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HomeMy WebLinkAbout0031 COTUIT COVE ROAD - Health 31 COTUIT COVE RD. COTUIT ---- - ---- -----� A = 005 037 i a f.t TOWN OF BARNSTABLE .,tom I}OCATION 3 CiO C&V'e, SEWAGE.# VIILLAGE CM G T ASSESSOR'S MAP & LOT00�`'�� INSTALLER'S NAME&PHONE NO. 9OT '!.0l, SEPTIC TANK CAPACITY 6-de— LEACHING FACILITY: (type) -s�L 6e4 Pori 60 (size) /o`st 3f IA..? I NO.OF;BEDROOMS BUILDER OR OWNERde PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) A4 Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 3 Feet Furnished by «, aqh. a -\ GOmMON E_ALTH OF N kSSACHUSETTS ` EXECUTIVE OFFICE OF ENVIRONMENTALAFFAIRS. EFARTiYi ?�T OF 3�IVIROIVlYIENTAL PROTECTION TITLE 5. OFFICIAL INSPECTION FOR IT—NOT FOR VOLUNTARY.ASSESSMENTS SUB-SURFACE SEWAGE DISPOSAL SYSTEM FORM. PART A CERTIFICATION — 0�5 03 Property Ad d ress: Owner's Name Owner's Address/ Date of Inspection: ©,(� Name of Inspector Iease-orintj_ Company Name \� Mailing Address:. Telephone Number: a CERTIFICATION STATEMENT I.certify that I have personally inspected the sewage disposal system at this address and'that the information reported below is true,accurate and.complete as of.the time of the inspection. The inspection was performed based on my training and experience in the proper function andmaintenance of onsite sewage disposal systems.I ain.a DEP approved system inspector pursuant,to Section 15.340 of Title. (3.I0 CMR 15:000): :The system: 1✓ Passes CondidonaIly.Pmses "j '= Needs Further Evaluation bythe*.Local Approving Authority -:s ils ! 1 r Inspector's SIduature:. — Date:. of The system inspector shall submit a copy of this inspection report to the Approving Authority. (Board of Health bF DEP)viithin'DO days of completing this.inspection..ifthe system is.a shared.system or has`a design flow of 10,000 gpd or greater,the inspector and the system owner shall subriiit the.report to:the appropriate regional office of the DEP.The original shouldbe sent to the system-owner and copie's sent to the buyer, if applicable,and the approving authority. Notes and Comments t .-.****This report only describes.conditions at.the time of inspections,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. Title:5 Inspection Form 6%1572000 page 1 Page 2 of]I- OFFICIALINSPECTION FORA-NOT FOR��LUNI'r�R�ASSES'VIENTS` SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORS PART A CERTIFICATION (continued) Property Address: 1 Owner Date ofln ection: t — "7 ` Irspection Summary: Check' A,B,C,D or E/ALWAYS complete_all of Section D A. S stem Passes: V7 I have not found any info at', rm tan Which.indicates that any 0t=the failure criteria described`in i 1.0.CMR 15.303 or in 310 CMR, 15.3N exist.Any failure criteria.not evaluated are indicated below:: Comments: B. System ConditionaIIy 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; 6(ill pass. Answer yes,no or not determined(Y,N;ND)in the 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 exf1tratian or.tank failure is imminent:System will pass inspection if the existing tank is replaced with-a-complying septic tank as approved by.the Board of Health. *A metal septic tank will pass inspection if it is structurally sound;'not leaking and..if a Certificate of Compliance indicating that the tank is less than 20.years old is available. ND explain: Observation of sewage.backup or break out.or high static water level in,the distribution box due to broken or: obstructed-pipes)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 obstruction is removed distribution.box is leveled or replaced ND explain: The system required pumping more than.A times a year due to broken or obstructed q P P l: y pipe(s).The system will pass inspection if(with.approval.of the.Board of.Health): broken pipe(s).are replaced obstruction is.rernoved . ND explain: Page of 11 OFFICIAL IISPECTION FORM -.NOT FOR' QLU3YTARY ASSESSMENTS SUBS-CIRFACE SEW-AGE.D.ISPOSA •SYSTEMINSPEGTTONFORM PART.:A` CERTIFICATION,(contirnu ed) Property Address: CJ4 da�L?