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HomeMy WebLinkAbout0227 EISENHOWER DRIVE - Health 227 Eisenhower Drive, Cotuit _k F Commonwealth of Massachusetts 4�)`39— .23 o Title 5 Official Inspection Form ; ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f Z—`tseo Agwet,- oDlItle- J`j Property Address � Jr ��id ev►q o :� Owner 04 information is Owner's Name u`. / v ' OC4'? n0 required for every /!page. Cityr7own State Zip Code Date of Ins p ction 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 filling out forms A. Inspector Info tion 01# //37-T � on the computer, use only the tab key to move your Name of Inspector �w (0 cursor-do not �/ use the return Company Name / .Q key. � / o`1 _9U Company Address ;_� �/ QS 7 (/J a N'/ _ �� City/To wn -i+� /�/ �O State � Zip Code Telephok_Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the syste 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. '❑ Fails �- Lo Inspector Signature Date 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 has a design flow of 10.000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. 5insp.doc•rev.7fM2018 Tile 5"`day lrspection=0=,!subsurace Sewage Csposai System•Paget of 18 L ' Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address /^ �y 1 Owner Owners Name C information is required for every 1,4 0.2 4 3 ji; c2- a page. CitylTown State Zip Code Date of In ection C. Inspection Summary Inspection Summary: Complete 1, 2: 3, or 5 and all of 4 and 6. 1) System P s: 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: 2) 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 exfiiltration 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): A 45insp.tloc•rev.726/2018 Tale 5 07fioai inspe^_acn=0 m:Suosurace sewage 7sposai system-?age 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form 1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments Property Address Owner Owner's Name ,L� information is co �.1 //�/J �as �5' C�f7 required for every page. City/Town State Zip Code Date of Insp tion C. Inspection Summary (cons.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.7/26/2018 .,tie 5 officizi:nspeccn Form:Suosutace Sewage.�isposai System•?age 3 of 78 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System For m -Not for Voluntary Assessments Property Address old / 4ow� r vla Owner Owner's Name l information is Uf �pL 3� O� �s p�Q required for every CO page. C4 Town State Zip Code Date of Insp ction C. Inspection Summary (cont.) ❑ 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 b. 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. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well'. Method used to determine distance: **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 must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No" to each of the following for all inspections: Yes No ❑ Backup of sewage into facility or system component due to overloaded or gged 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 t5insp.doc•rev.7262018 Title 5 Oi9dai'nspecaon Po.-:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address, Owner Owners Name � / information is a� O��3�/° , required for every page. CityrTown State Zip Code Date of spec6 C. Inspection Summary (cost.) 4) System Failure Criteria Applicable to All Systems: (coat.) Yes No J Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool u Liquid depth in cesspool is less than 6' below invert or available volume is less han 1/2 day flow ❑ i— Required pumping more than 4 times in the last year iYOT due to clogged or obstructed pipe(s). Number of times pumped: Ly� 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. LK Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. �� Any portion of a cesspool or privy is within 50 feet of a private water supply well. I� 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.] —a�The system is a cesspool serving a facility with a design flow of 2000 gpd- 0,000 gpd. Le 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. 5) 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 C.4. 