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HomeMy WebLinkAbout0099 HIGH STREET - Health �Y 99 Hsgh Street Cotuit cP A = 035 035 1 I i i No. Fee �® y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: es PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for 3i!5pozar *p5tem Construction Vermit Application for a Permit to Construct( , )Repair(✓)Upgrade( )Abandon( ) O Complete System 21lndividual Components Location Address or Lot No.� /pp9 f s Owner's Name,Address and Tel..No Assessor's Ma /Parcel ? � G�f Installer's XUI�57; Tel.No. Designer's Name,Address and Tel.No. Type of Building: i Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) f/C�14 �li� �ir Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by s d ea Signed Date1&uo Application Approved by Date �T Application Disapproved for the following reasons Permit No. c ab 135 Date Issued /0 No. _C��03q " 3 .. ('4 Fee 50 THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ^l.es ti PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 2pprication for Miopoof *patent (Construction Permit Application for a Permit to Construct( )Repair( ✓Upgrade( )Abandon( ) O Complete System LJIndividual Components i Location Address or Lot No., s Owner's Name, Address and Tel.Nooj. f Assessor's Map/Parcel ✓ 4 R veal, l, � 3 S CO4/f Installer's N e,Address,and Tel.No. /~� Designer's Name,Address and Tel.No. �0/ -7 71-�13yy 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 gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature oURepairs or Alterations(Answer when applicable) r ' Date last inspected: Agreement: The unde signed agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by `s'�o d .Pfleal . / Signed y Date Application Approved by 4" Date Application Disapproved for the following reasons Permit No. Cl'S q — 13 5 Date Issued 0 ------------------------ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY, that th On-site Se age Disposal System Constructed( )Repaired( �Upgraded( ) Abandoned( )by , at V .&W 1 ,S has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 0 q - 1?,S dated ! Installer Designer The issuance of t f's p unit shall not be construed as a guarantee that the S.Silt% will nction Ldesigr%. Date Inspectors --- .._. _ - No.—d ----------------------- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Mtz pozal bpgtem Construction Permit �- Permission is hereby grante/d}to Construct( )Reep�a' ( k/ bpgraade,( )Abandon( ) System located at 9 7 /T/�� ✓/ • C.�!/��/ �" " 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:Constructi n must be completed within three years of the d to of this p Date:- �9�a Approved by Page10of1i OFFICIAL I�";SI�.�"�xO� � �3 �_NOT {+'OR VOLUNTARY ASSESSMENTS SUBSUIt 'CE SEVVAG-E DISPOSAL S"STI:M INSP*CTION FORM PART C SYSTEM E' F0jtMj--°,TION(continued) Property Address:. 9 u .Date of Inspection: 7 SIaTCH OF SE WAG DISPOSAL SYSTEM Provide a sketch of the sewage disposal_system including nL ties t0 at least t1Y0 permane nt reference benchmarks,.Locate all wells with P i landmarks or �r. I fl0 feet. Locate ,ocate��hcre public eater supply enters the building Al . e o,+ `J LO IF'LTO f h� f J� 10 - COMMONWEALTH OF NLASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTM T OF ENVIRONMENTAL PR T I MAR Y 92004 "0W N_0 TH R1VS-r DEpr TITLE 5 OFFICIAL INSPECTI —ON FORM. NOT,FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION C Property Address: C' Q MAP � PARCEL ,�:,., Owner's Name = ® Owner's Address: Q LOT ' Date of Inspection-- Name of Inspector• (please print) (` Company Nam Mailing Address: ,0 vy )A Oa(o Telephone Number: 9 CERTIFICATION STATEMENT / I certify that I have personally inspected the sewage disposal system at this address and that the information rfported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP' approved system inspector pursuant to Section 15.340 of Title.5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: %' Date: The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system 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. Notes and Comments &Sq � ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 611512000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A J CERTIFICATION (continued) Property Address: ,Q/ A Owne Q/ Date of Inspection: ja Inspection.Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. /System Conditionally Passes:. V One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please explain. A ® The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a.complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: yeJ Observation of sewage backup or breakout or high-static water level in the Rstribution 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 is leveledor replaced J / / ND explain: J`,/'�p� vr'a"1 'goo/ J 1,ae S�IOIeI��C� C—leweea' cING� /d1S�C'C 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 I'1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A- CERTIFICATION(continued) Property Address: Owne Date of Inspection: Q� 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. n 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any)determines that the system is functioning in a.manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. 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 0EP certified laboratory,"for"'coiiform' 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: Page 4 of 1 I OFFICIAL.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 9 Owne a.