_ago/ Owner; Date of I. speciion: C. Further.Evalnation 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. I. 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 whjch•will•protect-pubfit'health,safety and`the environment: .Cesspool or pritiy.is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt°marsh F j Z. System will fail unless the Board of Health ('and Public.,Water:Suppl.ier,.if at y).determines that the system is functioning in a manner,that,pratects the public health,.safety,and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS�is within 1 OO feet of a. surface water supply.or tributary to a surface-watensupply: The system'has a septic tank and SAS and the SAS is within-a Zone l-of a.public water supply. — The systern has aseptic tank and SAS and the SAS is.within 50 fe'et ofa private:water supply well. The system.has aseptic 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 yvell water,analysis,'performed at aDEP certified laboratory, forcoli.for n bacteria and volatile organic compounds�indicates.that the well is.free from pollution from that facility and the presence of amnalonia nitrogen and niiate ritrogen 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: 3 Page 4 of. 11. OFFICIAL INS.PECTIQYFORMI NOT FOR VOLUNTARYASSESSMENTS SUBSU-RFAC •SEWAGE DISPOSA-t..SYSTEM-INSPECTION.FORM PART A CERTIFI CATION'(continued) Property.Address: Owner: Date of I pection: A-&,i_etA �` Q D. System Failure.Criteria applicable to all systems: You must indicate"yes" or"no"to each.of the:following for all inspections: Yes Ng i/ Backup of seWage into.facility.or system component due to.overloaded or clogged SAS or.cesspool Discharse-or ponding of effluent to the surface'of the ground.or surface waters due to an overloaded or clogged SAS,or cesspool Static liquid-level in the distribution-box above outlet.invert due to an overloaded or clogged SAS or cesspool Liquid-depth in cesspool isless.than 6"below invert or available volume is less than %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-SAS,cesspool or privy is..below high around water elevation. Anyportion.of cesspool or privy is:within 100>.feet of a surface.water supply or tributary to.a.surface water.supply _ V Any-portion of a cesspool.or.privy.is within:a Zone 1 of a:public well. Any portion of a cesspool.or is within 50 feet oft-private water supply well.: Anyportion of a-cesspool or-privyis:less than 1.00 feet but, eater.than..50 feet.from a private water supply well with no acceptable-water quality analysis,.[This system- passes-if.the well water analysis, performed at:.a DEP certified laboratory,for coliform.bacteria and:volatile organic compounds indicates that the.weli.is free from pollution from that.facility and:the:presence-of ammonia nitrogen andinitrate'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.] (Yes/No.)The system-fails,I have determined that one or more of tfie above failure criteria exist as described in :lfl CIMR 15303,therefore-the system fails.The.system-ownei should contact the Board of Health to dete'rmine�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 1.5,000 gpd. You must indicate either":yes" or"no"to each of the following: (The following criteria apply to large systems.in addition to the criteria above) Yes no the system is within 4.00 feet of a.surface drinking water supply _ — the system is-within 200.feet.of a tributary-to a surface drinking water supply — _ the system-is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone II of.a public water supply Well If.you have.answered".yes:"to any question in Section E the system is considered a significant threat, or answered "yes"'in Section D'above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system-in accordance with 3.10 CMR I5.304.The system owner:should contact-the appropriate regional office of the Department. Page 5 of 1.l OFFICIAL.I :SPE:GTION: 'ORS✓%—NO T FOR vOLtNT ARY