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 —i the system is located in a nitrogen sensitive area (Interim Wellhead ad Protection L Area—IWPA)or a mapped Zone It of a public water supply 7 i9e 5;:fSCa inspetion For:subsu=ace Sewage aseosal System•Fage 5 of 18 t5irtsp.doc-rev.7262018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -NNot for Voluntary Assessments Property Address , Owner Owner's Name '^ information is I /T 0 G,3s �Id S �V required for every /14page. tY Ci (Town State Zip Code Date of Inspecto C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no" foe each of the following for all inspections: Yes o ❑ umping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑r s the system received normal flows in the previous two week period? ve large volumes of water been introduced to the system recently or as part of inspection? re as built plans of the system obtained and examined? (If they were not ailable note as N/A) as the facility or dwelling inspected for signs 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? r,/ ❑ Was the facility owner(and occupants if different from owner) provided with Ird' 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)] ?iUe 5:1t`aai inspa;�on=pr;n:Subsurface Sewage Disposal 5yste..•?age 6 of 18 t5insp.doc•rev.?l26=18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �- Property Address Owner Owner's Name // information is O I �/� 0.1G3 � 1 required for every �/� O` page. City/Town State Zip Code Date of Insp flion D. System Information .1. Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): DESIGN flow based 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: / /�O aip? _I G G tow Number of current residents: Does residence have a garbage grinder? ❑ Yes No Does residence have a water treatment unit? ❑ Yes '— No If yes, discharges to: Is laundry on a separate sewage system? (include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes RNo Seasonal use? ❑ Yes L_No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump Pum ? Yes P Last date of occupancy: Date [Sinsp.tloc-rev.712620t8 Title 5;,"tdai lospectior,=cm:suesudace sewage Disposal system•Page 7 o'18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a Seytiave., Property Address , Owner Owners Name information is required for every GI l/a bJ� O?� page. City/Town State Zip Code Date of lnspe tion D. System Information (cont.) 2. Commercial/industrial 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information.- Was system pumped as par of the inspection? ❑ Yes �No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.0oc•rev.7126/2018 -itle 5 of oal inscec:on=orrm Subsurface sewage Disposai System•Page 8 of 18 Commonwealth of Massachusetts w Title 5 Official Inspection Form t Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owners Name c information is 04(,41V � 0a6�3 �J �O required for every page. City/Town State Zip Code Date of Insp ction D. System information (cost.) 4. Type of S m: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all lcomponents, date installed (if known) and source of information: / 9 A0 Were sewage odors detected when arriving at the site? ❑ Yes ' o 5. Building Sewer(locate on site plan): A f Depth below grade:. feet S Material of nstructi�40 st iron �PVC ❑ other(explain): / G � I Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): -tle 5 ci 4rspecticn Fo,^r:S::^surface sewage Disoosai system•Page 9 of 18 t5insp.doo•rev.71262018 Commonwealth of Massachusetts Title 5 Official Inspection Form k Subsurface Sewage Disposal System Form -Not for P Y Voluntary Assessments Property Address Owner Owners Name ��04::;) O on is 6dG /required for every S= page. City/Town State Zip Code Date of Ins ction D. System Information (Cont.) 6. Septic Tank (locate on site plan).- (/ Depth below grade: / feet Material of struction.- concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: -years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: '15 X Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 31-3 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 were dimensions determined? ao �C Comments (on pumping recommendations, inlet and outlet tee or baffle conditi structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ld� f✓I I?0/ �l2.C� 4 GN (vi d (oN C -'4-00 At tSinsp.doc•rev.7126/2018 -iae 5 oiniaai inspecoon Form-suosurace Sewage Disposal System-Page 10 of 78- Commonwealth of Massachusetts Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Formm--Not for Voluntary Assessments Property Address QV1�0 Owner Owners Name information is u page. Clt / required for every _Tovm State Zip Code Date of Inspect' n D. System Information (coot.