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4120 FALMOUTH ROAD/RTE 28 - Health
4120 18t'r Cotuit 1 A I� C� 1 Town of Barnstable MAS& Board of Health 91A$3 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 Paul J.Canniff,D.M.D. FAX: 508-790-6304 Donald A.Guadagnoli,M.D. Junichi Sawayanagi Certified Mail# 7006-0810-000-3525-3787 May 7, 2018 Mohammad Shafigue Pepper's Pantry - Big Daddy's Pizza 4120 Falmouth Road Cotuit, MA. 02635 Email: partypell@yahoo.com NOTICE OF HEARING .- BOARD OF HEALTH RE: Pepper's Pantry - Big Daddy's Pizza, 4120 Falmouth Road, Cotuit , 1 st Violation On 4/16/18, cigarettes were sold to a minor (a person who was under the age of 18 years) by a person employed at your store. According to Section 371-7(B) of the Town of Barnstable Code, revised on August 23, 2016, no person, firm, corporation, establishment, or agency shall see tobacco products to a minor. According to Section 371-8 of the Town of Barnstable Code, "any proprietor(s) or other person(s) ... who fail(s) to comply with these regulations shall be subject to the following actions for each offense: A fine of $100 may be issued for the first offense. A fine of$200 along with a 7-day suspension of their tobacco permit may be issued for the second offense, a $300 fine along with a 30-day suspension of their tobacco permit within a three year period may be issued for the third offense, and if a fourth violation occurs during a three year period, they will lose their tobacco license altogether. You are hereby notified to appear before the Board of Health on Tuesday, May 22, 2018 at 3:00 pm to show-cause why your tobacco sales permit should not be suspended and to discuss any future plans you may have to comply with this regulation. The hearing will be held in the Town Hall, Selectmen's Conference Room, 367 Main Street, Hyannis, Massachusetts. PER ORDER OF THE BOARD OF HEALTH Thomas A. McKean, RS, CHO Director of Public Health Q:\TOBACCO\WP Files\tobacco hearing letter Big Daddy-Pepper Pantry Apr 2018.DOC S MTCP ID: Tobacco Compliance Check Form 2014-2015 Section 1: Establishment Survey Participants Name: ���� ID of Purchaser: Address: q1 Age: ❑ 16 17 Sex;g-Male ❑Female �t,,�; Name of dult Supervisor: City: Z, C t.(/(-f Zip Code: 6C Time of Check: amR�pm❑ Type of Establishment: ❑ Chain c9 Independent ❑ Not Known Date of Check: A / Day of the Week Man ❑Tues❑Wed 0-tM Q l� CCU 1 ❑Thurs ❑Fri ❑ Sat ❑Sun Style of Establishment(Check Only One); Convenience Store ❑Grocery Store ❑Bar ❑ Department Store ❑Liquor Store ❑Private Club FW Legion,etc.) ❑ Gas Station Only ❑Pharmacy/Drug PharmacyjDrug Store ❑Restaurant ❑ Gas Mini-Mart ❑Other(bowling alley,golf club etc. ❑Tobacconist Section 2: Was Compliance Check.completed? Yes e No El If Yes please conlimse on to the new question,i(No please skip this section and go to section 3. H9 w was tobacco marketed? CK-Over-the-counter:youth asks the clerk for the product. ❑ From a vending machine with a lockout device. ❑ Other Describe: Was the Purchaser asked for ID? Yes❑ No Was this an ID-based check? Yes❑ N004 Was the Purchaser asked his/her age? Yes❑ No Sex of Clerk: Male❑ Fe=46 Approximate age of clerk:❑Teen ❑Young Adult 09 Adult ❑Older Adult Type of tobacco asked for: ❑ Cigarettes Brand of cigarettes asked for: Marlboro ❑Newport ❑Other: ❑ Chew/Dip ❑ Cigars ❑ E-Cigarettes ❑ Other Brand: Was the product requested flavored(NOT Tobacco or menthol)? Yes ❑ No Was the sale made? Yeq%-No D 1 'If"Yes"how much dial the product cost: $ f/ I� Was a receipt given?Yes❑ No Purchaser made payment using.❑ 1 bills ❑ 5 bills ❑ 5 bill and$1 ill r chankc❑ 10 bills 20 bill ❑ change Section 3: If the youth did not enter the premises or did not attempt to purchase tobacco products please indicate why: ❑ Out of Business ❑ Temp.long term closure ❑ In o eration,closed at time of visit ❑ Drive thin only ❑ Does not sell tobacco ❑ Unlocatable ❑ Unsafe to access ❑ Tobacco out of stock ❑ Inaccessible by youth ❑ Wholesale only /cartons ❑ Presence of police ❑ Permit Suspended ❑ Private chib/personal. ❑ Machine broken ❑ Other residence ❑ "Don't sell"but tobacco seen in ' storeltias permit 4/14/15 q = 9 COMMONWEALTE OF MASSACSUSETrS 'BUCLMn OMCE OF ENVIRON WZWAL AFFAIRS DEPARTmmNiT OF ENVIBONDAENTAL pROTzCnOx � w TTn.E 5 Omcu L INSPEi noN FORM-NOT FOR VOLUNTARY ASSlESBMEN'i'S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CFRTMCATION Properh►Address: 7. . O�er's I + ` q j Zoe o X, Date of L bqpdwt p*d)h 11641k. f"" r- 'lFelxpheslo Nambmr. - . CERMCATION STATEMMT I ow*dot I have personally idepmxtod the wwaa disposal system at this addmu add dot the below is true Saco a and CWWO as ofthe time ofthe bspecdon.The � in� wm patted based an my. pauper tmcd=and nnimemem of an ales nwap dim!syetemL I ap a bgp approved baeenr Fmmt to SOW=13.3i0 a This S(310 CHR J&WI MW Purees •• CoadkiooaftPrimes g. Needs FGAW EvaliMm by lk Local Approving-Auft ity . 7-7 hmpfttoes S Daft 7be sY shoo sakmit s oopry►vit�is rep��lo the A A9►(Hoa3ti ofIV DEP)whin 30 days of eom tie impatim If the system is a dwW symtam or bes a desip Bow of 10,t Od ar 11 .the bRwcwr cad to system am=shill s ftb rho npott b to qp apimM&W oR6ct of DER 7%arigioa!should be seat to the symm owtmr and copal sent to the boyar.i!`applicek,and the Y• NOW add com omb. /000 G'4Z 6 � �I -� ' �t /000 64Z. � ZC gCYJ �)fi.� m ,ova 47"'Z �excp e- 19M / p� .*"'7'hb.report ad1►aeeetibas st the�of impeelion sad aaler tlge eemliMaas of aa�e at first time.This dove not>dble+=ter fly eymftm wW perbsat b dm llgilroGedwthessmardUbramt caedidoas of ass. e Page 2 of I 1 Olt'FiCIAL SP I.'!'IOMFOWN—NOT FOR VOLUNTARY A&US SAWJM BUBSMACE SEWAGE DMOSrtiL STBTEM INVECTION POIM . PART A • CMTMCATION(Continued) PMP"Address:, 2, Date of Inspectlon: Sammiuy: Check AAC D or E/ mmPlde VID of Section D A. System pames: I Uvi'M fotmd any h ormaticn Whfch it�dlcams that ofthe 15.303 or m 310 CUR 15.304 exist.,may More pia not = are m �� -d in 310 CMR Comments: B System Conditiona jy Pasacs: One or more SYSIMm components as d=Tfbed in the"C l pue aaaian need to be�plaoed or npau�ed.The sysopm,apon cOpkon of the replacemM'Or VRM,as approved by the Board of Heahh,win pass. Answer yes,no or not detamnned(Y,N,ND)im the for the fonowing statements.If`not determiner please �md,�tank Is metaland over 20 y dokgdo or the septa task( metal or�is ' mfiitration or acifiOratlon�tank�e is bmmmcmt, °'�' .stank is replaced with a compl*8��as htank eel by the Board of System�l�mvectiam if the sephe tank will Pass inapaxian Wit is any ; Wftft8 dM the tank is leu than 20 yeses old isavw3able. �S and if a Certific ate of Complia e ND avlahL 4'. Obsovmion Of sewage bada:P or b=*ant or odd p3pe{s)ar dne t0 a �ati* level in the distrMW n boot doe to1 .e approval Of Board Qf }: ,steed o!n base.System Will1�s mspax�on if(Witham Ot Waken )aced .......... t+emovrd �`' r. beat is m or replaced ND explain: systemreq=Wpwnping more than 4 times a year due to pan if broken or Will oval of the Board of Heahh); o pipe(s)•lie kokm PIPG(s)am raphtced obstnutka is rawved ND expo; Page 3 of I l OYMCML IN8PECTI09F6ItM-140T FOR VOLUNTARY SSMbUM SUMUMACE SEWAGE DEPOSAL SYSTEM INRZCTION FORM PART A CERTIFICATION( PropertyAddrw: AM RTH a Owner: G Date of Inspection: C. Further Evaluation is Required by the Board ofHealth: Conditions exist which require ii dw evaluation by the Board of Heath in order to daumme if the system is failing to protect public health,safety or the environment. 