ASSESSMENTS SU18SURFACE'SEW-AO.E DISPOSAL :SYSTEM IN' SPECTI03v FORiY1 PART B. i CHECKLIST Property Address: 2 Owner: i Date of pection: '. Check if the following have.been done..You must indicate`yes"or"no" as to each of the following:, Yes. Ito PPummiig,information was.provided by the owner,,occupant, or Board of Health. V Were any of the system components pumped out in the previous two weeks °' Has the systen received normal flwxs in the previous-two week period T Have large volumes of water been introduced to the system recently or-as.part o,fthis"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 siQns.of sewage back up? ' _ 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? . V — 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'determinedffbased on: Yes no .. _ Existing information. For example, a plan at the Board of Health.. _ Dete;mined in the field. if an• of the failure criteria related to Part C is at issue a' ration of distance ( Y PProxi is unacceptable) [310 CNiR 15.302(3)(b)] k Page 6 of 11. QFFICIA14 1NOECTION FOR VOLUNTARY.ASSESSMENTS. SUBSURFACE:SEWAGE:DISP.OSA'L SYSTEM INSPECTION. FORM .PAR.T. SYSTEM INTORIMATIOIN Property Add:ressc Owner: , 426J•- 'J.. Date of 194 pecti0n: 7 / FLOW CONDITIONS RESIDENTIAL�! Number ofbedrooms(design): Number of bedrooms(actuaI),: �J DESIGN flow:based on`310 CNl 15.200(for example: 11:0 gpd.x'of bedrooms): y Number.of current residents:. , J Does residence have a garbage grinder(yes or no):,1C0 Is laundry on.a separateaewage'systerr� (ye or no). .[if yes separate inspection required] Laundry system inspected(ye .or no):� . Seasonal use:(yes or na): Water meter readings, if av•ilable(last 2 years usage.(gpd)): Sump-pump (yes or no). O Last date of occupancy: ? J A46&te_,e9 ` COMMERCIAL/IND USTRIALvAh Type of.establishment:. Design.flow(based on 3 10 CM'R I5.203): gpd' Basis of-design flow(seats/persons/sgft,etc.): Grease trap present(yes:orno): Industrial waste holdinal tank.present(yes or no):_ Non-sanitary tivaste discharged to the.Title 5 system (yes or no): .Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION ` Pumping Records �/ Source.of information: Was system pumped as part ofthe.nspedion,(yes or no):�_LV() If yes, volume pumped: allons--How was quantity pumped determined? Reason.for pumping: TYPE OF SYSTEM Tai Septic tank, distribution box,soil absorption,system Single.cesspo.ol _Overflow cesspool Privy _Shared system (yes;or no)(if yes, attach previous inspection records,.if any) _Innovative/Alternative technology.Attach a copy of the.current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copyof the DEP approval _.Other(describe): roximate age of all components, date instal ed(if ow ) and source of information: Were sewage odors..-detected when.arriVing at the site (yes or no}: 6 Pare 7 of I l OFFICIAL INSPECTION FORM-NOT FOR'VOLUNTA:RY ASSESSMENTS SUBSURFACE SEWA*GE-D.ISPOS 'L SYSTEM.I3VSPECTTON FORM PART:C SYSTEM-1-INFO -M:ATION (continued) Property Address: l Owner: 1 Date ofI pection• -- � a? dez PUILDII*TG SEWER(locate on site plan) AYU Depth below grade: Materials of construction._cast iron 40 PVC other(explain): Distance-from private water supply well or suction Iine: . Comments(on condition`o`joints, vend-zg, evidence of leakage, etc.): R t SEPTIC TANK: V Iocate"on site ulan —( ) jeu Depth below grade:d �'�u u 1� jr ' �� Maternal of consruction:. oncrete•metal fiber-lass_polyethylene t —other(explain) - If tank is metal list age:_ .Is age:confumed by a Certificate of Compliance(yes or no)'.:—(attach.. copy.of certificate) Dimensions:?15. (1, ' Sludge depth = Distance from top of sludge to bottom-of outlet tee or.baffle:. Scum.thickness:, Al Distance from top of;Scum to top:of outlet tee or baffle` Distance from bottom of stun to bottom f outlet tee.or baffle: _ How were dimensions.deternine.di Comments (on.bumping recommendations, inlet and outlet tee or baffle condition, structuial integrity,liquid-levels