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑i fiberglass ❑ polyethylene ❑other(explain): Dimensions'. Capacity: gallons Design Flow: gallons per day T;de 5(:f`aa'.irspzcuon Forn:suosudace Sewage-Disposal System•?age 1 t of 18 t5insp.doc•rev.7126=18 1 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments L Property Address evlcr Owner Owner's Name information is Co 4C41 required for every page. City/Town State Zip Code Date of Inspec' n D. System Information (cons.) 8. Tight or Holding Tank (cont.) 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 9. Distribution Box (if present must be opened) (locate on site plan): /�Iv�>rr ✓�. Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): I / rye 00 Z-oca�ed . ?;te 5 of`�.cei Msp�uon=0=.Suos::face Sewage Disposal System•?age 12 of 18 t5insp.Coc•rev.7/262016 c� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / L /Seel ho clew— Property Address r Owner Owner's Name /VXDd ��� information is required for every State Zip Code Date of Ins ection page Ci 17own D. System Information (cont.) 10. 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.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan; excavation not required): If SAS not located, explain why: �6 c f w Type: u O leaching pits number: ❑ leaching chambers number: 17 leaching galleries number: leaching trenches number, length: ❑ leaching fields number, dimensions: [] overflow cesspool number: ❑ innovativeiaitemative system Typeiname of technology: -ine 5 boa ns?e-von=orn:S's"' Sewage Disposal System•?age 13 of 18 :Sins,doc•rev.71262018 Commonwealth of Massachusetts �,N6�,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments I el lSem hoc4� 0/ Property Address �q Owner Owner's Name ' information is AV' /�J required for every N v�b 2 Q page. City/Town State Zip Code Date of Inspepon D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): A 4-e �S 0.3 o i`�' I is 114ly- 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7f26f2018 ':ine 5 Dfficai;r.spevion Foam.Sucsudace Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title, 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C) )r _ Z— eve Property Address . elil A t� Owner Owner's Name r� information is - O, a a0 required for every page. '6-,- Town State Zip Code Date of Inspe tion D. System Information (cons.) 13. 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.): Tore 5.?fhaa,insoacuon=arm scosurface sewage Disposal system.Page 15 of to 5msp.coc•re,7[262018 Commonwealth of Massachusetts Title 5 Official Inspection Form �'� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address � Owner Owner's Name NA 0 information i 4-s required for everyCo_A4OAJ7 5 Y /.�. page. 5 /Town State Zip Code Date o-i insp ion D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the§ewage disposal system, including ties to at least two permanent reference landmarks or marks. Locate all wells within 100 feet. Locate where public water supply enters the build' . Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately I f A /ten Sep4r c NHS ��reYs �za i -z,, Sfnh j i t5insp.doc•rev.7/26120 1 8 Title 5 Baal icspectlon=ozn:Suosurtace Sewage Disposal System•Page 16 of 18 I Commonwealth of Massachusetts e Title 5 Official Inspection Form 1 b Susurface Sewage Disposal System Form -Not for Voluntary i94'W;-'74Z P Y o untary Assessments Property Address Owner Owners Name n e&I information is required for every page. City/Town State Zip Code Date of Inspe on D. System Information (cons.) 15. Site Exam: Ej � O Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells 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 ❑ O ed site(abutting propertyiobservation hole within 150 feet of SAS) Checked with I'll-Ward of Health - explain: G s ❑ Checked with local excavators; installers- (attach documentation) ❑ Accessed USGS database- explain.