�P,09 ,0,, A�a"O_pn, Date of Inspection: , a(� D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to_each of the following for all inspections: Yes N _ Backup of sewage into facility or system component due to overloaded or clog-aed'SAS of 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 '/z day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times.pumped _ Any portion of the SAS, cesspool or privy is below high groundwater elevation. Any portion of cesspool or privy is.within 100 feet of a surface water supply or tributary to a surface _ Jwater supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. i/ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a.DEP certified laboratory,for 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: 1 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 failure. E. Large Systems: To be considered a large system the system.must serve a facility with a'design flow of 10,000 gpd to.15,000 gpd• You must indicate either"yes" or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II.of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall.upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART.B CHECKLIST Property Address: 1 t Owne Date of nspection: Check if the following have been done.You must in "yes"or"no"as to each of the 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? t/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 for signs of sewage back up? V _ Was the site inspected for signs of break out? .: V Were all system components, excluding the SAS, located on site,? _�_ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge and depth of scum? V _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems ? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no 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) [31.0 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION-FORM—NOT FOR VOLUNTARY°ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION Property Address: ��")��►�� Owne . �Q®7� Date of Inspection: /& /a. oIV FLOW CONDITIONS RESIDENTIAL >/r Number of bedrooms(design):- . Number of bedrooms(actual): DESIGN flow based on 310 QMR 15.203 (fiff 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):�).[if yes separate inspection required] Laundry system inspecte y s or no)./ Seasonal use: (yes or no): Water meter readings, if a ailable(last 2 years usage(gpd)):00 1�4®d 0,--IIZI�90U Sump pump(yes or no).430 Last date of occupancy:�1L�. COMMERCIAL/INDUSTRIAk/q& Type of establishmente- 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 or no):_ Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records - Source of information: Was system.pumped as part of the inspecti (yes or no) If yes, volume,pumped: ,-._._gallons--How was quantity pumped determined? .' .; _ .• Reason'for.pumping: TYPE,&SYSTEM _j,,/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 _Other-(describe): pproximate age of alo7onents,date i stalled(if known)and source of information: Were sewage odors detected when arriving at the site(yes or no) 6 Paize 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION(continued) Property Address: qq Owners Date of Inspection: ,�2iz , 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 line: Comments(on condition of joints,venting, evidence of leakage, etc.): SEPTIC TANK: (locate on site plan) Depth below srade:�). Material of construction:__L,�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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 17 Scum thickness: ) ' Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom orf outlet tee qr baffle: , How were dimensions determined: " , Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels elated to outlet invert, evidence of leakage etc.): GREASE TRAP (locate on site plan) ..Depth below grade:_ Material of construction:_concrete_metal_fiberglass___polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date 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.): 7 Page 8 of 1 l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Owner Date of Inspection: /Q QOO 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_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 last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid,level above outlet invert: Comments(note if box is level and distribution to outlets equal, any evidence of sblids.carryover, any evidence of eakage into or out of box, etc.): /o" fiy 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.'): 3 Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: � A Owner. -/ / Date of Inspection: /,,? SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type eaching pits, number: j 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 ponding, damp soil; condition of vegetation, c a 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: -(„,I X 'I ezo Indication of groundwater inflow(yes or no):- Omments(note condition of so' , signs of hydraulic failure, level of pondipg,condition of vegetation,etc.): lotmupv 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.): 9 Page 10 of 1] OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) Property Address:. �Y Owner: Date of Inspect►on: /C�pp SKETCH OF SEWAGE DISPOSAL.SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. N0 a �� l �� A 0 /000 10 I Page 1 1 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: pQ, Owner: ; Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water / 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: Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: 