a related to outlet invert, evidence of leakage; etc.): J - GREASE TRAP-j (locate on site plan) Depth below grade:. Material.of construction: concrete' metal_fiberglass_polyethylene°=other • {explain): — — .. Dimensions: Scum thickness: ' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum.to bottom'of outlet tee or baffle: Date oflast.punping: Comments(on pumping reconnendations; inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage;etc.): Page 8 of 1.1 bFFICIAL..INSPECTION -FORM-N0T.'FOR 0LUN-TAR--'.ASSESS)IIENTS. SUBSURFACE-SEW-AGE DISPOSAL, SYSTEM INSPECTION FORNI PART C. SYSTEK-INFORNIATION(continued) Property Address: C Owner: Date of In pection: . -0 TIGHT or HOLDING TANK: (tank must-be pumped at time of inspection)(loc.ate on.-site plan)- - ...f Depth.below Fade: Material of construction: concrete metal fiberglass_polyethylenz other(explain' Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present.(yes or no):. Alarm level: Alarm in working order(yes'or no): Date of last pumping: Commentsi(condition of alarm and float switches, etc.): DISTRIBUTION BOX:/(il'' resent must beo ened)(locate on site.plan)P P s Depth of liquid Ievel above outlet invert:21 Comments (note if box is.Ievel and distributiorrto outlets ual;.any evidence of solids carryover,.any evidence of ljzgka(7e 'nto 0 out of box, etc.), ,. PUMP CHAMBER:: �(locate on site plan): .. Pumps in working.order-(yes or no): Alarms in working order(yes or no)-. Comments (note condition of.pump chamber, condition of pumps and appurtenances, etc.): ;t i Page 9 of 11 OFFICIAL INSPECTION FORM.-NOTYOR.VOLUNTARY ASSESSMENTS SUBS'URFACE-SEVIAGE DISP"OSAL:SYSTEM h1SPECT ON FOR1�S PART:G ''SYSTEM INFORMATION(continued) . Property Address: L Owner: Date of In pection: SOIL ABSORPTION SYSTEM (SAS): � ✓ (locate on site plan, excavation not required) i If SAS'not located ex-olain why: Type - - . " . - ,, •.. � - - ` . i leaching pits, number:. =Xleaching'chambers,number: ileaching.,galleries, number: Ieaching trenches,f number. length: leaching fields,-number. dimensions: overflow cesspool; number: innovative/alternafive system. Type/name of technology: Comments (note condition of soil,.signs of hydraulic failure,level of ponding, damp'soil,'condition of vegetation, et ): .J 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.ofgroundwater inflow (yes or.no): . Comments (note con dition-of soil, signs of hydraulic fai lure,.level ofponding, condition of vegetation, etc.'): , PRIVS':, (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,)- 9 Paae 10 of 11 OFFICIAL INSPECTIO r TORM ..NOT FOR.VOLU-INT-ARY ASSESSMENTS .. SUBSURFACE SYWAGE:DISPOSAL SYSTEM INSPECTION FORM. PART,C- SYSTEM'JNFORMATION(continued) Property Address; Owner:; '. Date of I spection:. P? 7 .20 SKETCROF SEWAGE DISPOSAL SYSTEM Provide a sketch of the,sewage disposal system including ties to at least.two permanent reference.landmarks or benchmarks.Locate all:wells within 100 feet:Locate.where public water supply enters the building: ' ' IT . . Tk4 a 1V f 1 j l , Pate 11 of 1 1 OFFIC.IAI.,INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURTACE SEWAGE DISPOSAL SYSTEM.INSPECT]ON FORV1 .PART C SYSTEM.INFORMATION-(continued) Property Address: Owner: Date of I spection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated.depth to ground•water.! ' feet Please.indicate (check):all methods used to deternine the high ground water elevation: Obtained from system design plans on record -If checked, date of design plan reviewed:. Observed site(abutting property/observation hole within 150 feet of SAS) i Checked with local Board of Health-explain: hecked with.local excavators. installers- (attach documentation) f V/j Accessed USGS database-explain: You must describe how you established the high ground water elevatior: , , 5➢ ' g2r, ® alp" 11 f Permit Number: Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION n Site Location: Ll'l G j` Lot No. Owner: Gd�J�> Address: . Contractor.