- You must des e w you estabiis d the ni ground water eievati n: X9 t-1 �a e . S, 14. f-5 A620//Z— i o a „ �l✓r�-9r�' Before filing this Inspection Report, please see Report Completeness Checklist on next page. 5inspAoc•rev.7/262018 -R;e 5�tic;al.nspemon For:suosutace Sewage Disposes system•Page 17 of 1a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address , Gem o Owner Owners Name L /�information is C041W f T (/ required for every page. City/Town State Zip Code Date of Inspecti n E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. Certification: Signed & Dated and 1, 2, 3, or 4 checked inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 dure Criteria)and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached p For 15: Explanation of estimated depth to high groundwater included isposal system•?age 1b o!18 t5insp.doc•rev.7/26/2018 ';ue 5�eoai ins?e-=n=o� Suosur"ace Sewage D PAN TRY AREA = = " 84-*S.F. HALL WA Y AREA = 4° 51-*5 F LA UNDR Y ROOM o AREA = 149--kS.F 11=7" DRW PROPOSED PA N TR Y A ND LAUNDRY ROOM LA YOU T SCALE 4 1r r 1 �_.. TOWN OF 13ARNSTABLE LOCATION Z-?7 ' An' SEWAGE # VILLAGE ASSESSOR'S MAP &LOT � INSTALLER'S NAME&PHONE NO. ©��G© /9 7�7��✓7T 1� SEPTIC TANK CAPACITY 006) 6M LEACHING FACILITY: (type) (size) b 7y NO.OF BEDROOMS ll// )) BUILDER O O J`Q11M. y PERMTTDATE: ,,�COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bonom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist Feet on site or within 200 feet of leaching facility)t Edge of Wetland and Leaching Facility(If any wetlands exist s /� Feet within 300 feet of leaching facility) i Furnished by 1 �7vl a O 40 y . No. d f n I Fee y 'THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 3pplicatiou for Oigpogai *r5tetu Cottg;tructiou Vermit Application is hereby made for a Permit to Construct( )or Repair(tan On-site Sewage Disposal System at: Location Address or Lot Np. Owner's Name,Address and Te.No. ��p�1 y'f1iy1 �m�/1J4� Installer's Name,Address and Tel No. .7 b J , Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Garbage Grinder( O Other Type of Building lfC2 No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow OW/9 gallons per day. Calculated daily flow 3 �� gallons. Plan Date Number of sheets Revision Date Title Description of Soil / /DOO Or G Nature of Repairs or iterations(An wer 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 th' d ealth. Signed Date Application Approved by r Application Disapproved for the fo owing reasons Permit No. �� " 2�l Date Issued �' rf No. , V l o. Fee yTHE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIPPrication for.Mi000l *wpm Com9truction Permit Application is hereby made for a Permit to Construct( )or Repair(✓�an On-site Sewage Disposal System at: Location Address or Lot No. Owner's Name,Address and TSI.No. Installer's Name,Address,and Tel.No. ,.y Designer's Name,Address and Tel.No. t Bo yD��Cr�ystr j r� ,e�lQrs�o�s'�.//,s Type of Building: Dwelling No.of Bedrooms 3 Garbage Grinder(✓ D Other Type of Building zlt 5/ �NC2 No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow // gallons per day. Calculated daily flow 330 gallons. Plan Date Number of sheets Revision Date Title Description of Soil Nature of Repairs or `)terations(An wer when applicable) �5��� /DDO�,r'��Od �l %>` rose l'��,a14 _ p 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 t '. d ealth. Signed � 7�� _.--- Date Application Approved by Application Disapproved for the fo owing reasons - 711�r Permit No. / G 'c2 �� Date Issued THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO C RTIFY,that the On-site Sewage Disposal System installed( )or rep ' ed/rep .ced( on by �� /? G O for 7�®j9'1 /%O Z4 as 2 2 7 G/S,0N 4®k/,10'" ,Dr: CD X W) 7- has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. ., / dated -r- 3 0 -t . Use of this system is conditioned on compliance with the provisions set forth below: ' I '0_+ ez, No. /G 1 3 Fee T b i t THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mfgpo!gal *pgtem Construction Vermit Permission is hereby granted to to construct( )repair(d/)an On-site Sewage System located at X 2 :7 cat v/7- 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. All construction must be completed within two years of the date below. Date: .S--3 o'"r Pe; Approved by 0 l CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION I'Elt11111'(�V11'IIUU I'llCSIGNEU PLANS) hereby certify that the-application for disposal works construction permit signed by me dated concerning the property located at meets all of the following criteria: /Ticreem are no wetlands within 300 feet of the proposed septic cyst 1cre arc no private wells within 150 feet of the proposed septic system :/Tlic observed groundiviter table is 14 feet or greater below the bottom of the leaching racility t/ T "re is no Increase in flow and/or change in use proposed There are no variances requested or needed. i SIGNED: DATE: LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER JAtfach a sketch plan or the proposed system. Also if the licensed Installer posesses A certified plot plan, this plan should be submitted). MIPll Wg 'r .