1. System will pass auks Board of Health determines in accordance with 310 C IR IS303(l)(b)that the system Is not lhnedoning In*manner mbM will protest public health,satiety sad the environment» _ Cesspool or privy is within 50 fnt of a surface avatar c ._._ CesspoW or pay is within 50 feet of a bad= vegetated w+ dand or a salt marsh L• System will tall unless tire,Board of Hed&(and Public water SuppHw if any)determines that the system Is lbndioning in a manner that protects the public la W4 safety and eievironmeait: N. . _ The system has a septic tank and soil absarption system(SAS)and the SAS is within 100 Beet 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 wed : The system has a septic tank and SAS and the SAS is less than 1001id but 50 feet or more fiom private water supply well**.Method used to determine distance "Ibis system passes if the well water analysis,performed at a PEP catti$ed laboratory,for coliform :. bacteria and volatile rapt c compoamds Heat the well is firem tlm"86,polbn m from that the presence of ammonia ntrog anti nitride 4 gi is equal tour less"5 ppm,provided that no farluta uiteria sp tt%Vred.A copy of the analysis must be attached to this farm. 3. Other: = ilyl . Page 4 of l l OMC AL INSPEMON•FORM•—NOT FOR VOLUMAEY ASSESSMVM .. SUBSUWACE SEWAGE DEPOSAL SYSTEM INSPECTION FORD PART A ` -C,ERT MATION( Property Address: J Owner: Date of Ia gwCAon: D System ARM Crkwb applicable to all systeme: You mast k4W to"yes"of`ne to each of*e following for gLhmpecdns: Yes o Bscloip of sewage late facility or system oomporreaR dne to overloaded or clogged SAS or cesspool _. Die or pmgg of effineat to the sntf M of the ground or aw im waters due to an ovrwioaded or clogged SAS or cesspool �. Static Uquld level w the dim box above outlet invert due to as overloaded or cloMd SAS or ,r CCSsp001 Liquid depth in cesspool is less the 6"below invent ar available volume is less thw%day$ow Requfrwi pumpk8 more than 4 flumes in flue last year M due to clogged or obstructed pipe(s).Plumber of times,pumped __.. Any partiatn of So SAS,wool or p tv7 is below high ground water elevadom Any portion of cesspool or privy is within 100 feet of a sarfine weber supply or en'buoary to a surface umbra supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. Any portion of a cesspool or privy is within 50*et of a private water supply well. Any portion of a cesspool or pfivy is Jess than 100 feet but gt+eater thus 30 Dees from a private watery,:, i supply weB with no accqtbk water malysas DIft SYNOM passes lithe well waftmatyai+g performed at a DIP end labond ry,hrr coMn u baeWia sad vahas otlateie;eearposmds twileafts tint the wen is tree Omar pollution errors that heinty sad the presses of amsmosin nitrogen and nitrate aitrogm Is agwAte or lees d=$" a,pr+oMed that so adwc idmre criteria ` are triggered.A eopy of the analysis out be attwhed to this form.] (YOWO)The system k1k.I have determined that one or man of the above 6tilure criteria,c&as ' desat'bed in 3l0 CIWR 15.303,tbeoe6oerr the system"L Thu syao m owaff should contm the Boa of Health to deoermine what will be ncmwy to correct the faun: L Lap To be emoddend a large systew the system mast serve a bretNty with a derma flow of I8'M ad to You mossireeither"yes"car-w to each ofthe (The fillowmg aft ern apply to law systwon iandditioam to tha cz me&above) yen no _ doe system is v4tVn 440 feet of a swr6ee&h&iug water supply the is vvittmo 200 feet of a systr� >:ftary to a scafaca drml®g water supply . the systetp is located in a nitrogen seaskive area(Interim Wellitead Pry Area—IWPA)or a mapped Zame IN of a public water supply well If you have answered W to any question in Section E to system is coudder+ed a sinflkwa threat,or amswend "yes"in Section D above the large sysb M has sidled.The owner or operator of a W large system considered a significalt Hoerr tender Section E or failed carder Section D shall Wade the system in accMhmce with 310 CMR 15.304.11w system owner should ewer the appmopriate regional office of the Department. I Page S of 11 OFFICIAL INSPt'CTIOXF0M-NOT FOR VOLUNTARY ASSESSMENTS SUBSMACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B'BECKLJS`T y Property V �b'irT Owner: Ay/ = �� Date ai Inapectlon: �� Check if the Poll have been done.You meat indicate "or-acr as to each of the foLVA. Yes No _ ping information was provided by the owner,occtpaat,or Board of Health Were any of the system components pumped oa is the previous two weeks? Han the system received normal Bows m the previvas two weals period? x Have large vohnnes ofwater been to the system rem*or as part of this won? Were as built plans of the system obmiaW and ?(If that'wens not available note as NIA) Was the&G ty or dwelling inspected for signs of wwage back up? Was the site inspected for signs of bawls out? _ Werra all system components,excluding the SAS,located on site? _ Were the septic tank manholes uncovered,opened,and-the of the tank inspected for the condition the of baffie s or tees,material of suction,dimensions,depth of tiquK depth of sfidge and depth of scam? Was the facility owner(and occupants if dit8ereat from owmr)provided with nnf motion on time pamper mafomocna- of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has ban deaf mdwd basal: Yes no Fadstng won.For w mmple,a pion at the Hoard of Ebaw . Determined in the field(if any of the fsib a critark sainted to Part C is at issue apFOXimation of . is unacceptable)C310 CW 15.302(3)(b)] �A": t (50 Ile Page 6 of 1 l OFMCIAL D (UPECTION FORM—NOT FOR VOLUNTARY . t' MENTS SUBSITIti+ACE SMAOE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION Pmp wq Adam: L&LO1 �owner. l er , . Date of Inspection:_ M A&L u w CONDITIONS REsia�ENTIA , Number of bedrooms(desip): Number of bedrooms(acwW. DESIGN Boat based on 310 CMR 15203(for cwmpla:110 gpd x#of bedr wo). Number of slut ram: Does reddwe have a garbage grindar(yeas br ao).' 13 bua&y on a sere somp wistem(ya or no): [if yes sepave Wpoedim nquh433 P Laundry'syst=bspected(Y=or up).� 2 Z D CIO GA(- D w 'm�err , (1a ;ymusw 8 o): loo q W ®oo(3,AL 610 G PD F Sump pump(yes or no): Lam date of omupmtcy: COMMMCULANDU Type of establialmmt Design BOW(based on 310 CMR 15203)•_ and Bads of design flow(saaWpaa.=- Gnaw tp l (Yes arno . or Nw"odtary �to the Title 5 sy syne (yes or nod Water meter readings,if le: �,�D5 'Z O 6�� 3 3 Last date of ►lf — a a y 113 0 vo sxl 610 Ca.PJ OTHER(dm*e): 3 GEMRAL INFORMATION PMpIWRe nb V, Was system pumped as part of the non(yea or no,): If yes,votaw pumped: s--Haw was gnamity ptmaped detetmiaed? for pimviv. TM OF WMMM -5, tmd6&Mlxdm box,so0 ai>snrpm'mmsystM - _._.. w cesspool �MY .Shared system(Yes or no)Of yes,attach previous impection r+000a+ds,if eery) ImsovativeJAhernedw Wcftobgy.Attach a cvpyof ties cmrant ope radon and mai m ome camum(to be obtamed from system owner) AU=h a wpy of dw DEP approval Otha( )r App=imm age of all wopamems,date installed if ��and somve of kfimua* : were sew w odors detected why arrivhsa at the site(ves or no)- Page 7 of l 1 OFFICIAL D(SPECTIOA FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM 1NSPEC n0N FORM PART C SYSTEM INFORMATION(wed) . Property Address: 0 9R tl T 1{t'f Owner. 0 Z,,Q,AW, I` t Date of Inspection: BUILDING SEWER(locate on site plan) Depth below'gradr. Materials ofc:onmacctiioa:peat iron L40 PVC.,_ether.( laid): Duce limn private water supply well or suction line. ' Comments(on condition of vet evidectx of mac. r�1 �:©oKS 1L�► ��b Catiy 1'i�1• SEPTIC TANK:)L(locate on site plan) Depth below tip= Material of w conc Ia motel_fiberglass__,lwlye&ylm other(explain) . If tank is metal list age:_ 1s age confionned by a Certificate of Compliance(yes or no):_ (attach a copy of certificate) Dimensions: k Shiage dqA: Distance frown top�to bottom of outlet tee or baffle: Satm th dwess: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scam to boom of outlet tee or baffie: Haw were dunenaiona determined: aft" 01/1'41 k��C. j — l� S l',(w_ e S� Comments(on pumping recontmendations,inlet and outlet toe or bdb condition,strommaal integrity,liquid*Ws as nhftd t D outlet invert;evidence of bdook etc.): A::. GREAK :�Loocatc on site plan) lid 1 of eonstradion:�Conc�e_metal_fiberglens_polyethylene other Distance fivm top of scum to top of outlet be or baffle: lie fit=bottom of=na to bottom of ou t tee or baffle. Dmms~o€laat pod ca ( phig t+ecbm nendations,laid and outlet tee or baffle amdition,stractsnal mtog*,lig d levels as related to outlet invert,evidence of leakase,etc.)