv I and conforms to the Zoning By Lows of the Town of �1Fd 01 pj(f/T BA-Y SHORES Barnstable. - io cRETE COTU/T; BARNSTABLE .' MASS. /975 GRETE M,. BOHANNON, R.L.S. West Bridgewater Mass., 02379 I 5/10/2021 ShowAsbuilt(1700x2800) houyt d7 Cit. LO-C T q(O SFWpGE �PE'RMIT NO, A 10 // CGS %l )rim e- VILLAGE INSf L LL E R'S/J'''''N A ME /}& ADD R/E/$S 8U1'L0ER OR OWNER C 77 DATE PERMIT ISSUED . /O � 3 7 DATE COMPLIANCE ISSUED https:Hitsqldb.town.barnstable.ma.us:8431/Home/ShowAsbuilt?mp=056030&sq=1 1/1