- Address: z Notes:__ STEP 1 Measure depth to water table to nearest 1/10 ft. ...................... .... .. ............:................ Date month/day/year STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: OAppropriate index well,........ !�w l OB Water-level range zone ................ STEP '3 ` . Using monthly report"Current Water Resources Conditions" determine current.depth to water level for index well ........... month/year STEP 4 Using Table of Water-level Adjustments , for index well (STEP 2A), current depth . to water level for index well (STEP 3), and water-level zone (STEP 213) determine water-level adjustment ........... .......................................:.............:......... STEP 5 Estimate depth to:high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) .................. ....:... .....:..:..:...... o .... ........................................ Figure 13.--Reproducible computation form. 1 6 .Of too. IF I /-IC: 6 fX 1 /y// ///pyJ fed I Loa5 -0 7 No. G�CJ _��/ ''. R Fee / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZippYication for �Diopogar *pgtem Congtruction Vertu Application for a Permit to Construct( )Repair('")Upgrade( )Abandon( ) El Complete System L?Irtdividual Components Location Address or Lot No. ` / _au C0� I� Owner's Name,Ad-drr�ess and T 1.No. e,A Assessor'sMap/Parcel �►- 4,,a g8hl`6iv/�G ®/y—�r- Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -7 71�g. �� Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( � Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow f L� gallons per day. Calculated daily flow .��d gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank fODD-Po/ . iY),,;/-I�rr- Type of S.A.S. y` /� G¢ ze l Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued b is Board of alth. Signed Date ®� Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued D,3 7 No. F;_:; A.� Fee a THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: �es Yes PUBLIC HEALTH DIVISION -TOWN-OF BARNSTABLE., MASSACHUSETTS ZIppYication for Di!5.pozal *p5tem Con5tructiou 3Permcit Application for a Permit to Construct( )Repair � )Upgrade )Abandon ❑Complete System L/Individual Components PP P ( Pg ( ( ) P Y P Location Address or Lot No. Owner's Name,Address and Tel.No. ���d �✓' ,5c��/tduliCf� Assessors Map/Parcel Installer's Name,Address,and Tel No Designer's Name,Address and Tel.No. ? 71- �3e9 Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder Other Type of Building ( 3�a?-,OV'e No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 1/d gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 106� 91 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) r Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar of Pealth. Signed Date Application Approved by Date Application Disapproved for the following reasons t Permit No. Date Issued ————————— —————————— r THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERYIFY, that the On-site Sewage Disposal System Constructed( )Repaired(V)Upgraded( ) Abandoned( )by er�Olf� j CDr1v` at 3 LEI D C t� UI has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. dated I Installer 1 Designer A n /i r• The issuance of this pemut/steal, o be con t construed as a guarantee that the sy m will function as des•'�gne� / Date / £ u 00 InspectorVi I ( 7Z� Fee J THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 'Wi5po5af *pgtem (Construction Permit Permission is hereby ran ed to Construct( , )Repair U�grade( ) bandon( ) System located at � and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this eit. Date: Approved by NOTICE: This Form Is To Be'Used For the Repair Of Failed. Sep-tic Systems Only. - CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS) i L � 4 hereby certify that the application for disposal works construction permit signed by me dated t? ZDz�D concerning the property located_at 3 / l,DAP/1`6011f- l" ', 60141 1—meets all of the following criteria: +� The failed system is connected to a residential dwelling only. There.are no commercial or business uses.assocated with the dwelling. /rae oil i s s classified as CLA„S I and the^ere ' � .;otanon rate is less than or _dual :o _ minutes pe. .nc:t. There are no wetlands within 100 feet of.he-=posed septic system +� :here are no private wells within 1-40 feet of the proposed septic sysem here is no increase in flow and/or change in use proposed There are no variances.requested or needed. The bottom of the proposed leaching facility will not be located less than five feet above the ma.