• �p 'Page 8ofll OFFnaCIAL DtsA 'I'i09WAm—NOT FOR VOLUNTARY ASSES3�S SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM PMRMATION(eked) Property Address: � 010 0 Owaer: (, . Date of Iaapeelf�n: G D�, TIGHT or BOLDING TANK: (tank must be pumped at time of iaspearonxkxm on site plan) Dq&belmt►grade: Material of coustnXtion• eoncreoe mast': Sberglass•,polyethylene otber(uplain): Dimensions: Design Flow: day >' Alarm pant(yes or nol Alarm level: Alarm in watNg aft(yea or no): Date of im pumping Camenams(eou&tkm of slam►gad Boat swkcbea,etc DISTRIBUTION BOX: (if pa cut=at be opu ed)(loeate on site plan) Depth of hgmd level above oudet invest: `,,f 0 J vp°) M'4F t'zic Xrle,9 Comm(note if box is level and dWriludou to outlets equal,any evidduce of solids czar ,yover,air evidence of leakage into or out of bm PUMP CHAT MAX. (locate on site plan) Pumps in waift oa+der'(yes or no): Aiarms ... itt worlamB miler(yesorno): ComEw"(nee eoafton of pwV n of pumps and appoomweek etc.): Page 9 of 11 OFFICIAL INSPECTION'FORM—NOT FOR VOLUNTARY ASUSSN04TS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C "STEM INFORMATION(cam Property Address; �� 00�0T owner. ULexyv ►��1`� Date of Inspection: b SOIL.ANOR'MON SYSTEM(SAW X (IMU ma 09 Pbm,8110M tiom met required) If SAS located lain why: f ftltlt s JV9 0234 pitk .L leg chumbom number. leaching galleries,namber: leaching troches,number,length: r�Inching field as,numb ,ddiman la V w. erf1c� 1,fiber. � �y� - a Typoinaine Vy a tGWYWlow. Commenis(note condition of soil,sWa of hydraulic failure,level of poo4d4 soil,condition of vegetation, ew.): • t CESSPOOLS: (cesspool must be pumped as part of inspectionxlaate on site plan) Number and configuration: -t�of liquid to imlet imrmt Depth of soft layer: y Depth of scone layer: : Dimeomsions of txsRML Materials of consovctim ; Wig of Sw=dwaw inflow()vs or n4- Cow(nqo condition of soil,signs of hydraulic level of pondb*oond6m of vegy�ation,ate.}: Prjo: oocwx on Sim pkg) Mated*of construction: Depth Drimme Co wndition of sod,signs of hydraulic brae,level of pondnmg,c co tion of vepubon,dc;.r Page 10 of 11 OFFICIAL 1NSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SKWAGE DISPOSAL SYSTEM FORM PART C SYSTEM WORMATION(continued) Property Address: P( ATE 0 0 Owner. C-eA , T, LL r— � Date of Inspection: SKETCH OF.SEWAGE DISPOSAL SYSTEM Provide a skew of the sewagp disposal system including ties to at least two permanent rem marks or benchowkL Locate all webs vvi"100 fret locate wbere public water supply eimers the building. As 31 0 9 i3E '-A D 3 t CY ,, 2cj 9-T z C. � i Page 11 of 11 OMCIAL INSPEC'TiON-FORM—NOT FOR VOLUNTARY ASSESSMENITS SURSUWACE SEWAGE DISPOSAL SYSTEM INSPECI"dON FORM PART C SYSTEM INFORMATION(continued) Property Addres• •.� Owner. 'Daft of Inspection:_ •C 1-i d SITE EXAM Slope Surface water Check cellar." Shallow wens Em mated depth to ground water „feet Please indicate(check)all methods used to detemaine the high ground water elevation: Obtained ftm system design plans on record-if checked,date of design plan reviewed: Observed site(abutting popat.T.Ful , - hole widit 150 feet of SAS) Checked wilt local Board of H1mn: Checked with local excavators,installers-(suach damn) Accessed USGS plain: You most describe how you established the high ground water elevation: ". Y - r - COMMONWEALTH OF MASSACHUSETTS I EXECUTIVE_OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION t ' yy TITLE 5. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:. 1.,,20 Owner's Name: a. i Owner's Address: elo 1..-5 Date of Inspection: 3))i /o/ - Name of Inspector: (please print) C. 8 • f-tO a RECEIVED Company Name: ( e»J`�1's�lf, �ry,� i�nL�j�� �'c• , Mailing Address: w /� MAR 2 6 2001 Telephone Number: 50L V,a4-' g< TOWN OF BARNSTABLE HEALTH DEPT. 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 and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.34.0 of Title 5(310 CMR 15.000). The system: /Passes Conditionally Passes . eed urther Evaluation by the Local Approving Authority . Fai - i' Inspector's Signature: Date: �af . The system inspector shall submit a copy of this inspection report to the Approving. g 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 I0,000 gpd or greater,the inspector and the system owner shall submit the report to the.appropriate regional office afthe. DEP.The original should be sent to the system owner and copies sent to the buyer,.if applicable,and the approving authority. Notes and Comments of inspec tion and under the conditions of use at that ****This report only describes conditions at the time o p 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 6/15/200.0 page I Page 2 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: .)U x t 7t b mod, Owner: Date of Inspection: Inspection Summary: Check _A,B,C,D'or E/ALWAYS complete all tit 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 I5.304 exis t.An .failur e re criteria not evaluated are mdtcated below. . Comments: B. -System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair, as approved byB the oard of Health,will 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 exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a. omplying 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.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 obstruction is removed distribution box ifleveled or replaced ND explain: 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 obstruction is removed ND explain: 2 Page 3 of 1'l OFFICIAL INSPECTION FORM. - NOT FOR VOLUNTARY`ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION:(continued) Property Address: b a� Owner: ;O Date of Inspection: -2/,)//O✓ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system' is failing to protect public health, safety or the environment. L < System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b).that the system is not functioning in a manner which.will protect public health,'safety and the environment: _ Cesspool or privy is within 50 feet of a surface water Cesspool or privy.is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system.is functioning in a.manner that protects the.public health;safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is.within.1'00 feet of a surface water supply or tributary to a surface water supply: i tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic P _ 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 coliform. bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure;criteria are triggered.A.•copy of the analysis must be attached.to this form... 3. Other: 3 +3 Page 4 of I I OFFICIAL.INSPECTION FORM=NOT.FOR VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE`DISPOSAL SYSTEM-! NSPECTIM FORM PART A CERTIFICATION(continued) Property Address:Vdka Owner: Date of Inspection: 3 D. System Failure Criteria applicable to all systems: You must indicate".yes"or"no"to each of the following for all inspections: Yes Nr/ / Backup of sewage into'facility or system component due to overbaded"o"r'clogged SAS`orcesspool' _ Discharge or ponding of effluent to the surface of the ground oraurface 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 '/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ' of times.pump`ed Any portion ofthe SAS,cesspool or privy is below high groundwater elevation. Any portion 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 privy is within 50.feet of a private water supply well. Any portion of a cesspool_or.privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. ]This:sys'tem passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well.is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or less than 5 ppm,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 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 systen must serve a facility with a-design flow of 10,000:gpd to.15,000 gPa• You must indicate either"yes"or"no"to each of the following: (The following criteria applyto large systems in addition to the criteria above) yes no _ the system i.s.within 400 feet-of.a surface drinking water supply the system is vithin 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 310 CMR 15.304.Thesystern owner should'contact the appropriate regional office of the Department. '4 r Page 5 of l l OFFICIAL INSPECTION,FORM, NOT.FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST. Property Address: _Arw&je A Owner: _ M Date of Inspec ion: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No Pumping..information.was.provided by the owner,.occupant,or Board of Health .,, .t 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?(1f they were not available note as N/A) _ Was the facility or dwelling inspected for signs of sewage back up V i _. 