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Home My WebLink About4742 FALMOUTH ROAD/RTE 28 - Health 4742 FALMOUTH RD. COTUIT \ A = 010 001 001 i r i u f It Town of(Barnstable Geographic Information System March 29,2013 010043 99999 �tai t tSt 39 01000'1002 #474,D ,Vc^u s D1DD03 021 0100D1001 #4742 v� - y,p 5�r 010002 009031 44758 iF 4748 00"03 04702 009L002 q3 125 Feet OD0004 DISCLAIMERS:Tnb ma Is for mmn purposes only. Itrs not ao=_ �-te rori� i Map:010 Pareel:001001 N tounoary de0-rminaucn er rsgu�ry interrpret�auon. Yniar,-rrpn s teycna a scal cr Selected Parcel Owner GlL'AORE,'t.1ARYAIJN Total Assessed b'a.lue:S1z1200 r-ttn•may not meet estaeusnt-d Map accuracvstan0ards. The paaceilnzson±usmap yy E na acrly.grapnlc repesem3llons cnAssessor:staxparcats.Tney arenot true property Co-Owner: .Acreage:DAD acres Abutter. tounuanes and 07 not represent accurate reranonsnipsto pnyo arreatures on me map. Location:4742!FALMOUTH AOADIRTE 28 'r %`.•`.,. ,$r suxr astunoing to autos. Buffer ..- Commonwealth of Massachusetts Title 5 Official) Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 4742'Falmouth Road Property:Address Karen McCue Owner Owner's Name information is required for every Cotuit MA 02635 03/40/42' page. CityRown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms rnay:not be altered in any way.Please see completeness checklist at the end of the form.. 9 Important:When filling out forms A. General InformationiA� I; on the computer, +use only the tab 1. Inspector: key to move your cursor-do:not Michael Kellett ke'Qhe return Name of Inspector -1 y .. z'a Aardvark Environm.entaG Irts ections e6 Company Name. PO box 896 ' Company Address03 w East Dennis MA 02641 City/Town State Zik Code 508-385-7608' St 3742: Telephone Number License Number [3 M � rvt 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 16.340 of Title 5(310 CMR 15.600)."The system: ® Passes ❑ Conditionally Passes: ❑ Fails ❑ Needs further Evaluation by the Local Approving Authority 4 yin tI r 03./12/12' Inspector's Signature P 9 Date The system inspector shall'submit:al copy of this inspection report to the Approving;Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or,greater,the inspector and the system owner shall submit the report to the appropriate regional office of;the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ""This report only describes conditions at the time of inspection and underihe: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•11/10 Tide 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection: Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4742 Falmouth Road Property Address Karen McCue Owner Owner's Name information i e required for every Cotuit MA 02635 03/1:0112' page. CityfPown State Zip Code Date of Inspection B. Certification (coat Inspection Summary Check A,B,C,D or E I 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 snore 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"notdetermated"(Y;N; ND)for the following;statements.,if"not determined,"please explain. The septic tank is metal and!over 20,years old�"orthe septic tank(whether metat or not):is structurally unsound,exhibits substantial infiltration or exMtration or tank failure is imminent.System will pass inspection if theexisting tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is,structurally sound,not leaking;and.if a Certificate of Compliance indicating:that the,tank is less than 20 years old is available.. ❑ Y ❑ N ❑ ND-(Explain below): t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official, inspection Form _ a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4742 Falmouth Road Property Address Karen McCue Owner Owner's Name information is required for every Cotuit MA 02635. 03/1'011'2' page. City/Town State Zip Code Date of Inspection B. Certification (coat 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 wilt 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:(Explains below),- distribution,box is leveled orreplaced' ❑' Y ❑' M ❑ ND below (Explain ) i ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will.pass inspection if(with approval of the Board of Health): ❑ broken;pipe(s)are.replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is-.removed ❑. Y ❑ N ❑. ND(Explain below): C Further Evaluation is Required b the Board of'Healtl:: q Y ❑ 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 riS 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 El Cesspool or privy is within 50 feet of a:bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 