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HomeMy WebLinkAbout0040 LOVELL'S ROAD - Health 40 Lovell s Road cotuit A= 040 - 171 f/ L CA.TION '� 8�E%�S SE17AGE PER Ell T p0. 7 _A ZT ell �7 A fo�p O vo-b7o I N S T A LLER'S NA01E i ADDRESS �L- zi d: I 0 ID U I L D E R OR OWNER �i Gr--0/1 JQ L76-12.0 S 9 G 4 7" Y Tle tJ -f 7 DATE PERMIT ISSUED D.AT E C 0 M P L I A N C E ISSUED SLY Y b Lo t r Commonwealth of Massachusetts Ep T "Ve 5 Official inspection Form _ G Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address 1' Owner Owner's Name information is —, / required for _ il';'Jilleve a e. Cityrrown State Zip Code Date of In ectib c Inspection results must be submitted on this form. Inspection forms may not be altered in any �f way. Please see completeness checklist at the end of the form. ,3 Important: When filling out A. General Information forms on the computer,use 1. Inspector: + only the tab key J/ to move your cursor-do not Name of Inspector use the return _ key. Company Name — Company Address j Cityrrown _ f State Zip Code Telephone. umber License Number f: I B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function anc�tnaintenanc.e of on�site sewage disposal systems. I'•am a DEP approved system inspector pursuan.116 SectioQ5.34:0>of Title 5 (310 CM 15.000). Ttie.system: Passes. ❑ Conditionally Passes ❑Falls tv _ ' ❑ Needs Further Evaluation by the Local Approving Authority ,? N i 9 I{�I II jilt' ; Inspect 's Signature Date . j` 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 (t ;. has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use „ at that time. This inspection does not address how the system will perform in the future under i the same or different conditions of use. 16 1 15ins•09/08 Pys Tile b Ocial Inspection Fo m:Subsu ce Sewage Di;os e, •Paae ci 17 l� • p. 1 I t IpCommonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Forme Not for Voluntary Assessments Property Address -- ---- I� + f Owner Owner's Name information is �— required for rr t�l< A'd 11 d: every page. CitylTown State Zip Code Date of Ififspedlion B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: hhave 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 i' indicated below. Comments: 13) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be + replaced or repaired. The system,.upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not i 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 l f will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. .P `A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of i" Compliance indicating that the tank is less than 20 years old is available. ii ❑ Y ❑ N ❑ ND (Explain below): F ,i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal S,siem•?age 2 of 17 y fF 1 t _ 1, 4? Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form o Not for Voluntary Assessments Property Address �C1�U f9"0—E,/7 Owner Owner's Name I information is �.� •�,� i � 0j 6 Y' /,g/// required for —� �7 every page. City/Town State Zip Code Date ofllnspection B. Certification (cunt.) f , B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due j) Il l to broken or obstructed pipe(s)or due to a broken;settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced T❑ Y ❑ N ❑ NO (Explain below): 1 1 ❑ 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): l ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is y Required b the Board of Health: q ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system 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 i t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 cake✓/;- ,� r Poe Address r J� Owner Owner's Name / r' information is - r required for 6"1 ,' �� f 5 every page. City/Town State Zip Code Date of4nspection B. Certification. (cunt.) 1 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. L ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or I more from a private water supply well". 1 Method used to determine distance: i This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform It bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other'failure criteria are triggered.A copy of the analysis must be i attached to this form. ; i tf 3. Other: s D) System Failure Criteria Applicable to All Systems: t You must indicate "Yes" or"No"to each of the following for all inspections: Yes No 3r � ❑ Backup of sewage into facility or system component due to overloaded or `I clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ [Z�-' Liquid depth in cesspool is less than 6"below invert or available volume is less t than %day flow i. t5ins•09/08 - t Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface.Sewage Disposal System Form Not for Voluntary Assessments iF `? U �0 a--C t//S i c, fr Property Address I I i Owner Owner's Namer9 j information is ; required for every page. City1rown State Zip Code Date of I spec ion B. Certification (cunt.) — Yes No d; 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 ground water elevation. ❑ Any portion of cesspool or privy is within 100 feet of a surface water supply or ,tributary to a surface water supply. ElAny 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. ❑ Lam' Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence f , 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 i and chain of custody must be attached to this form.] ❑ ❑s- The system is a cesspool serving a facility with a design flow of 2000gpd- 000gpd. ❑ ET Te 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. I 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. For large systems, you must indicate either yes or"no to each of the following, in addition to the questions in Section D. Yes No j I i ❑ ❑ the system is within 400 feet of a surface drinking water supply r ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply It 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. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage DispDsel System-Page 5 of 17 1 � , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Ii Property Address -- IJ+ II! Owner( Owner's Name information is C, J required for '�~'� ✓ I G'j every page. City/Town State Zip Code Date of Inspection i C. Checklist �i Check if the following have been done. You must indicate','yes" or"no"as to each of the following: r Yes No ❑ lla Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal flows in the previous two week period? if. Have large volumes of water been introduced to the system recently or as part of this inspection? 1 t Were as built plans of the system obtained and examined? (If they were not available note as N/A) I ❑ Was the facility or dwelling inspected for signs of sewage back up? { i I LJ ❑ Was the site inspected for signs of break out? I i It ❑ Were all system components, excluding the SAS, located on site? '4 ;t Lam' ❑ Were the septic tank manholes uncovered,"opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? � ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System SAS on the site has been determined based on: Existing information. For example, a plan at the Board of Health. l i ❑ Determined in the field (if any of the failure criteria related to Part C is at issue ,I(fII I' I approximation of distance is unacceptable) [310 CMR 15.302(5)] t D. System Information Residential Flow Conditions: Number of bedrooms (design): Number of bedrooms (actual): _5.5 C. DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): t 15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page o of 17 ;I I Commonwealth of Massachusetts _ Tide 5 Official Mspectl®n Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments +IF 2 Property Address fie ! Owner! Owner's Name information is required for ° I. every page. City/Town State Zip Code Date of Ir/.peciion s D. System Information I 31 Description: � 6^ /J i f le4V fCl 1 Number of,current residents: ( Does residence have a garbage grinder? ❑ Yes 21NO i Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes [�No Laundry system inspected? ❑ Yes 20 Seasonal use?` El Yes No r Water meter readings, if available (last 2 years usage (gpd)): Detail: . t 1, Sump pump? ❑ Yes No i Last date of occupancy: Date l Commercial/industrial Flow Conditions: i , l' Type of Establishment: — f Design flow(based on 310 CMR 15.203): Gallons per day(gpd) u II Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No 1 Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑. No S d Water meter readings, if available: — r t8ins•09/08 1 i Title 5 Official Inspection Form:Subsurface Sewage Disoosal System•Page 7 of 17 i � t i Commonwealth of Massachusetts t,= Title 5 Official Inspection Form -i i subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address Owner Owner's Nameinformation is i required for i 0: O! I { every page. City/Town State Zip Code Date of I(lspection D. System Information (coot.) Last date of occupancy/use: Date Other(describe below): I 1 it 1 General Information Pumping Records: • ! Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: i� Type of S stem: , t Septic tank, distribution box, soil absorption system t ❑ Single cesspool �' I ❑ Overflow cesspool ❑ Privy it ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) `` ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. i ❑ Other(describe): I �t5I s•0911 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 - ir Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form "Not for Voluntary Assessments Z c, � � 1rs ' Property Address ! Owner Owner's Name information is -- r required for C`7 a<! / 34 b �I every page. City/Town State Zip Code Date of lns4ectiofi q D. System Information (cunt.) Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ❑ No i Building Seger(locate on site plan): %f Depth below grade: feet 1 Material of c nstruction: cast iron 0 PVC ❑ other (explain): Distance from private water supply well or suction line: feet 9E a4 Comments (on condition of joints, venting, evidence of leakage, etc.): I Septic Tank (locate on site plan): Depth below grade: feet YYY I Material of struction: concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) i Il If tank is metal, list age: years i Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No r Dimensions: �( a Sludge depth: "in 5•o9i� p !!' j Title 5 official Inspection Form:Subsurface Sewage Disposal Sysem•?age 9 of 17 � I ' ! f Commonwealth of Massachusetts ( MUMTitle 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I Il't II I w 0 ��ly / f ✓ MI Property Address i' Owner Owner's Name , information is co, 4C41 �, required fori i every page. City/Town State Zip Code Date of I pection D. System Information (cont.)' Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 1 Scum thickness e SS rt { !i i Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 149 �ol How were dimensions determined? t Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I //'_ � ,[✓ I� Grease Trap (locate on site plan): ,. Depth below grade: feet i Material of construction: k. ❑ concrete ❑ metal ❑fiberglass polyethylene[] pol eth t y y ❑ other(explain): r 3; Dimensions: Scum thickness I Distance from top of scum to top of outlet tee or baffle i Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date ---- t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposat System•page 10 or i 7 I Commonwealth of Massachusetts T 'Ve 5 Official Inspection Form Subsurface Sewage Disposal System Form ••Not for Voluntary Assessments Property Address Owner Owner's Name �C4 .Linformation isCO rrequired for lll..��� f every page. City/Town State Zip Code Date of Inspection D. System Information (coat.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): I Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): i" Depth below grade: 3 Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons J iI isi , I Design Flow: gallons per day �I l " Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No It Date of last pumping: pate Comments (condition of alarm and float switches, etc.): i Attach copy of current pumping contract (required). Is copy attached? ❑ Yes, ❑ No l: 1 {f5ins•09/08 - It Title 5 OYdal Inspection Form:Subsurface Sewage Disposal System•Page 111 cf 17 II 1 .t i 'js i' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary.Assessments Property Address 911e� i 3j Owner Owner's Name / information is �0 4-(A d - f Io `t J to required for _ every page. CityTTown State Zip Code Date of Inspection D. System information (cons.) Distribution Box (if present must be opened)(locate on site plan): f Depth of liquid level above outlet inve!# ;l. Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): ! 1 I � I, it Pump Chamber(locate on site plan): t 1; Pumps in working order: ❑ Yes ❑ No I Alarms in working order: ❑ Yes ❑ No f M1� F II Ii�, i Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): t 13{ it .f Soil Absorption System (SAS)(locate on site plan, excavation not required): t If SAS not located, explain why: i t5ins•09/08 Title 5 Official Ins! pection Form:Subsurface Sewage Disposal System•Page 12 of 17 {I ,f } I j, I Commonwealth of Massachusetts Title 5 Official Inspection Form of Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Property Address is a ;t it it Owner Owner's Name information is 6 � .�� required for • / j /� every page. City/Town State Zip Code Date of I&Ipection D. System Information (coot.) Type: leaching pits number: IF ❑ leaching chambers number: I iII ��� f �� �li ( ❑ leaching galleries number: l" ❑ leaching trenches number, length: i ❑ leaching fields number, dimensions: l ,E r ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): / % „t zr � 7r AO fr A -4L,�. 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 ;t Depth of scum layer i, Dimensions of cesspool �►►Is ��fli�� I i Materials of construction f t { Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 i' 'f r fill, i Commonwealth of Massachusetts Title 5 Official Inspection Fora f a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Zijk-e A, Property Address Owner Owner's Name 7 information is -, I required for ° sf % �� every page. City/Town State Zip Code Date of in p ction D. System Information (cost.). Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, i etc:): � 5 1 — ic � — . !E it 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, i etc.): ii � I i I t ,t if , a ;j ,t f t5ins•09/08 Title 5 Official Inspection Po•m:Subsurface Sewage Disposal System•Page 14 of 17 �f i Commonwealth of Massachusetts Title 5 Official Inspection Form I � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �I Property Address f Owner Owner's Name information is required for every page. City/Town State Zip Code Date of Inspect on i D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate jl�� II iil�i I where public water supply enters the building. Check one of the boxes below: E hand-sketch in the area below ❑ drawing attached separately i t,5 r j zl I 4 A.