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: Yes no _j l _ 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(3)(b)J 5 l Page 6 of l l OFFICIAL INSPECTION,FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION`FORM PART C SYSTEM INFORMATION Property Address: 64 Owner: Date of Inspection: 3/aj/0 i FLOW CONDITIONS RESIDENTIALL(j- Number of bedrooms(design):' Number of bed.r`ooms:(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have.a garbage grinder(yes or no): ,.•; Is laundry on a separate sewage--system(yes or no):_.f if yes separate inspection required) Laundry system inspected(yes or no):_ Seasonal use: (yes or no)`._ Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):_ Last date of occupancy: . COMMERCIAL/INDUSTRIAL Type of establishment:' TRIAL. Type /eUT9z'e 0g� � Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): , Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes orno): NO Water meter readings, if available: Last date of occupancy/use: OTHER(describe): " GENERAL INFORMATION Pumping Records n Source of information Was system pumped-as part of the inspection(yes orno):. If yes,volume pumped:_ gallons--How was quantity pumped determined? Reason'for pumping: TYPE OF SYSTEM Septic tank,distribution box,soil absorption system Single cesspool _Overflow cesspool _:Privy Shared system (yes or no)(if yes,attach previous inspection records,if any) Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy'of the DEP approval Approximate age of all components,date installed(if known)and source of information: Weresewage odors-detected when arriving at the site(yes or no)"IZ1>1,6-- 6 r Page 7 of I 1 OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE.DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION:(continued) Property Address: dll. iL A Owner: d_" jl� `a, Date of Inspection: BUILDING SEWER(locate.on site plan) Depth.below grade: Materials of construction:_cast iron _40 PVC_other(explain): Distance from private water supply well or suction liner Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:v((ocate on site plan) Depth below grade: �uaO�e Material of construction: k<oncrete . metal_fiberglass_polyethylene other(.explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a.copy of certificate) Dimensions: S 'X Sludge depth: Distance from top of sludge to bottom of outlet.tee or baffle: ` 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 baffler Now were dimensions determined:, , row (}ah��� Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels. as related to outlet invert,evidence of leakage,etc.): GREASE TRAP:✓(Locate on.site plan) Depth below grade:_( '& Ate`"`' 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): LP2f Gt1ta /OOp z� Q 1 ,� aawy' 7 Page S of I I OFFICIAL:INSPECTION FORM,-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART C SYSTEM INFORMATION(continued) Property Address: �b 112-011 A — Owner:. gne_114`,4..��-Alnyl a Date of Inspection: TIGHT or HOLDING TANK(flank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete_... . .metal fiberglass_polyethylene�other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of fast pumping: Comments(condition of alarm and.float switches,.etc.): DISTRIBUTION BOX:_t�(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: 1Z � Comments(note if box is level and distribution to outsets equal,an evidence of solids carryover,an evidence of q � Y STY � Y leakage into or 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:): 8 r Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE.SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION.(continued) Property Address: Owner: Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type - t/feaching.pits,number: t/leaching chambers,number: 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 pondinng, damp soil;condition of vegetation, ,?/,9 �2 l a d abC ,Co lek_ -P" 7� 40 a/A, 4 CESSPO.OL$e)a(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 or no): Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation;etc.): PRIVYV2:y pcate.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.): v - 9 Page 10 of 11 OFFICIAL INSPECTION FORM NOT TOR'VOLUNTARYASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYST:tM INSPECTION'FORM PART C . SYSTEM INFORMATION(continued) Property Address: ZI- dD ` o) Owner: Date of Inspect(on: 3/tea✓/C�/: SKETCH'OF SEWA GE DISPOSAL SYST EM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within ]00.feet. Locate where public water suppl enters the building. LAU lip /7 23 10 Page I I of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART.C . / SYSTEM INFORMATION(continued) Property Address: L//a® ko2h �e Z Owner: J Date of InspectiO : SITE EXAM. Slope Surface water Check.cellar. Shallow wells Estimated depth to groundwater 2 feet Please indicate(check),all methods used to determine 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) Checked-with local Board of Health-explain: hecked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: ®Gl Il TOWN OF BARNSTABLE LOCATION W49 4"-?f 2SPlWeb61413 SEWAGE # VILLAGE CO 1117 ASSESSOR'S MAP & LOT OW`11-5- INSTALLER'S NAME&PHONE NO. r � t SEPTIC TANK CAPACITY Coo 8 LEACHING FACILITY: (type) gut.."- t, (size) Y 5 ta—Evc NO:OF BEDROOMS BUILDER OR OWNER PERMTTDATE: A/7 —/f 9� 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by c i ]et-c- I D Ai �` 1417 or 3 s a No. "EH FeeTHECOMMO F MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Application for Mizpozal *potem Construction permit Application for a Permit to Construct( )Repair(/)Upgrade( )Abandon( ) ❑Complete System 0Individual Components Location Address or Lot No. L11 �TL/g/^, Ow rsName,Address and Teel.No. Assessor's Map/Parcel f1rA 'fJk114 94 , r Y ' � P a -15 Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building 404111e-&*APC& No.of Persons Showers( ) Cafeteria( ) Other Fixtures ® e `J Design Flow ��® gallons per day. Calculated daily flow 7 7' S gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /,l®® 4.�i10 ✓ 9 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when/applicable) �i G[ �O�f�� � $f 2 /w 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 this B and f Health. / Signed Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued i - ,. No. ( - Fee THE COMMONrWEALTH JF MASSACHUSETTS Entered in computer: l/ Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 21pplication forlmizponl 6pStent Construction permit Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) O Complete System Vindividual Components Location Address or Lot No. Own is Name,Address and Tel.No. Assessor's Map/Parcel /��i3Jdb1�� /' �/C✓� p COI`GIi�T G�c� Installer's Name,Address,and Tel.No, Designer's Name,Address and Tel.No. U Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building lah vieee e No. of Persons Showers( ) Cafeteria( ) Other Fixtures /J Design Flow gallons per day.,Calculated daily flow ..t � 7 7' gallons. Plan Date Number of sheets ? f " 'y-. RevisioW Date M "» Title t Size of Septic Tank /✓4p �,1'/«�r�N9 Type of S.A.S. 5 ?JG S 9�Any®7 ;i r' /OOd,4/ Description of Soil ��'4G6f CyQ'.ty 6z�'S Nature of Repairs or Alterations(Answer when pplicable)� � g. "�<�w �© d awal i ,o� /'e � fay/�Gt' .�� Date last inspected: 111 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 this`/Bard •f Health. I Signed (./ � vl�"' Date //1,/ Application Approved by Date ;/v Application Disapproved for the follow ng reasons 1 �1 �t Permit No. Date Issued" ? F - --.-. --.-..�.�.�.------------j--- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired(V)Upgraded( ) Abandoned( )by O//e- 4 7/ GD.*157" at `//ZO W T Z e /'Yl AW.1-17-e` rel has been constructed in accordance V with the provisions of Title 5 and the for Disposal System Construction Permit No. dated ' R Installer Designer The issuance of this p t shall not be construed as a guarantee that the system will function as designed. Date I O/ T Inspector No. O +O V`!� Fee k THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS xitpogal 6peum Con,5truction Vermit Permission is hereby granted to Co,}'struct( )Repair(►' )Upgrad ( )Abandon( ) System located at Y/ ZD zS�t, 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 permit. Date: Approved by 14 tT�;- c ` 10MM NOTICE: This Form Is To Be Used For the Repair Of Failed a Septic Systems Only... _ - Sep y y CERTIFICATION OF-SKETCH AND APPLICATION FOR A , DISPOSAL WORKS.CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I. (�0'0�✓� iJ, ®/'�®�, �hereby certify that the application for disposal works concerning the e �l K construction permit signed by dated, m a � property located at /2� /?