3 of 17 Commonwealth of Massachusetts Tithe 5 Official, Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4742 Falmouth Road Property Address Karen McCue Owner Owner's Name information is Cotuit MA. 02.635 03'11.0/1'2' required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fait:unless the Board of Health (and Public WaterSupplier,if any) determines that the system is functioning in-a,mannerthat 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:septictank 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 t00 feet but50 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 ofammonia 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 ❑ ® 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 ❑ ® Static liquid Level in the distribution box above:outlet invert due:to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6",below invert or available volume is less than day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official: inspection- Form s Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments 4742 Falmouth Road Property Address Karen McCue Owner Owner's Name information is Cotuit MA 02635 03l10'/1`2; required for every page. CWTown State Zip Code Date of inspection B. Certification (coot.) Yes No Required pumping more than 4 times in the last year NOT due,to clogged or ❑ obstructed:pipe(s). Numberof 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 ofa cesspool or privy is within a:Zone 1 of`a,public well. ❑ ® Any portion of a cesspool or privy is within.50 feet ofa private water supply well. ❑ ® Any portion of:a cesspool or privy is Jess 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 feca'l coliform.bacteria indicates absent and:the presence of ammonia nitrogen and nitrate nitrogen isequalto or less than:5 ppm, provided that noi other failure criteria:are triggered.A copy of the analysis and chain of custody must be attached to this form.],, El ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The systemfails..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 1 ,000.gpd to 15,000 gpd. For large systems,you mustindicate either"yes"or"no"to each of the following,in:addition to the questions in Section D. Yes No ❑ fl the system is within 400 feet'of a surface drinking water supply ❑ ❑ the system is within 200 feet of 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 11'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-11/10 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 4742 Falmouth Road Property Address Karen McCue Owner Owner's Name information is required for every Cotuit MA 02635 03/1 OK2` page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following;have been done.You must.indicate`yes"or"no"as to,each:ofthe following: Yes No, ® ❑ Pumping information was provided by the owner, occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two,week.period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(if they were not available note as'N/A) ® ❑ Was the facility or dwelling;inspected forsigns 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? ® ❑ 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)j D. Systeminformation Residential Flow Conditions: I� Number of bedrooms(design):; ' 3 Number of bedrooms(actual), 3 DESIGN flow based on 316 CMR 152M(for example 110,gpd ::x#of bedrooms) 330 t5ins•11/10 Title 5 Official Ins pection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System,Form-Not for Voluntary Assessments 4742 Falmouth'Road Property Address Karen McCue Owner Owner's Name, information is Cotuit MA 0263'5: 03'/1'0/1:2 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information Description:. Number of current residents: 1 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 years.usage:(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercialflndustnal'Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 1'5203): Gallons per (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? Ell Yes ❑ No Water meter readings if,available: t5ins•11110 Title 5 Official Inspection Form:Subsurrace.Sewage:Dsposall System•Page 7 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System form-:Not for Voluntary Assessments 4742 Falmouth Road Property Address Karen McCue . Owner Owner's Name information is required for every Cotuit MA 02635 03/1:0/1:2 page. Cityfrown State Zip Code Date of.'Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe,below):: Generat Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑I Yes; No If yes,volume pumped gallons: How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box,.soff absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared systems(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 M system by system operator under contract ❑ Tighttank.Attach a copy of the DEP approval., ❑ Other(describe): t5ins-11/10 Trde:5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora s Subsurface Sewage Disposal'System form Not for Voluntary Assessments 4742 Falmouth Road Property Address Karen McCue Owner Owner's Name information is required for every Cotuit MA 02635 03/10112 page. City/Town state Zip Code Date of Inspection D. System Information (cont.) Approximate age of all:components-,date installed,(if known)and source of informations 06129/01 per BOH Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 2.5 feet Material of construction. ❑cast iron 40'PVC ❑ other(explain): Distance from:private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): Depth below grade: 1.8 feet Material of construction: ®concrete ❑!metal O fiberglass ❑polyethylene ❑other(explain) If tank is metal,list age: years Is age confirmed by a Certifica tel of Compliance?(attach a copy of certificate).. ❑! Yes ❑ No Dimensions: 1,500 gal . . Sludge depth: 3" t5ins•11/10 Title.5 Official Inspection form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4742 Falmouth Road Property Address Karen McCue Owner Owner's Name information is required for every Cotuit MA.. 02635 03/10/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cost:) Distance-from top of sludge to,bottom:of outlet tee:or baffle: 28" Scum thickness 2' Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom,of scum to bottom of outlet tee or baffle 17.E How were dimensions determined' measured Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): The tank was sound and.tight with,tees in.place and liquid at outlet,invert. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: [I concrete El metal 0'fiberglass E]polyethylene Q 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 outlettee or baffle. Date of last.pumping: Date t5ins•11/10 TrUe..5 Official Inspection Form:Subsurface Sewage.Disposal.System•Page 10 of 17 tsx Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments 4742 Falmouth Road Property Address Karen McCue Owner Owner's Name; information is Cotuit MA: 02635 03/10/112 required for every page. CitylTown State Zip Code Date of inspection D. System Information (cont.) Comments(on pumping,recommendations,inlet and outlet.tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc:): Tight or Holding Tank(tank must be pumped:at time of inspection)(locate:on site plan). Depth below grade: Material of construction: ❑ concrete ❑ metal ❑.fiberglass Ell polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons:per day. Alarm present: ❑` Yes, ❑` No: Alarm level: Alarm iin 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-11/10 Title Official Inspection Form:Subsurface;Sewage,Disposal:System-F'age 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form: Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4742 Falmouth Road Property Address Karen McCue Owner Owner's Name information is required for every Cotuit MA. 02.635 03/10/12' page_ City/Town State Zip Code Date of Inspection D. System Information (coat.) Distribution Box(if present:must be opened.):(locate:on site plan): Depth of liquid;level above outlet invert even 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.): The box was level.and:tight with,no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑, Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition�ofpump chamber,condition of pumps and appurtenances, etc.): Soil Absorption System;(SAS)(locate on site:plan,excavation notrequired)..: If SAS not located;explain:why:', t5ins•11f10 Trtle.5 Official Inspection Form:Subsurface Sewage Disposal'System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official lnspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 4742 Falmouth Road Property Address Karen McCue Owner Owner's Name. information is Cotuit MA 02635 03'/,1`0/1'2' required for every page. City/Town State Zip Code Date of inspection D. System Information (cont.) Type: ❑ leaching,pits number: ® leaching chambers number: 2 ❑ leaching galleries number: ❑ leaching trenches number',length,:; ❑ leaching,fields number;.dimensions, ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil'',signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has 2 500 gallon drywells surrounded by 5'of stone.There was no sign of ponding or failure in the stones. 