�- 9- i I(I;�� 11'tl it I t - i 1i f 1 ?f 15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 i p i Commonwealth of Massachusetts Title 5 Official Inspection Form } _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments zo Property Address Owner Owner's Name information is required forfl every page. City/Town l State Zip Code Date of Inspection I D. System Information (cont.) Site Exam: 1= t ❑ Check Slope- El Surface water ❑ Check cellar " ❑ Shallow wells i Estimated depth to high n P 9 ground d water: feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record ' If checked, date of design plan reviewed: Date ��� a it liih' i ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: I ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: 14, l S ' �bOF`'A— is Before filing this Inspection Reports please see Report Completeness Checklist on next page. t5ins•09/08 Titfe 5 Official Inspection.Form:Subsurface Sewage Disposal System•page i 6 e£17 F . Commonwealth of Massachusetts �l !. Title 5 Official Ins ectlon Form a ►I r - I Subsurface Sewage Disposal Sys/tem Form - Not for Voluntary Assessments Property Address Vie";k? Owner Owners Name information is , required for �� T�-t` � �� ,� !!/ / every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist i inspection Summary: A, B, C, D,-'or E checked inspection Summary D (System Failure Criteria Applicable to All Systems)completed [2/'System Information— Estimated depth to high groundwater ; e EgXS ketch of Sewage Disposal System either drawn on page 15 or attached in separate file , l ,i I, r i I� I is i� t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal system•Page 17 of 17 , t y\ ti % T07 OF BARNSTABLE LOCATION �Zee., ��5 �U(J SEWAGE# o y VILLAGE C� r'v % ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO.A&G A-Y SS o 7-2 > r_3 SEPTIC TANK CAPACITY e P fl 0 LEACHING FACILITY:(type) 715 C �► NO.OF BEDROOMS 5- OWNER �� y PERMIT DATE: -5— 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 A- IRS-: 3 �'° a TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 0 Parcel ' l Permit# �( �.,,. Health Division 1,�-��G 3 �,� � 4 �,Datte,l sued t I�� 1 7i1 LLED la g Conservation Division " CGWLIA�NCr !' I r H TITLE 5 Tax Collector EN'V ry q N + �+r�.,, I uPL C'rJ�Sio AID® C �: 4 J 1y irc i!aZ Treasurer Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address a Li: N Village Owner-J,;) _91:-JOL d- kId av R RN g Address 'go L 9d �cn��a i f Telephone —,-ti 01 a 11 Permit Request Add 1 ofj adaan .- o- a.,vz Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cost 000 Zoning District Flood Plain Groundwater Overlay r Construction Type Ujmo a1 Fkd Lot Size VD 0 Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure s.S Historic House: ❑Yes XNo On Old:King's Highway: ❑Yes Nr�o Basement Type: ❑Full ❑Crawl I 'gfWalkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 2'1 Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing__ new / Total Room Count(not including baths): existing �g new First Floor Room Count Heat Type and Fuel:, Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes ,l No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes �&o If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name s �.��_/r�S�,� Telephone Number 0 k' -2 R-0 o Address !�i':3 ✓k/A v r_ r ;a All-= License#- n . I •.3 a r e —TA I&AA 0 Home Improvement Contractor# 1 U 72 F-k C� (o V Worker's Compensation# /y A ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 9 A!/ LOCATION 5 E W A G E PER171T I30• 3 z VILLAGE INSTA LLER'S NAME & ADDRESS BUILDER OR OWNER DA T E PERMIT, ISSUED 11Z / rP;2 DAT E COWPLI. ANCE ISSUED z� ® J�r'Af A ��a 3e . .�4d +s. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH /- l / ✓..... ....................0F.5..... 2= ..C----------..---.------.-.-------.-..----- �/ Appliratilan for Bispniial Works Tonstrurtion Famit Application is hereby made for a Permit to Construct (!)e,) or Repair ( ) an Individual Sewage Disposal System at: .boy � l�G.ao ........... .�- ---------•............. l:oT..�ii �.��...-•--••-------___---- ... ..................................................... Location-Address or Lot �fGr�.... .-•--•---------------------•-•• ?lzB!t ... r.....s! wner ••----.Address a .. .. ••--•- -- •---- --- --- --------- ------------------........ Installer Address VType of Building Size Lot...a`�E__ t?_Ct_.__.Sq. feet Dwelling—No. of Bedrooms.____,�............... ...___.._.Expansion Attic ( ) Garbage Grinder ( ) a'4 Other—T e of Building �&Y E ______. Showers — Cafeteria YP g ------------�------------- No. of persons-------�:-•.----• ( ) ( ) Otherfixtures --------•---•--•-•----•---•---•-- • -----------•••---•••••-••---•-••••••-••-••••---••-•--•••-•-•-•••••••-••--••-•....._..