�'"Z g �fUs�eels all of the Pro P y F, ioilowing criteria: /TT"here are no wetlands located within :00 fee:of:he proposed leccang ;aciiiry /7nere are no private veils •viEhin ifJ :eel of:ne:roposed septic systern r There is no Increase in ow andiar_hange :n Ise:r000sed i ere are no varancas requested or seeded. if the proposed leaching fac:iity will �e :ccatac-x thin :4�0 fee: o and wetiards. :he dercr �r Ze proposed leaching faciiity wiil =:e :ccated :ess:han :ourree: :e.:acove :he tax:n �r •=r roursd:aatEz.'rh.�eievatirn. - -_ Please complete the following: ZI5 A)Top or Ground Elevation k'according:o the Engineering Division G.1.S. ,napi B)Observed Groundwater;able Elevation(according to Health.Division well mho i a. 7r�g Z, ICI Z DATE: SIGNED LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER �Axttach a sketch plan of the proposed system-Also if ttie Iiceined installer poses=a cergfied plot plan. rMJ• .}�rp�:...�,,-�.x. �s��1 # " 1_..3 'tat-«;s' �s � iPW s -�6:t'.J4 K u ': Yw - ":.Yy r •j�f+^�k}.�r x h ri y} .3 f `?t+'-�Ps t'' *"_ ', �-Y..L�:'•a' S.yx''n•,rm,#�"+�`w +t�r�'# yhd��t � �. J� ..C. '� r�'!•r��fi oi``'Vr�'Jx �'��-',•'�,.+iu5 �'�c s �.!'�.=�'a.,v. � v. .��i -s.�^�'�, ,..,�..,e ��'-. — • -k':` .ss "r-'s? �.s.- �,-i �` 3: �u4€" ',e i.l'' � r.�` '3.:d+a+r-.. �-'.. _ �' ''=� S[ ..i V4 5,tv)P IA(rN ,7 / 5 O p� . I TOWN OF BARNSTABLE LOCATION �IQ?. � D )SEWAGE # VILLAGE �� t pL ASSESSOR'S MAP & LOT �&—, INSTALLER'S NAME & PHONE SEPTIC TANK CAPACITY AQ0 IG 66-0 027/9 LEACHING FACILITY:(type) 05 jIS -9? (size_)—6- ',e /b ol NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER BUILDER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No"— P, AN, No..................... FEB.... o-�... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for Di-npooul Works To$totrnrtion rrrmit Application is hereby made for a Permit to Construct ( ) or Repair 4Y—) an Individual Sewage Disposal System at: ( Ye/Ls r� y [-Address or o. ------l --•-•-..-- r/ � _CrZ� � K-e. /.{ldress l I�� �.V(.�a .....................•••••••••••••-•-------•-------•-•--•-••-•.............................. ...............................................! .74--•---•-•-•----------------•---------------- Installer Address UType of Building Size Lot............................Sq. feet t-, Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures - --• -----------•---•----•---------------------------------•--- --------......------•=---••••..............••---••----.-•-•-• W Design Flow................:... ...................gallons per person per day. Total daily flow-----------------s2 ..............gallons. WSeptic Tank—Liquid capacity.10QO___gallons Length---------------- Width---------------- Diameter......__-___.._ Depth__--________-. x Disposal Trench—No. .................... Width-------------------- Total Length--------- Total leaching area....................sq. ft. Seepage Pit No.......... .......... Diameter.._....�U..__-___ Depth below inlet..... _.._... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by..................................................................... ••-- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ W -------------------------------•----...•••------------•---•-•-._...---••--•--•-•---•---••-•••----........-••••--•••-••-•...•-••--•----•.......-------••--•-- 0 Description of Soil........................................................................................................................................................................ x U •--•-•---------•---------•-------------••------•-••-•--•-------••----••---•---------•--••••-•-•--•-•---•-----------•---•......----------•-•----------- ................................................ x --•----- --••------------- ------------------------------------------------------ -----•------•--•-- --------------------------------------- ---------- U Nature of Repairs or Alterations—Answer when applicable----,A.o_o A-------.��y.c�_ __...:.....��-�+� YET .W......7�------.`�iJ-�.-----SZ�3�--------�.......)'-4-------.....................................� ;� .............................. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complianjes/b n 12, issued b e board of health. Signed ........ J'��. g --------------- � /5 ........ /.... %..-..:.....:. Application Approved B - - � ` Date Application Disapproved for the following reasons- ---------------------------------------------- ------------------------------------------------------------------------------------ ............................... ................................................ ............................... Permit No. ---- ....... Issued .......-/ e G ............. ............... Date No._ � 3 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliration for MiVn!3tti Wor1w Towitrnrtiun Vamit Application is hereby made for a Permit to Construct ( ) or Repair (i<_ ) an Individual Sewage Disposal System at: --------•-----------------------•--.....--------...------....----------------------............... .----•------•------••••-••--•-•------•-----•-••--...-.--.--- ---------------'..---...•---- �----5�n-Address i or Lot No. c' U GL � S -------- ------ ••• ---- c /J ` U - Us�l LC„� Owner dress a i� CCU,...... 1 ,�!t�&..... '7 LPS �,��!�... Y ,NI . ✓cal � vt S Installer Address Type of Building Size Lot............................Sq. feet Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons___--__-_.____-__._______._. Showers ( ) — Cafeteria ( ) 0.1 Other fixtures -------------------------------- - - W Design Flow.............. ..__gallons per person per day. Total daily flow_-__-_.-•__--____,-- d__-------•.•__gallons. WSeptic Tank—Liquid capacity..! __gallons Length---------------- Width---------------- Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length-------- ------- Total leaching area....................sq. ft. Seepage Pit No....___..�...-._..._ Diameter____.__6v.__-.___ Depth below inlet..... ............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by..................................................................._...... Date- ------..'.'_.................. ....... Test Pit No, 1----------------minutes per inch Depth of Test Pit................ . Depth to-ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit__.______..._....... Depth to}ground water........................ ODescription of Soil.........................................................................................................................-•••-•-••••••-•••----•------••-••..........•--- x U w U Nature of Repairs or Alterations—_Answer when applicable- _.,Q �__.___...�GV-L�-- �.....(?��_c3 U} _.L�!�I ' U P PP _ �� _ S ... i7.pT.....__..l,,lf r _...__...- _ `" ....._ Z��1 _.._.`?- `rt ` g-! `J� "S--1=S'-�'-''-` Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the States Environmental Code—The undersigned further agrees not to place the system in operation until a Ce`rfificate of Compliance has been issued by/the board of health. i � AA64 ..� Signed .........f.......... ................ ��. - ...- - / DT Application Approved B /.///'�/ ` y ---------- --------- -:��'.. . .....- -...----w..---- - --.-...----'--------------'-------- Date Application Disapproved for the following reasons: - - . . . .................... . ..................- . ............. . . ....--..:................................. . -------------------------------------------------------------------------- ........................................ _ ace Permit No. c i '� `� ...--/..; .'"1'F ---.--- Issued '9 ` Date ------------------------------------------------------------- ----- �J THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (VITErtifi.rate of (ILTamplianre THIS IS TO CER,,,,IF_ hat the Individual Sewage Disposal System constructed ( ) or Repaired ( ) Y - ------------------------------------------- - .... - - - ---------------. "t't:y- � Installer �2 1 at . l ----` -6-------- ------_-....--------------------------------:.----__----_`.------------ f'� I--�.1.