` 4,�,^2v�'�' c ' .. _ ai%._� :C..L • dSROOSEVELT ROAD. � LOT 54 FLOB"' 2 I F j IA 21, 1'63 s•�. �� a T k QLi ny' LOT 55 � C ER.Ti PIED PLOTIr ONUS PLAN f sct�i_re L.00ATtOtV., •cQ7tJ.t�, SCALE . . �. O -YpA >t " PLAN REFERENCE • ANG�. 11014AS E. KP;LLI;Y CO. ,L.7.PJ �C'. . . .� .r�..b 2 `...��t . • _. LAND SURVEYORS f 34G LONG POND DRIV$ t SOUTH YARMOUTH. MASS. • - 1 CERTIFY' THAT THE .f•?.7Vhltr� l�.s,l. ,SHOWN ON THIS'PLAN IS LOCATED ON THE GnOUND I AS'SHOWN HEREON AND THAT IT CON FORMS TO f W RMAL-rY ��2V;-r- THE ZONING LAWS OF TFIE TOWN OF 5 7 Q M iq I N v -r♦R E 1:T ' 31.E. , WM EN POMSfRUCTEO. ?r ?"I7f:lkir_;� �( Y,� N :\l r KA _ GATE . '�9�7� /1�'�.,. : . ,� ,% y z# , ' L000T1.QN 5EW W:G E PERMIT-._1J0. . ; �pdu'a3 . VILLAGE ' ZgAn- IwSTAl L:ER�S U&NlE e, ADDRESS �UILdR`� tJ & &.DDRE SS . DIN, :P� :RN�1T ISSUED 6 I- x ' COMPLIb6KICE ISSUED — — nF r of - o i - � .ran. t €' a k"'` ♦ -Y'17' k °,wy {°73t9F�'� --C�/Y✓ GT-_/eve , - — — IhIST-ALLER�5-IJ�NIE--�--ADDRE.S.S------ - - - - --.- - - �' RO BUILDER. _- D.AT-E- -COMPLI W ACE -ISSUED "�Z - eoE c i O / - THE COMMONWEALTH OF MASSACHUSETTS BOARD-OF HEALTH l5 �9 .............. oll .--. - OF.................. s. -.. ..L44./.-o.........-............... Applirtttion -for Uhipoottl Workii Tonitrnrtion Vaniit Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal System at:, d ............................................ Location Address ot' -0.„ Oyknor dres O��nstall �yy�' _ Address Q Type of Building �d JJ/// Size Lot----------------------------Sq. feet U Dwelling—No. of Bedroom -_______-__��_____. __ -_________Expansion Attic ( ) Garbage Grinder ( ) Other—Type T e of Buildin C______________ No. of ersons--______3________-_ A, YP g�-- --�'---- P ______ Showers ( ) — Cafeteria ( ) I a' Other fixtures ------------------------------- -- W Design Flow---I......................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity_/L'Lt_U-.gallons Length.... ......... Width................ Diameter---------.------- Depth---------------- x Disposal Trench—No_ ____________________ Width____________________ Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No--------------------- Diameter-------------------- Depth below inle�j___G_.-_________ Total leaching area------------------sq. ft. z Other Distribution box ( ) Dosing tank / ;G i2 aPercolation Test Results Performed bY-------------------------------------------------------------------------• Date-----___------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water_:___-____-__--____-_- fs, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water__-__-_________-____---- �+ ----------------------------------- O Description of SoiW- 10-1 .�' ---- ------ � v� 't � ' ------------- c� .. ----------- 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 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 the board of health. Signed...... s _ •- ......� cl --- - Date Application Approved B ! `� �I 7 - PP PP Y '!! � `��% --------------- -•-•••---•--------------------••--------•--._...-•----------•----------••-••.._..--•--- Date--•---•--..._. Application Disapproved for the following reasons:- ' --•--•-------------------•----•----------•------•-------------------•--------------------------------------------•----•--- ----------•----•-•---- -------__-----------------------•--------------•- Date PermitNo....................................•.................... Issued....................... ................................ Date u...a�- --- �...�.. ..�..—. . ------------------------' --� L- K. THE COMMONWEALTH OF MASSACHUSETTS BOARD-OF HEALTH .__.......�-.. (���i. ......OF....!.......:��� .. .0......................... Appliration -fur Prrtltit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at wb 1�---L°) ........................X- -.1-___ _.A-------••--•-----------------------•--•--•-•------ _ Location-Address or Lot No. k.0 ^ .. O nor Addres Installer Address UType of Building _ Size Lot---------------------------- feet Dwelling— � -�_____________________________ExpansionttAttic (- ) Garbage Grinder ( ) p, Other—Type er Typeoof Buildingm __ ._.