11 Permit Number: �j Date: Completed by: HIGH GROUND-WATER LEVEL COMPUTATION Lot No. Site Location: Owner: /1 %��ID �S�i% Address: f/ Contractor: ����/� � Address' Notes: �r's STEP 1 Measure depth to water table to nearest 1/10 ft. .............................................................................. .Date month/day/year j STEP 2 UsingWater-Level Range Zone I and Index Well Map locate site and determine: l (A Appropriate index well.................................................... I OWater-level range zone ..................................................... STEP 3 Using monthly.report "Current Water Resources Conditions" determine current depth to .o21Dq water level for index well ........................... month/year STEP 4 Using Table of Water-level Adjustments for index well (STEP 2A), current depth to water level for index well (STEP 3), and water-level zone (STEP 2B) 2,6 determine water-level adjustment ............. STEP 5 Estimate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water level at site (STEP 1) ................................................... ......................................................... . Figure 13.--Reproducible computation form. 15 ....... .rs�.lx'i r.a ^�:.. ............•..�..-,,.,.�....+...a,n.m::. ta�..�...r,:l a-•. ....n..............._v ..�......,... :......,...�,.... ..�. ...;..�....... ,...�•,........,...••...r..`� .•.�,v.....n'iC.E l.i..r.v........w....�.. ..a.., InI��l11 .. ...`..._...�._......�.� Of! ! ' I I Se ch'farMap/Paresl�/ 035035 7ovVf Barnstablf+u! or Paresi Tlumber,035035 \ \ g Rental Prope l'/N} i , S"usmess Na � _ one of�wGontnbutioi��N) Area mber �' � �` � � Cantam�riantRei(YIN) 6 Phone 000 0000000 Fuei Stora e lank Permit TGartlQn File y ; Disposal Works Perc Tss Welt°Permit Construction dI / 179 Oyu 94 ,. Issuance>'Date. . .; i 04/19/1994 ' %, ✓i G� � H \, � .. �s� mmerltS :K; k REPAIR T 5 \ ' map�iar 035035 £pwner NICHOLSON DEAN E TR propI_ 99 HIGH STREET OR M innovative/Alternat�v" Technology Septic 5yT MR��������`iIAT pe I/ �Sery Ice G �rP / SA TOWN OF BARNSTABLE -OCATION 4Z G,,V S / SEWAGE # �Y VILLAGE G O T v �� ASSESSOR'S MAP & LOT VEd9��, GYS' INSTALLER'S NAME PHONE NO. A G e m/6 eR f- 5 0,,/ SEPTIC TANK CAPACITY O Of LEACHING FACILITY:(type) e/ T (size) �• o o a NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BM&DER OR OWNER Ifl e-fe 4;f/ DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: � �.,._ i� VARIANCE GRANTED: Yes No y -- � L u 4.. ,`'I/ /� I ! ' �� i � � � ! O ` 1 � r �� - �� .� � � • s� GL o �� � . . a .t .. ' TOWN OF BARNSTABLE LOCATION SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. 704 H 19, �r'll� '1,2$-rrS�s- SEPTIC TANK CAPACITY LEACHING FACILITY:(type) vco���'/o+� ff?l?4�4 (size) 6,Y10 NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER 0-kc. BUILDER OR OWNER ;PPan �ic* 4d3oh DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No �� 1 `y / q $ 30 00 No.44...../—/- APPROVED FRs............................. ' BarnstabgCOnSMVatiM fi 1"MONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 3 S 6 � S 8 OF BARNSTABLE Appliration for Diti-poottl Worko Tomitrnrtion Famit Application is hereby made for a Permit to Construct ( ) or Repair (X)� an Individual Sewage Disposal System at: ...99 Hich Street Cotuit ...................... ..••-- ••---- --•---•-•-----•-------.........----•-... ---- ------•-•-•-•---•-•----•-•---•------...--- Nicholson Location-Address or Lot No. Owner Address WJ..P.Mac ombe r...1 .................................................. Installer Address Type of Building Size Lot............................Sq. feet U Dwelling-X No. of Bedrooms..............3_.._•_________ _ _ _______Expansion Attic ( ) Garbage Grinder ( ) ►-+ aOther—Type of Building ____________________________ No. of persons---------2_________________ Showers ( ) — Cafeteria ( ) 04 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. Seepage Pit No..................... Diameter-__-.---._--..-__.__ Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Gi, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a •-----•---------------------••-•-----•--------•--•---•-------------•••--------------........---•--•.......................................................... 0 Description of Soil........................................................................................................................................................................ W Santa U ---•-•--...•-•-----....•--•--•-------•-•-•••-----•--••-•••-----------•--•-•----•-•••---------------•-•-------•----------•------•------------•••----•---••---•--•---•.....•-••-----•-------•------------ W UNature of Repairs or Alterations—Answer when applicable._.__...?_-1.000 gallon septic tan_.. added to existing system. --------•--------------------------••------------- ----------------------------------•-------------------------------------------------------------------------------------------------•--•---.....---- 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 Compliance has bee/is ued by the board of ealth. Signedi"W;04Z . .. .. o.......... ..... .......... a/16/ga....... � Date .. . Application Approved By ----------- ..... .................��.-. L) Application Disapproved for the following reasons: ..... .............................. ...... . ... . . ...... .............. . ..... ..... ............ ..................................... ..... .............................................. ..... ............ .................................................................... ....................................... If Date PermitNo. .......7..�.. ... j 7-�-------------------- Issued ........................... .................................... Date } 3 Q.--0 0.. THE COMMONWEALTH OF MASSACHUSETTS IIA.,I iBOARD OF HEALTH TOWN OF BARNSTABLE 1 1 6 3 S 6 3 s Appliration for Dhi-Vo ttl Morks Toastrurtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 99 High Street Cotuit .................._.............................................................................. .....•............................................................................................ Location-Address or Lot No. Nicholson Owner Address a J.P.Macomber Jr. Installer Address Type of Building Size Lot............................Sq. feet Dwelling-x No. of Bedrooms..............3-------------------_--------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons.........2_------------.--- Showers ( ) — Cafeteria ( ) dOther fixtures --------------------------------------------------------------------------------------- ------------------------------ -----= W Design Flow............................................gallons per person per day. Total daily flow----------------------------f�-------------gallons. 9 Septic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter._._g=- Depth................ Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leachin4 area....................sq. ft. Seepage Pit No-------- ----------- Diameter.................... Depth below inlet.................... Total leachiA area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------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........................ 0 Description of Soil...............................................................................................................................-------------••--•----•---....-••-•••--- x Sand U ---------------•----...-----•----------•----------•••-------------••••-••-••---•--------••••-•-------•-------------------•---------••---•--------•.......----•------------------....--••--------......•. W UNature of Repairs or Alterations—Answer when applicable..__.---1-1000 gallon septic tank added to existing system. ------- -------------- ......................................... 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 Compliance has been ,issued by the board of health. Signed -- ,� .,� ./:'-- + 4/16/9.. ..v..... _.........../--L- ................_.. ............_..Dare_............4 Application Approved By .............C ��._te_�... .............../.-../.cf.-.. �•l �I?are Application Disapproved for the following reasons: ...................................................--------------......------------------------..............----------------------------------------------------......_.........................._. ............ --- ................... pp� 'K Dare PermitNo. ... ..-/.. �---------1--7--�-------------------- Issued ................................................... ... .--.............. Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE llertifi atr of Glom Barrie THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired �CXX ) J P.Macomber Jr . by ---- ------------------------------------------------------------- ---------------------------------------------------- Insr.Jler at ...99 .Hi.gh Street Cotuit -------------------------- --- ----------------- - ... ..-...........- - has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. -9c-l=-._7--- ------------- dated -..-._--_.............................._.... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. / i Q " Ins ectorf 7J�a' -� -- - ---- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �iu�usttl urk� �unu#riir##iun �ermi� Permission is hereby granted.....J.P.Macomber Jr. - ----- to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at No...99.__High Street Cotuit . . ..................................................... ------------.........-------------•••---------------------••--••--•........... Street F as shown on the application for Disposal Works Construction Permit No-----y!!I-----_ Dated--------7-_- -------- -- ---- Board of Health DATE.................... --`•. •-- *--------------------------- FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS .. F�s....'...........a......... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............. .................OF....................................... Appliration for Disposal Works Tonstrurtiun Prrutit Application is hereby made for a Permit to Construct ( ) or Repair (-�an Individual Sewage Disposal System at: f ................`� _.......!,y.. ..... ................................................. ---......_............-----�' ------------------------------------------------- Location-Address ,v p or Lot No ..............�'1� !QlSsr't ._.._...._......... !:.(................... fP yJ..t....G `* /� �7 O` -er ddyess W ................a�� ....!! 1!u'.`.O .1-`S0 `Z�'- f S7..../v/c�rS�, S /�S .................................................... Installer Address UType of Building Size Lot_..ya�'_'.'`____._._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............................................ 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.................... 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........................ V-4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Descriptionof Soil s......'