-.: has been installed in accordance with the provisions of TITLE 5 f The State Environmental Code as described in the application for Disposal Works Construction Permit Nod" ''... Yam. ----.-- dated -�''.- ` .:."' THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL/FUNCTION SATISFACTORY. � DATE -....../ _ ..... f'7--------------- ------- --- Inspect r f , �✓ /.-` '1 P eo VO I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 3U No....... ............. FEE. .....__............. Uispoii i1 lVorkii Tonotrudion "unfit Permission is hereby granted....................I�G�T ------t-'U - � .l/-.v=s-i„=......"�o.� to Construct ( ) or Repair (\4) an Individual Sewage Disposal System _ -; F� '�4 Stlreet/J Ile, �'^ as shown on the application for Disposal Works Construction Permit Iuoi ..___ _ Dated.._' ��..." .. �� �� .�� .. :� Board of Health DATE-----•-- --------.. •••-- FORM 36508 HOBBS Q WARREN.INC..PUBLISHERS AsBuilt Page 1 of 1 IVWty Ur l3A"b-1AlsLt LOCATION y/ZD �C y` Z$ Or�pl ewl; J�Gt'• SEWAGE#1 P''371 VILLAGE C'O7`4-K17— ASSESSOR'S MAP&LOT INSTALLER'S NAME&PHONE NO. C~, 77i-Q.3Yr' SEPTIC TANK CAPACITY��,000 C LEACHING FACILITY: (type) �o y r � „� (size)--Y .5&51,C NO.OF BEDROOMS O BUILDER OR OWNER PERMITDATE: n'/$9E' 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) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by i d4 V D Alt z4=}7't http://issgl2/intranet/propdata/prebuilt.aspx?mappar=040115&seq=1 5/7/2019 i ~G a TOWN OF BARNSTABLE LOCATION ,1 �' SEWAGE # y VILLAGE � ��' ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO.y -14�O;4i' v}S�,' elcl Z(c SEPTIC TANK CAPACITY /K-6.0 C,�V LEACHING FACILITY:(type) O� ,S ��� (size)..... 'X /6 NO. OF BEDROOMS PRIVATE WELL R PUBLIC WATER BUILDER O OWNERS; of- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 4' VARIANCE GRANTED: Yes No .� Jp E7 P« r'�Q TOWN OF BARNSTABLE LOCATION toeif0al 420JGfc ~r f7-,-1- SEWAGE # 7 7 VILLAGE C o l-y 1 '7- ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. C/3pa co p 5ff p rj c 1,2 SEPTIC TANK CAPACITY / d® 0 G WL S LEACHING FACILITY:(type) Fa C fg.P (size) /0 Q 674Z- NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER PU6ki BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: - Gs S/ VARIANCE GRANTED: Yes. No_� a_ c' G q d T(-VT1( S Q", k "'TTOWN OF BARNSTABLE LOCATION � � ATE' � SEWAGE # VILLAGE ®'yVT ASSESSOR'S MAP 6z LOT INSTALLER'S NAME & PHONE NO. \e-n SEPTIC TANK CAPACITY LEACHING FACILITY:(type)t"� sQ,--,c_-T (size) loop NO. OF BEDROOMS p E +:E1 L O PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE .COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No Y s�Lsr. �9-I1Gb Iwo Gnu ps� I / 1"4- v� 4 0 t� 0 � L I I � � 1 I ri L0CAT ON SEWAGE PERMIT NO. VILLAGE INSTA LER'S NAME 8 ADDRESS y BUILDER OR 6tllER� DATE PERMIT ISSUE DATE C0MPLIAPICE ISSUED, R�Y'LtXS" TL`e �O L :SCo�tw _'�:�' C e R►V 8 S 5 �i4 /11O r� (//C k IV A I, y�y L0CAT ON SEWAGE PERMIT NO. VILLAGE INSTA LER'S NAME & ADDRESS R UILDER OR OWNER DATE PERMIT ISSUED,,j DATE COMPLIANCE ISSUED �� � L.S C oFtrJ �.2 C®Rtv r 2-9 Co 7-u I i N ® OS 8/ S THE COMMONWEALTH OF MASSACHUSE17S BOARD OF HEALTH Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Location-Address or Lot No. ------------------9......... .............................. .................................................................................................. Address . The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of'-!',U4 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of � Application Approved By.......�_�!,n ............... ..... . --' Application Disapproved for the following reasons:................................................................................................................. Date _ Pero .\ . ate N .$_/-.505- FEB...3 D...j THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH O.ln/ / �� 4'�/si11136. �= O F... .........��.................... ApplirFation for Uhyosal Works Tonstrnr#ion rnmit Application is hereby made for a Permit to Construct (A/ or Repair ( ) an Individual Sewage Disposal .. .- 42..................................................... Location-Address or Lot No. ...... .r�r4L1?1N:ifr .Q wi 1K.......f12A&. ....--------- ...........................•-•-......--• -r........_..---•--..........................•--- �wner, j Address W 9_t In r Address d Type of Building Size Lot__.2`_ -.C.....Sq. feet U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—T �-,of BuildingNo. of persons............................ Showers — Cafeteria-- 4w1 Other fi............................ tures .............................................. .. W Design Flow.........,7.5.........................gallons per raper day. Total daily flow..........-��_Z._...................gallons. G4 Septic Tank—Liquid:capacity/UUU_gallons Length_���: .... Width:�'_�=/v._ Diameter................ Depth-.. ':-.7 xDisposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.._................Sq. ft. Seepage Pit No.___..../............ Diameter.../0..._..._. Depth below inlet.... Total leaching area.._4.-k.Z_sq. ft. z Other Distribution lidx �t ) Dosing tank (� `-' Percolation Test Results Performed by,/� __.._. Z2�Z2Gt /`.`-i2........................ Date_.��___�_el __/--•--.__. aTest Pit No. 1.. .___.----minutes per inch Depth of Test Pit...f�.�'`:_... Depth to ground water......................... rT Test Pit No. 2................minutes per inch Depth>•of Test Pit.................... Depth to ground water........................ •---------------------------------------•---try::---- --... O Description of Soi1.4_'--,F---------.._ .5�..-•---.�.:.-•-- •----� --------------- ----------------•-----------------------•-----------•-------•- �r W ------•--•-----------------------------------•--•------------------•-----------------------•-•------- ---•--...•-----------•------•---•--• .................................................... txj Nature of Repairs or Alterations—Answer when applicable_______________________________---------------------------------- ..------•--•-----------------------••--•--••------•-------•-------------------------.................---•--------•----••-•--••-------••---•--•---•----------••....--••--._...---••...........------..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of`:TT s: y g g p y 5 of the State Sanitary Code—The undersigned further agrees not to lace the system in operation until a Certificate of Compliance has b is the board of heal / f Si ned _.......... -- ... d� •. ------ te Application Approved By...... �_ __ .. �7 _ .. ............. ........•------ Date Application Disapproved for the following reasons: __ ........ .._ ........................ -/......._ .... ..................•--•--•---:.---....----...----.....---------•------------------•---•-- ------ .----- ............................................................1 : ..._ K i - . Date Permit No..... Issued..................................................I... Date THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH ..........Gt ,?Pik...........OF....... My� .......:............................ .r %CertifirFa#r of Twr ,,pliFanrr THIS IS CERTIFY That the I9dividual Sewage Disposal System constructed (v) or Repaired ( ) by .:r . .... .................•---•--...•...----------•-•--•-••---••--••--........----------........_..-------•--•---•-•---....._. Installer -•-------•-------- _. has been installed in accordance with the provisions of TI r~: j of The State Sanitary Code as described in the application for Disposal Works Construction Permit No. 0_5*05------'--------- dated---A--------------------------------•----------- THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A_`GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE . .........................--------. Inspector.- ---`...................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH +c?^? ...............OF...... •� y c N 'L. . Q.S.. FEE:..?..?.:.............. ioatl orks Tons ainn rrnti Permission is ereby granted................. ...... V--------•------------------•--••-----...................................... to Construct or Repair ( ) an In dual Sewage System atNo...... d..... :.40..------.... ........................... 1 U Street as shown on thekapplication for Disposal Works Construction Permit No..................... L?ated.......................................... .