-dmum adjusted groundwater table elevation. (Adjust the groundwater table.using the:t mptcr method when applicable] /If the S.A.S. will be located with 250 feet of any vegetated wetlands. the bottom of the proposed leaching facility will not be located less than fourteen(14)feet abovethe ma:dtnum adjusted groundwater table elevation, Please complete the following: . A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation +the MAX High'G.W. A*==./• DIFFERENCE BETWEEN A and B 3`7` Z SIGNED: DATE:. . /lalD (Sketch proposed plan of system on back]. 4;ham AQW..an I i TOWN OF BARNSTABLE LOCATION 3 Z &Q t T Q!/e° ✓ /, SEWAGE # VILLAGE 60 17 ASSESSOR'S MAP & LOTOO -03 INSTALLER'S NAME&PHONE N0. ,gor 1--e1.l-) SEPTIC TANK CAPACITY &VZ C-96 n / l LEACHING FACILITY: (type) 1+.f,L 4+n tars ��lJ (size) 170 r:t 70' A-? � NO. OF BEDROOMS 3 BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: 00 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist /d 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) "'(f Feet Funushed by (jCL c ale i ,he _ 'll,�i0AT1.0N SEWAGE_PE.RMIT NO_. —I, 32_C_otui_t Gome_Rd_. 81-269 VI-LL WE Cotuit Barnstabel, Mass. TNSTALLER__S _NAME_&_ADDRE_SS Old Town Landscape Contractors, Inc. 75 Dale Street, Abington, Massachusetts 02351 _BUILDER'S NAME _& ADDRESS _Seaside Associates --P-.Q._B_ox--?--9_,—Konum-e-nt B-e-ac-.., Mass. —.DATE_PERMIT_I.S-SUED:_May 2$_,_1981 —DAB—C_O.MP_LIANCE_LS.S.UER: ` I ' � Y'.'t l - ''6 G s �q a 1� 6i 6 — . �'� w i L0 CATION SEWAGE PERMIT NO. VILLAGE I INSTALLER'S NAME i ADDRESS i _ ►�� '� �C tq iCLJ tCZ BUILDER OR OWN R DATE PERMIT ISSUED 1I SE ✓t'e��fL. 7/23 �j DAT E COMPLIANCE ISSUED F rya b I a { THE COMMONWEALTH.VF MASSACHUSETTS BOAR® OF HEALTH 7 ( .41: .........OF......��� sa:. ..: Appliraa#iun for liapusFal Workii TouBtrnrttun Vand N OF�gs Application is hereby made for a Permit to Construct �, or Repair ( ) an Individual a is o System at: ROBERT_ � GORDON N ................--.... t�-i t /% --, *-----4� %�&'--- ----------_-. .......................... t•�----- �' � ---•-- r" --H&ERISD.N.. - Location-Address or Lot No. -.-� n � G)q��g 0 17493 Q Owner 0-Wt ,lam Address �S (Sa ......0 . Installer Address Type of Building Size Lot.... q. feet Dwelling—No. of Bedrooms............._�._._......._........___._..Expansion Attic ( ) Garbage Grinder ( ) P4 Other—Type of Building ....... No. of persons......... ._. ( ) ( )............. Showers — Cafeteria P4 Other fixtures ............................ ---•--------------------------------- WDesign, Flow...............................: �_.gallons per person per day. Total daily flow----....3_1�......._.......--..... lons. WSeptic Tank—Liquid'capacity.,l �4.'gallons Length...... �__ Width......: . . Diameter______ ______ Depth..-_.._a...... x Disposal Trench—No. .................... Width.................... Total Length..._.................Total leaching area....................sq. ft. Seepage Pit No..........J........ Diameter.......1.4...... Depth below inlet.......6-......._. Total leaching area...ZA..%.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) '-' Percolation Test Results Performed b ..._. A.R. _. �!�G�4'® _ .d C......... Date...:Z_A`:�f_ Y ``.. Wa Test Pit No. 1_4- _. ...minutes per inch Depth of Test Pit.....1 Depth to ground water...A4'M�f: Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ ......................................................... �....... O Description of Soil-1 :Z.... ..............