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•11/10 'Title 5 Official Inspection Form:Subsurface Sewage'Disposal System•Page 13 of 17 Commonwealth of Massachusetts W`s Title 5 Official Inspection Form Subsurface'Sewage Disposal System Form-Not for Voluntary Assessments 4742 Falmouth'Road Property Address Karen McCue Owner Owner's Name information is required for every Cotuit MA 02635 03KOL12' 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-11/10 Titles Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 f Commonwealth of Massachusetts Title 5 Official inspection Form Sufuurface Sewage Disposal System form-Not for Voluntary Assessments 4742 Falmouth Road Property Address Karen McCue Owner Owner's Name information is Cotuit 1 MA 02635 0311`0/12 required for every C otu fawn ; State Zip Code Date of Inspection Page- D. System lnformation (cont.) Sketch Of Sewage Disposal.System:Provide a,mew 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 n. drawing attached separately i i t j Ceos- -2 3 z 3a i f i t 1 TH*5offiewinspamnFam-.Subsu ftcOS—JgeDkPO W SYSMM'Page 15 of 17 t5ins-11/R) 1 Commonwealth of Massachusetts Title 5 Official: Inspection Form Subsurface Sewage Disposal System Form—Not for Voluntary Assessments 4742 Falmouth'Road Property Address Karen McCue Owner Owner's Name information is required for every Cotuit MA. 02635 03/1'0/1'2 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 1:8.1 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 06/25101pate ❑ 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 USES database-explain: You must describe how you established the high,ground water elevation: Engineering plans show 18.1 feet to ground water. :Before filing this inspection Report,please see Report Completeness Checklist on next page. t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form. Not.for Voluntary Assessments, 4742 Falmouth Road Property Address. Karen McCue Owner Owner's Name information is required for every Cotuit MA 02635 03/10/12 page. Cityrrawrr, 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 high7 groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or,attached(in,separate file I t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 f i i Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 4742 Falmouth Road property Address Karen McCue Owner owner's Name MA 02635 _ 03110/12 information is ilJft Zip Code Co State Date of lnspedion regtrired for every C tu ftwn page. D. System infivrmation (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 1.00 feet.Locate where public water supply enters the building.Check one.of the boxes below: han d-sketch.n the area below �. drawing attached separately 33 i i r a � a{ ag i 3a aD' Tale 5 Otfuyaf bspecnon Fortrc SihvutFeCe Sevwa9 �A Syg m•Page15of17. t5ins•11110 j TOWN OF BARNSTABLE :: LOC ON iz�S t VILLAGE. ASSESSOR'S MAP & LOT., �� / INSTALLER'S NAME&PHONE NO. SEPTIC:TANK CAPACTfl' ISOD' LEACHING FACILITY: (type) d .��PUIi�PA�S (size) NO.,OF BEDROOMS - BUILI17 ?FR.-OR OWNERr� �n PERMTTDATE COMPLIANCE DATE Separation Distance Between.the:.. . Maziinum Adjusted Grpundwater Table andBottom of Leaching Facility Feet Pnvate Water,Supply We1l.and Leaching Facility (If any:wells exist on site or within 200 feet.of leaching facility) Feet :Edge of Wetland and Leaching Facility(If:any wetlands exist within 300.feet of leaching facility) Feetp. ` Furnished by .ci r IF f i • , 6 Z. i v W. 3-�r r ' TOWN OF BARNSTABLE ; 'yy'�,/J l L"ocA Kr I TION �� F//INiUt'h �Q .SEWAGE #- VII..LAGE: .u,�`Y�/l ASSESSOR'S MAP & LOT' 1-O f j INSTALLER'S NAME&PHONE NO ( A�n ''SI�CC ire 3, �7'l SEPTIC,TANK CAPACITY 1SOD. LEACHING FACILITY: (type) oC Det-tax, (size) NO..QF BEDROOMS - BULL 1DF,R DR OWNER _ PERMITDATE 6/c��`��O IANCE DATE Z� 1 =COMPL :: Separation Distance Between the tt Maximum`Adjusted Groundwater Table and Bottom of Leactung Facilty Feet r "i P#yAte Water Supply Welland Leactung Facility (Lf any wells exist on`site or within 200 feet of leaching facility) Feet Edge of Wetland and'LeacWng Fac lty'(If any wetlands exist within 300;feet of' 'leachiing facility ) f F sht urns ed-b i Feet ' t ! i€' 3 C ...Y � E (2 36 ,1 - � 3�'6 k TOWN OF BARN.STABLE v LOCATION SEWAGE# 2-CO VILLAGE �'f� �,� ASSESSOR'S MAP &LOT /0 INSTALLER'S NAME&PHONE NO. �6� D :eyo 36 -3�d 1 SEPTIC TANK CAPACITY lSOO LEACHING FACILITY: (type) oC (size) NO.OF BEDROOMS BUILDER OR OWNER C7"-30 A PERMTTDATE: 6 AYJO I COMPLIANCE DATE: 6 Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge.of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by A 's :&v ;u4 U _ ID 3FV � -jC�3�Q� - C)3A M THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ve, PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zippfication for Digpoml *pztem Construction permit Application for a Permit to Construct( AZepair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. 