�_______________ No. of Persons... ._.............. Showers ( ) — Cafeteria ( ) al Other fixtures ------------------------------- -- W Design Flow.. .......................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity/C0----gallons Length______________ Width___.......... Diameter---------------. Depth.__.._-_._._. x Disposal Trench—No_ ____________________ Width-------------------- Total Length-------------------- Total leaching area.__..._.____...____-sq. ft. Seepage Pit No--------------------- Diameter---------------_.... Depth below inlet.................... Total leaching area______.._.___...__sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Z - ;� S-- 7 G# aPercolation Test Results Performed by---- --- -----------------------------------------------•------- -------- Date----•----------------------------------. Test Pit No. 1................minutes per inch Depth of "Pest Pit-------------------- Depth to ground water..________..-_.__.___- (Zq Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water_..__._____.___._______- ' `= O Description of Soil - �� ' Gr+ - G-Iv P ��¢ 1�.1 x - f/,'��./ /�I,c.2 �/ / W6= /fr 6lr�t —._.cT .---. fi --------------- ----------------------- -------------------------- ----------------------------------------------------------- --------------------------------------------------------------- V Nature of Repairs or Alterations—Answer when applicable..._____1 _______________________________________________________________________________ _ - - - -- - ------------------------------------------------------------------- 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 p the board of health. Signed...... f / Date Application Approved BY----------------------- ---3 -//- Z. ------------- / Date Application Disapproved for the following reasons:._.__---_ __________________________________1.---.---______-_______-_-__-----------_.-------__________•---- i t.,. Date Permit No.......................................... ` 1'. issued............ _ ._._.. L THE COMMONWEALTH OF MASSACHUSETTS-f ,,� BOA�ARD, OF HEALTH x ......::.. '�!`. .........O'F r':. ,.� r,�?.: dam. ...f.. ..................... vrrtifiratr of 10.111mphaurr ZS�TO CERTIFY, Tiat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) n Y Installer, at..._(�:tl�"'_-�--f------ �' :- - - 1- - � ¢ v td "-- r V........................................... has been installed in accordance with the provisions of A iclt XI of The State Sanitary Code as described in the application for Disposal Works Construction Pe-rmit,No.�•�":=:7j/-/..................... dated_._.__'-&...-:.7.. .............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------...... ................c_-2.--................._Z�..... Inspector---- C---- --= .. . ----- ---------..............-- THE COMMONWEALTH OF MASSACHUSETTS / BOA F HEALTH / 7 7... ... .. ........OF... ,.. ..... .A�..�.. .1... ........ .......... f No. ----•- FEE--•- L ............ �i�� �rk,� nl��� rttrti�at �rrmit 441 Permission is hereby granted---- - -....•--..----•-.......... to Con ruct ( ) or epair ( ) an Individu 1 Se age Disposal �System Street as shown on the application for Disposal Works Constructio ermi No---_ ---- ---------- Dated____,3.-.�-1-_7G................. -------------------------------------- f. DATE................................................................................ Board fflealth FORM 1255 _.HOBBS & WARREN. INC.. PUBLISHERS 1 Y {. l ZN U'� \ U o 4 p �M„4 uelL�'�rr� C EI°EGG U",11 E D / W LAry/CA'MNV .�•�,J-•j-, 7,t,wi�~! +14,!'�,1y:1�'.'.3•. , CA L C Jn'�.�6i'Q '""P' r, � r*n_• ;�' {r ss M , �•. ..r.. _ 2 j 1- c .J��.i;;J rl.i�..^ �.o . .0.`1..1y�Y: f': ,..•�. r LAND, SURV.EyOTtS sac LONG POND DRIVL I . . . . . . . . . . . . . . . . . . .. . . . . . . . . . SOUITY-.i 7CA"OUTH, MASS. - 92664 1 CEG•'4TI FY' TFV,T Th y .F';��?.,%1''d„i.�l,ti,,..,y :{,�'>!. Sn.9fabi'AJ 1 ON THIS PLAN i i t.:.GC/S.7'ED 0".14 "!'i~iY:: t:�lZ2:yUCG�) „'"3-ICiJ N 1-0-U0N ANO CHAT ITC014r0,c'As "i'U y:. J AL—rY THE ZONING LAVIS OF THE •4owra car- WHLN DAT .i �P Vr i'� { F> N ;,.1 4