�Y C �t�oyt..................... c _za F A4 - U -------------------- -------- ....I........................... 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 TZTLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' sued by th board of health. sig ---- - ......•Application Approved ..-----••--•-•-••......- -----• .•....... .. ..---•----- ate Application Disapp v or a following reasons:-•-----•------------------------------------------------------•--•--•---------------------------•-•----........_ .......................................... -••-----•------...........•••-----------.......-•---••....._ Date PermitNo......................................................... Issued....................................................... Date **TT ' k4 THE COMMONWEALTH 6F MASSACHUSETTS BOARD OF HEALTH tF° A .............OF...... .a. Af-'F!I 4................................................ Appliratiun for Disposal Works Tonstrurtiun permt OF Mgss Application is hereby made for a Permit to Construct or Repair ( ) an Individual e Dispp System at: ROBERT ................__........ .... Location-Address.......•••• ................. .............. •............ ...ors t No.----- - 0.1749 to �� /e �""� .. ¢„ c�W ..�......................... ................ ....... I$ ... ..... ........... ....................... ... ee -----• Owner �} JAddress - �p .:.1 t1Sa....w � "� 4 rod,, g •. @ 'ii,. ..................•---....--•-•••. • Installer Address dType of Building Size Lot.:.,% c.....Sq. feet Dwelling—No. of Bedrooms..........: : ...........................Expansion Attic ( ) Garbage Grinder ( ) W Other—T e yp of Building ....... '_'_ No. of persons............................ Showers ( ) — Cafeteria ( ) WOther fixtures ------------------------•--••••......-•------- W Design Flow.............................. 5 ..gallons per person per day. Total daily gow.......� �� ......_.... gal ons. WSeptic Tank—Liquid'capacity/,!° gallons Length....... Width-_ '.... ._ Diameter.....: .:....... Depth.. .... . .. Disposal Trench—No..................... Width.................... Total LeAgth.....................Total leaching area.._....,............sq. ft. Seepage Pit No........../........ Diameter....../ '_®..__ Depth below inlet......A.......... Total leaching area...: :�"_. ..sq. ft. z Other Distribution box ( ) Dosing tank ( ) r '-' Percolation Test Results Performed by...l'..............................................................£ ` 'e 't .. Y. .. Date...A1`..?............................ ,tea Test Pit No. L. ._ ._...minutes per inch Depth of Test Pit -_ ..... Depth to ground water......................... f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground-water........................ Q �r`"w �,. s NA^a.dot. Etl' ' . ;+'...�:SfAa.teM , w&'w vskl --��I_P�-------------------------------------------------------- Description of Soil r a •-•-•••.............. W ....----•-••-------------------------------•--•-•-•---•••----•-•-•----------------•-•••---••-•-------....•-•-•••-----.....-------•••-••--...---•-•-••-•----•-----•••-----------•........_..---•--....... VNature 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 TIT1..E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operat'on u it/Ceificcate of Compliance has been issued y the board o health. 00 Signed------_•----A lication A rove Date Application Disapproved for the following reasons:------•----------- .............................................................................................. ---•...........-•-•-------••-------•--••••-•---------•--•....................................•----•-•-•-.-•-•----•••--•--•----._.....-•-----•---•-••-••••------•-•-----•-••--••--•----•----------.._.... 