4;4a, F ql m oAb�?A . Owner's Name,Address and Tel.No. dAA. '�;Ob CA>b* j SSOUl--'05 Instal ee 's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -R5',h 5" /R _2/ — C. : Type of Building: Dwelling No.of Bedrooms 41 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow AST gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank R S QAI /T Type of S.A.S. . Drr ai up Us Al' Description of Soil Nature of Repairs or Alterations(Answer when applicable) f'�ABPt .p smears` Lg! 16-00 gal, /aAyt DR 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 syste:min operation until a Certifi- cate of Compliance has been iss b l this Board o flea h. Signed Date Application Approved by r Date WL17—_ Application Disapproved for the following reasons Permit No. Date Issued �� T * No.�/5 6 3 r. FeeG� THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:" es PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS TippYiration for Mi-qpozal 6potem Construction Permit - �y Application for a Permit to Construct( _ epair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. µ';142- Fq)moL4 JeA , Owner's Name,Address and Tel.No. Assessor'sMap/Parcel d a yool-Got C'�f�i tF Cs� 6SS Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. nC'e'sh 's —Ile <L/A VC , 4. 'ypQ•t�X A?,x 7` doh4.7! 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 ST gallons per day. Calculated daily flow SS gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank 1 500QAI s/Y' Type of S.A.S. 4 Dnit Ajp li s W <4o", Description of Soil 1 i t Nature of Repairs or Alterations(Answer when applicable) Po)Aee Qur OPssDm lit/ 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 syste t%'operation until a Certifi cate of Compliance has been iss �y his Board o Heal _ / . Signed _ NNN111 Date Application Approved by Date g:! f ®l 'Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance / THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired Upgraded( ) Abandoned( )by (?ASA '5' t��z laic at q '/Z has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Pe NAZ5/- Zvi dated 4> Installer Designer The issuance of this permits hV not a construed as a guarantee that the syste i funo`t`io-tva designed . Date to V Z% o/ Inspector l ff-/I ,A � _ 0 ;?7 No. '" �� ------------------------ ,a al- 4,"7 � �s THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS lwiopogaf */ p!tem Con0truction Permit Permission is hereby granted to Construct(✓)Repair( )Upgrade( )Abandon( ) System located at 47V.2. ,�A�i A A/, a,hj/ 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 •t. Date: �' �� Approved b - Z�l 1/6i99 NOTICE: This Form Is To Be Used For the Repair Of Failed _ Septic Systems Only. - CERTIFICATION OF SKETCH :-ND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PER ET (V=0UT DESIGNE},PImNS) Ash hereby cerdiy that the application for disposal works consrucnon pernit signed by me dated_ /Ol rQ z conce.r-111*na the property located at &2l=A �cy ��lb, meets all of the following criteria: R•�n� The failed sysem is tonne✓ed to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • The soil is classined as CLASS I and the percolation rate is less than or equal to 5 nunutes per inch. j� There are no wetlands within 100 fe`t of the proposed septic syse n There are no private we'ls within 1J0 fer:of the proposed scout srs°n • There is no increase in flow and/or change in use proposed There are no vananct requested or needed • The ooaom of the proposed leaching facliry will not be located less than five fee:above the m amum adjusted groundwater table cierauon- (Adjust the 2--oundwater table using the F=, ptor method whey applicable] • >f the S.A.S. will be located with=f0 fee:of anv vegetated wetlands, the bottom of the proposed lezic'ung facility will not be Iccated less hap founeen(1 feet above the ma.- m cimu .adiusted uoundwater table e!evadon, Please cotnolete the rollowina: A) Too of Ground Sur.-ace =!riation(usn;CIS iruornauon) 30' d 30• B) G.W. Ele•�ation S _the�tA2(. Fjah G.W. Adjustment . 4,7 = 4 8,> $�•8 D r)r_RE`+Cc BET-W=Ev ?,and 3 S! VDA7r--. (/ (S!�etch proeosed plan of s-;Tze-n on bac_c1. a::^.=h;old✓r.c� Yam e Q �j o ar NZ