--I--f------------------------•---------------'-----------------------------------------------------------------------•-•---..._•......---- V ................................ •-'-•-•....•--••-•.....•••--•----•'-'•-•--•'••-••--•-••-•'•-•-•--••-•••-•-•••••••-•----•-•-••-•---••-----•---••-•-----•••---•••••---•-•-••---'---•'-•.........-•-•------ W Nature of Re airs or Alterations—Answer when applicable--- ........ �O-iz ��p _r1C. .� ------------------------------------------------------------- Agreement:The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of ealth. Signed_._ ��_. 9' 9 -- ---------------------------------------•--- -------- ......_........_ Date Application Approved BY ..°�- � ` �' "x + ,� Date Application Disapproved for the following reasons--------------------------------•----•-------------------.....------------------•--------- -----••---'•-••--'---- ---••••-•.......--••-----•'•--••--"•-•-•......•--••---•----••'---------•-•"------'--.......-•-•-----•-•-----•---•••-•---•--••••--'--------•-----•••---'------•-----•-•••-•-••-----•------••--••-•••-" Date PermitNo.......... - .... =4y_'T--'-•-'------•-_. Issued....................................................... Date NO..4.J: FEs........:l................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH. ...........................................OF....................................... ... Appliration for Dispoti al Worse Tonitrurtion amit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: - ............................................................... ........................... - ..............._ 1�P r-L ratio -Address P or Lot �O�lo!?•.......................•................ ' •� . t b/w 6..b...'.3� J�`1 f .. 5T, �IG..... J Installer Address yG o�o UType of Building Size Lot-------....................Sq. feet Dwelling-No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther 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. Seepage Pit No..................... 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...----.--__-___-..----- f4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ M .......--•......-- ---•-•--•----•---•--•--•---•-•----•.....................•-•------................••--•-•-•....---...........-••••--•--•----•--•-•...••-- Descriptionof Soil sy H ---•--------------------------------------------------------------------------------------------------------------•--------------•--- V -•-------•••---•--••---•-•--••---------------••---••--•------••----•-••---------...-•-----•------•-•••-----•--•-------••-•••---------••-•-------•-••••-•-•---•-••-----•-------•--••......•-•---•-•--•-- W --------------------------------------------••--- --------------------- U Nature of Repairs or Alterations—Answer when applicable.-%h 3`��____v_�.Pv___ �Uw__.L.. _._ ovp ...v�� . ......-••-•••••-•..•••..�'=��y.f-A-•---------•--------•---•---------•-----•-------------•---•-••-------------------•------•------•---------.........--------------•---.................--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT11, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has JiLeen is6ued by the board of Iealth. Signed. . . l" ' Date Application Approved By..................... ` " —�� •^^-'"'= '} ---•--•----•---------- -------------e�--`-..`..._.... Date Application Disapproved for the following reasons-----------------------------•-----------------------------------------------•--•----------------...---•--..----- ---------------------•------••------------•-•------•----------....---------------•-----••---•-------•-•-••-•---•----------•--•-•----•-------•••-••----•--•....•••--•--•---------•-•----•----•-•-•--••--- Date PermitNo........ ` ...... ..? .................. Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH F............0.... - ":•----- .. ................................. (Inrfifiratr of Tontpliatta THIS IS�TO R IFY, T�aaIWIndividual Sewage Disposal System constructed ( ) or Repaired) by ((�11 �---•-------------------------------------------•---•----------•----•---------...............-----•-••---------..._ - staller .____._. 1 _ at....................../ ......-�{. ... . 2....-----.......------- . . has been installed in accordance with the provisions of 1' " 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.-_ -.. _ i ........... dated---..--------------------- ..................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................................................................................ Inspector......................................... ----••--................................. THE COMMONWEALTH OF MASSACHUSETTS f� BOA RD OF HEALTH No...a .... �r••• - '!`(.................OF..........1...:, P4-y ..................................... FEE...I�................ 'Dispoint V rk.5 Towitrnr$ion rrmit Permission is hereby granted............ .. -----•-•••••• . to Construct ( or Repair O an Individual Sewage ispo al System c atNo...................._ 2...... FL....'&7-----•----.....�%�a <2. -----------------------------••------------------•-----------------............-- Street —^ d as shown on the application for Disposal Works Construction Permit NJ)'� _-- Dated.......................................... J. DATE_ -----•-•-•-•---•••-•••-••-•----•-•---•---••_.... ----•----------••-•---•----•--••---••----••-•................................. Board of Health • FORM 1255 HOBBS & WARREN. fNC.. 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