1 Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (9rdif irat a of Toutpliattrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) bY---•------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•----------------- Installer at..................................................................................................................................................................................................... has been installed in accordance with the provisions,of TITLE 5 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 WILL FUNCTION`SATISFACTOR//Y. DATE............................................... , .. L..._.. Inspectors THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......................... No... ... FEE........................ Disposal Works Tuntrndiun rrmit Permission is hereby granted._.._`1/?.&'/e a---------------------------•----------------------..................................-•------- to Construct ) or Re air ( ) an Individual Sewage Disposal System atNo............. ? ------------ _ .f ._...... ----------------•-----•----------------------------------•---•---•----•--- Street as shown on the application for Disposal Works Construction Perm f. ..�� Board okHealth -----------•--------------------- •-------•--•----•--•--------------••------------------------------------------•-------.--._ / DATE................................ .............................................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) A , 11- I m / LI DATA it �i II !a° t i U �d{ EX!''�li rw'• � #' 7/1j1k113 �! \ t ' I jU, Zo.T' 30- Y n is r i ram; { /Z c-VISD 7- 2./ - fi3/ MCA E: L.'-7E s, _S_O LOG _NOTES P+ P_ + I Ew>'NQE FLOW= ��,�- �Yn=.. _V .� Z,5 L. � i 2. LE4( �i!''ti AREA= Ir J SEPTIC J '� p ! ' .3 / L ! �� ! 3.JE.fsTIC TANK - "mot, .f - �' �v��;��✓rn ( ' 4. A!L WGRK RUST COMPLY WITh lAt SS, FN�'�O;v'1IEN;M . C.C.DE TITLE 5 AND TOWN &OAt?D GI- HEALTH { spry { REGULATIONS _T " 5.BRICK TANK 5 PIT COVFRS TC+ W1Trift 12` ,)F C.RACE 6.THERE ARE NO WELLS V 17HIN IOC)' OF T HIS i_EEC?!!lJt, PIT, 10C,% _ 5A r V _ •,� .3EWAGE SYSTEM IS ?WORE THAN 25' F';iOM ,TRi- �f &: 7" c,o -' �,n E 'i—. (�j I"I/i Y�';lb 11 N �"I'- PERC RATE _ < p lJo.17453�p rt DATE' to2.� GR!1DE - ire 17 LZ- f"` .�„�-n ' ,a 7 L -- ��o �i ` nr` PI 'c: _s- -� . _ _1. j11IGH 1/4',rF�.?�Ii1 �( Ar,-�•.,_ i r19.7 0 9 ! f'sJ_ i I 9c?.77 �; G l ��s-o I r •0: �l _ . tL-1q.6 !� : { r 3/4 - l lf. Y.!.5;4 C! CFE TEE FI 5 FCztfNDATION SEPTI" TANK C�h: 6 r._'J"* P I T L ENGT:� . g wo-C H s L•EAr HINC, PIT S WERAC E SYSTEM JPROFILE WA-2F HARrxISG N� - -_ S CAL -= - ' PLOT; PLAN � �-�; SEWERAGE + EN�1^Jr ERLNG aATE _ h SYSTEM FLIN'i LOCKE JA",!w - 7- zU-err R✓: '^ �t:�J-..ar_ `'`� p I+}. r'art St I').1 iL�G /JS - �_- _ �_... �_ -3�---- S���^V t--���-�---�_'1`--•--�--- .� - .. _mac asp .._ F_. I I�"mil..`:'k c.::_ "ti S. .+naF .... � .. - .3 .._ L' ._e.-�ti"E.'�.-"#t)"',.:9ir...� '"»:.K•' Ii_- .. i i s'. .:.to=s.s :�Ni T'^_� i�,.�.r 3 _ _- �_ .. a � { i L > N 5 7- tt . Eypltn!�• ..r, I 0 +3o x o' 3Z „ L E etc r, r. fZtrUl��r 7 -Z3- 8 ! SCJ : E- DAT 501L. :.06 NOTES laa fS E lst'f-GE E:O.Y = _-_L f)A �L , 2. LEACHI'lio AREA= - c 7 5 ! j t 3.SEPT f t&NK 4..ALL WORK MUS7 COMPLY W1Th C a F'qvl^,0,N!Lr 'I7,,k_ t CODE TITLE 5 1.NIC'' TOWN 80ARU 01- ?'il^AL.714 � REGULATIONS -5.13RICK TANK & PIT COVERS Tii v TTHIN 12"3F CRAt?E I 6.THERE ARE NO WELLS WI'ii(N 100+ OF THIS LEaL:M�rbr, i, PIT.-AND—Tif-RE--iS-idf,'SEWAISE—L-*A-0HfNG--*&$-WIN lvl^' _ 1 e4---T.-HRi--WELL: �F 57ir 1 i W _•ftr• _ 7, -EWAGE SYSTEM IS MORE THAN 25' FR01`0 :-T;RI-ET �! ROR-R GOfi , + Z _,o b/4T HAriRiSON �;. A. PERC RAATE = < L //i rffi+ 4 'A N17a93�q i DATE: z FINI,H �r 4 a.,�•--- _.. - -_-ter_ ----� �= .--- �'" .�_ I 16 ww.yy��ss may^, 11 _ 11��—fi't l4 v G. _ u/� +lp TUH I,''4' F T.,AlN. '�TR"T` = /C +,ia �1, 98.77 ~f< / � ;v, s'o 1 ' 3 ¢" ;Ij �t<+Sl Cf TEE T'EEcIt FC .NDAT ION SEPTIC., Tt,NK i ' fi I -• Cep 6!-00' PIT WIDTI1 - st L'EA('HI(4C, PIT _ t � EMa�R�►GE SYS'TEl1 3' �FiLE w�>�f`e.� p1 �.^'3 S+f'��.G / 1/ S l..Y►E�'A V E HARRISON�.. �ENGIN� ,ERING � LOT" F�_ A� Y'S T c — " �v4l-n PSI?J'� LOCKS_ .rf1\i _ r : Z F0'2 5t A..iv r'4