----�`-/ -- --------------•-----.................._ - �` �• ) ) r of health DATE--------------------------- . !6 �J FORM 1255 HOBBS & WARREN. INC., PUBLISHERS f r - TOWN OF BARNSTABLE LOCATION tP-i Poo f 4201o< M/heT / r X j- SEWAGE # �'7-�f 7 VILLAGE C ASSESSOR'S MAP & LOT _, �7 INSTALLER'S NAME PHONE NO. CAP& Co D SFP ri C 3 a 4 t/ SEPTIC TANK CAPACITY / 00 6 G K-t-S LEACHING FACILITY:(type) F C eq.f I' (size) 10 O 0 6,14- NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER PU64.1C' BUILDER OR OWNER t- DATE PERMIT ISSUED: ® — DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No_� �- tNg STee1 Coves 4- C)%ST. 1BoX S STo ne lb ._..... ... THE COMMONWEALTH OF MASSACHUSETTS BOAR H ----------------------OF.....9.......... ....... Appliratiun for Disposal Works Tonstrur#iun 41ermit . ;�' ..` f s Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal °.• System at: / .... : .?+_ Z...r ZZ....q .....................................�T. �7.. ...i��21C Lpc f ddress ..........................................or Lot No. .._/.��....��:_err...r-- -------------------------------------------- . Address Installer Address UType of Building Size Lot. �j� ..:.._..Sq. feet Dwelling—No. of Bedroom .... .......................................Expansion Attic ( ) Garbage Grinder W6 Other—Type of Building ._.......... No. of pers nos ................. Showers ( ) — Cafeteria ( ) WOther fixtures ----------------••-----••-----...............-•-------.-----..............._............_.......--------.......----•---...........---------•-•-------- d W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity./ .gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area ...................sq. ft. Seepage Pit No.. ........ iameter.................... Depth below inlet.--................. Total leaching area..................sq. ft. z Other Distribution box (A Dosing tank ( ) aPercolation Test Results Performed bY....=..................................................................... Date........................................ Test Pit No. l................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ •--•---•-----•--•-------•..........................•-•-----••--•-•----------.................-----.......-----------•------...........---...........----•-•-- 0 Description of Soil................................................................................................................................................................... x ........................................•--•------------.....----..........---...-------------•---•------------------------------.....------.......------------------------...._...------••••------------ x y�,y- U Nature of Repa'rs or rations—Answer when ap icabl .. ___f� t1 .(f, ._.., �T.. - .............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLI 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha n s ed by th oard of health. Sign --------- ----•------••-•-----•-------•.............. • ..�.Z _ Date � Application Approved B ................. ....... — {�. _ //a PP PP Y _ 1- ....... Date Application Disapproved for the f o owin ns:•-----------•-------------------••........................-----------------.......----------------•-•-•-------- ---•••-•.............•---......-•----•••--•--......-----........----------...-----•-•--......•------•.......•------•-••-•--••------••---......-----•----------------------•...•••--------..._....-------- Permit No. �� Date..�------.. .. Issued--•---------------------------•-------.... ...... Date No tr..._.._.«...+.« Fps............._ THE COMMONWEALTH OF MASSACHUSETTS .r._— BOAR t"� .......................OF.:.:...e# ..... ...'..-------• .� ...................... Appliration for Disposal Worko Tonstrurtiun Prrutit i� Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System .....�, ..........................«...........C 03. ..�,�1/ ..../..:%,, «..---......._._ Loc t' ddress or Lot No. .. �., _.. « ... ....................................................... �O�ner . Address - - t A ,yic0�l Installer Address ^� g Sq. feet U Type of Building Size Lot___ WSJ./�- -. - ,.� Dwelling—No. of Bedrooms... .......................................Expansion Attic ( ) Garbage Grinder (rat) '4 Other—Type e of Buildin C- -_p-, yp g _-�._...___.... No, of persons____________________________ Showers ( ) — Cafeteria ( ) Q' Other fixtures -•---............................................. „ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity.& -gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No._:!'�"' ___,__Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (�) Dosing tank ( ) st a Percolation Test Pit No. I suits Performed nutes p r nch Depth of Test Pit..............•.. Depth to ground water..__.._........._....__. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ R', .....................•--•-------................................................-----------------.--......................................................... 0 Description of Soil..........................-----------------------------------------------•---••-••---••••-••------......-•-•------•---•-•-••••------------------------•-•----•-----•• x - V .....•••-•••-•-------•-------------•--......---•----•-•---------..._._....----......_ ._..._...------..----- -------------------•------•---•----•--------------.........__...--------•-•-•.--•-- ----- ----- W •••-------•------•--•••-----------••--------------------•-------•••••••••••--•------••...-••-•---••--•-_....- ------..... UNature of Repairs or rations—Answer when applicable � ___ ,c _...__,, C ...... .............. . .... _._ ...---...... -----------------------------------------------------------------------------•--------•----•-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha en s ed by th oard of health. Sin ----... .- .. •-•--•-•--•----••- •-•--•••--.... �C�-:'�f_.. ..._---- g 1 Date -_ Application Approved By.......... ..-_: _ -�- x : : ::._. �.: :. .:� �_-::.-_-- - ----------- � Dated Application Disapproved for the f o owin ns:-------•-••••.............••-••-----•-•--------------------•---••••••••-•-••......-------•......------•---•---- ....................•-•----•-•---•----............-•---------...----.....--•--••--------...-----...-----.-•------...._..----.................-••........-------••-•------•--------••....--------.._..•-- �^ Date PermitNo.............. .............................. . .. .......-------......---.. Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD PF HE WTH -, �.........................oF.. .:..... :.:... .............. Tntifiratr of Tnutpliaurr IS Tn XQA14, ual Sewage Di,g ,.,System constructed ( ) or Repaired by at.. ...._...... . � --- ...................... .... .............................................................................-........------------- has been installed in accordance with the provisions of T lE 5 of The State Sanitary Code as, de�ibed in the application for Disposal Works Construction Permit No.___.�;_- �.._...._�..l_. dated--------__________� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......................... ..-.L .l,.: Inspector.......... ---- ............. THE COMMONWEALTH OF MASSACHUSETTS BOAR HE L-W .,� ........................0 "` ......---------....................... '` s L ,, No..z�..�......j. 1h FEE..' Bill oil ttrt' rrutit Permission is here grante --•------• "...:_.•. . •.. ..... 4.... ---------.�, � to Co -or epair �ry n 'i Sever e > at N �. --- .. -- . ------------------•-------.........--•--•-----•---------------••--•---------...-•-- --•- Street as shown on the application for Disposal Works Construction Permit Nob.-1... _..Z_ Dated....------------ . Board of Health DATE............. .. .� ................. FORM 1255 A. M. SULKIN, INC., BOST N a THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I A , m / � �G�"- LI DATA Y �MEN, 1� r s Wa" w a I 4 4 i ` I i 3 _� --___ I � A '•a^ tar 'T \. � k'; •s,*,;�.�f�r�;�`5�"�a;�runs �.z y4T.Ci y£1 .#�ySv ¢.. r i xT.:-aa 7X � tier. t a M1 i F. k, ;_RTIFIED PLOT PLAN . IN ' k T 0 i T /✓I pSS , IRA R.THAC HE ,R JR `� � `• 'T('i$('S 14\RMTOWN OF BARNSTABLE LOCATION �// � SEWAGE # VILLAGE COfVlT ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type)gcerncT T (size) i0C0 GA` NO. OF BEDROOMS URiV A E W-E L O PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: a - f DATE .COMPLIANCE ISSUED: K- -.Sr 7 VARIANCE GRANTED: Yes No L/ f,. • �ti , SY STem logo lam Qj�A }1 _ .�f No..F2' 93 FF,19 .. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............ .........................OF.........................---•--.........-- Appliratinn for Biipniial Works Ton.strurtiun Prrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: e o Lot No. a .. - ......... •..................................... d.�..�. �kL; -------------------------------------------------- ner, .-� Address a •--•••...•. ----•-- �1�..•.................... - --•----•-----••---•--------•------------------•-•-•-••-•-•....•--------------------------- Installer Address Type of Building Size Lot____-L_.z}193�......Sq. feet , Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building _________________________- No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ..................... W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. Septic Tank—Liquid capacity/ ..gallons Length................ Width................ Diameter---------------- Depth---------------- W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No.....2—_=-/diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ (r4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P4 -----------------------------------•----•-------•--•----•------------------.-----•-•-----------••----------•-----------....-.-------------••-••---••--------- 0 Description of Soil........................................................................................................................................................................ W U --•-•---•------•------••••••••••-•-••---••---•--•----•---•-••----•-•----•-------•••-...........•----.....--•-•-•-----•-•---•-•--••-••-••••-----•-•-•-----•-•••-•-•••---•----••••--•••------•••--•-..-- W U Nature of Repairs or AlteAations—Answer when applicable....___ _ _ _ ______... ---------- N�......-•••-•......•-•--•----•-•-•--••---------------------------------------------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of i T'i..L 5 of the State Sanitary C4*�ssue he undersigned further agrees not to place the system in operation until a Certificate of Compliance has been e b of healtSigned---.....--- . .......................... ....-_�Yh, Application Approved By---------------- 3 s`--x- ram ........................... -•--•-•. Date Application Disapproved for the following reasons:-----•--------••----------------------------------------------•----------------------------••--•-------•-•••-•-- ---•-•-•••••••••-•-••-•--•••--•-•••--------••-----•-•---•---•----•-••--••••••-•--•------•----------------••-•-------•---•---••••--•-••---••---•--•-------.............................................. Date Permit No.....ff...2"--�0-3------------------------ Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............:..... .........O F.-..............-...--................................................................... Applira#ion for Dhipos al Works Chun.6trurtiun rranit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 0 L1 MSG t �_( 11G( r- Z a. ........................G �/ � ....................................................... } 'C essJ or Lot No. .. J ............................. .....................•----•-••--••...._......^__._.............................................. wner --------------•••••--•-- Address a .................... ----•-•• ................................. Installer Address Q Type of Building Size Lot___z:'Z ......Sq. feet aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) a Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ------------------•--------•---- - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. 9 Septic Tank—Liquid capacity_ 1�_.gallons Length................ Width................ Diameter---------------- Depth................ Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No------ iameter____________________ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------ fZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a' ---------•--------- ---------------•----••-----._...----....._......------------•---•-•--•.................................................................. 0 Description of Soil........................................................................................................................................................................ x U ..............................-.......................................................................................................................................................................... W -------------------------------------------------------------------------------------------•-----------•-------- ------------------•---------•-•---------------•----•------------------- UNature of Repairs or Alterations—Answer when applicable Q_t/-> - 0-�......L a_z- -_____�// Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of ITT...:: 5 of the State Sanitary Code—AThe undersigned further agrees not to place the system in operation until a Certificate of Compliance has been •ssue e b of heaL 1 Signed - ----- l 4 4 ate Application Approved By--------------- "` . ---� •""= ----------------------------- .......... Date Application Disapproved for the following reasons:................................................................................................................ ----------------•-•--------•••----...-------•----------•----...-••-•--------•----------.....-----....---•---•----••-------------------•------------------------------------------------•--••------------ Date PermitNo...... •----------------------- Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH (1( ..................................... QT.Irrfifiratr of TompliFanrr , THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by. �,,, --( -CERTIFY, That ...............•-----••---•-•-•--------------•--------..••-•-••-........---•---•.....----•--------.....-----.....-•-..._...•----••-•------ Install at................ r�....................... �w ..-•- •--- ---•--•--................................................................................................ has been installed in accordance with the provisions of TIME 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......... 3_-:._$i*_:3_________ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT YHE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector.................................................................................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � ...........OF........_.-I��f� : :r: ......;....T....................................... Disposal Workii Tunstra ion rrutit Permission is hereby granted......... :.--..T',- ' --------------------------•--•-•--------•••----•-•-•-•._.........-•--•---•...._....••••-._._.. to Construct ( ) or Repair an In�diividual Sewage Disposal System atNo............... V)j............................................................................................................... Street as shown on the application for Disposal Works Construction Permit Not)4Q_3__ Dated.......................................... ............................... ------------.._.......-------..._...__.._....__..... L. Board of Health DATE / r-":�_7--------------------------•-......__- FORM 1255 HOSES & WARREN, INC.. PUBLISHERS e� '/o' r � 0 y7 /00 Sy FT 1~ a u �\ Q . 2210 o \ v '� 141 O b y8,b /000 Z u J��Q s� T A b So.c T�sT Y9' Fo. 00 TO? /yYDQ. ,PO VTR o? CERTIFIED PLOT PLAN IN ELEI//9Tio,.s $/,i sED O `' .QSSv/rlr7 Co T C// 7- 14ASS . r7.a rim —/—o NyaAZ. so. o a Bc!NGj ;C oT y7 0�. pLio�v ak a8 2 P�?7 ro /�t:�,o cssF•�r!�«y T,yt� S,vmE IRA R.THACHER, JR. REG. LAND SURVEYOR �9P�aa�En SO. YARMOUTH, MASS. DATE -- SCALES DRAWN BY //LT_ SH EET .__!_ OF `SH Of Ma�q� OF M46. C CERTIFY THAT THEMARD - s ti auld..D//v -SHOWN ON THIS PLAN 0 JAMES �R CONFORMS TO THE ZONING BY- LAWS t? OH EARN 4 6 0 JR ti v y OF THE TOWN OF . 8/�QNST.yyL 23214 f T . 'P 4 _ FC S /STSIA SUR��'yo ~ ' =' REG. LAND SURVEYOR. . V LOCATION SEWAGE PERMIT NO. VILL Au" E I N S T A LLER'S NAME i ADDRES - / OR OWN R y e<� DATE PERMIT ISSUED--- // ,e. 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