•-•-•................ W Design Flow.... s................................gallons per person per day. Total daily flow-----------9.9-0.....................gallons. WSeptic Tank—Liquid capacity.104V..gallons Length._/O'k`".. Width..§_._._..... Diameter.?...____. Depth...(2:'_3. --- x Disposal Trench—No..................... Vidth.................... Total Length.................... Total leaching area...YA1.__......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..o."-f:!7Y!:'--- .......................... ....... Test Pit No. 1.....�__....._minutes per inch Depth of Test Pit•I .!........... Depth to ground water..; Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----.................... a ---••••--•••--------------•-•----•----------------------------...--.-----------•------•-----.----------•-----------••----........._..-•--------•--•••-•_•... O Description of Soil..Sir a --�/?!n,0.....eFUZ 1 A.t_[. ------/� 'chi_ = ....5ft c�1--------------------------------------------------------•-•---- W •-•••••----------------------•--•-•••-•-••------•-••••--•--...•-----•--••-•--•••••••-•............---•••......------.---••-----•••••-••-•-••--•----••---....-•------••••-••-•-----•••--._.............. U 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 iITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued b Zeoard of hea h. gn .-- .....•• �s P ............. D e Application Approved BY ----------- = 2 a �iv ---------- Date Application Disapproved fIth f ollowing reasons:................................................................................................................ .............................=.............................................................•.......................................................................................................-•--- Date PermitNo......................................................... Issued........................................................ Date THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINAL (S) I M /\C F DATA THE COMMONWEALTH OF MASSACHUSETTS BOARD, OF HEALTH OF... /J: i,� .......................................................... ApplirFa#ion for Disposal lVorks (nunstratr#tun runfit Application is hereby made for a Permit to Construct ( f) or Repair ( ) an Individual Sewage Disposal System at: �07' � i,.Play `�i� /1 w is I✓�T ' 1 Location-Address t or Lot No �• f/J / f �.'1 �,.'� / �t/.� .r t!"y: ..1�/' ......................»._..._...........•••...................................................... ..........._._...._...__._......_.._..........................._........_....._............._.... / Owner Address cart a.............. ...._::... ....................... ... Installer f Address UType of Building : "" Size Lot..._ _.. --. ----Sq. feet Dwelling—No. of Bedrooms....._.�:..................................Expansion Attic ( ) Garbage Grinder ( ) aOther—T` e of Building "Type g _;:___.___�_�_____________ No. of persons_______.-^�/................. Showers ( ) — Cafeteria ( ) Otherfixtures ------------•---••--------•---------•-•-----------•--.....•-----"---•------------------------•--...-•-•---"----"-"-......__.__...........•......-•-•-• W Design Flow.........:.................................gallons per person per day. Total daily flow............ .............................gallons. WSeptic Tank—Liquid*capacity..L.-..:.gallons Length...1.._._'...... 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._�<':a.':!.............................:........................ Date_"},." ..- .-:-'---- :.-----. W Test Pit No. I......::.......minutes per inch Depth of Test Pit-1.=.............. Depth to ground'water..-,-'.'-,-'_-_.-_.__.... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a .......................---................................................................................... ... O Description of Soil....== = == t'I= __�...r.:.=•----• ---"----• ' __/ I . r = " ------•-- •----••--••-•••-••-••-•-•-•..................•---••.......__.....----•- V .........---•--------••-••---••-..._....--••--......••-••-----•-•-••-•......-•-•--•--•........._-••--....__---••---•••••-----•-•----•-•--•--•••---••-•-••••.................•••---••-----••--•-••--...... W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ...-"-----------------------------••----"-----------------•-----------..._••--•-••-•------•-•--•------........-••--••---•--•-----•----•••••----••••-•---•---•---••-••-•-••......-•--.....----_.....•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of I- p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been#i'"ssued by the board of health. Application Approved ByIthlollowing r-d::_` .... c.- 7 Date Application Disapproved f reasons:--••---••---••----•-•----------•---•---••--- ..................•••-•--•.....--•-____...---••-••---••------••---•---•--•--•----•--••••......•--•...............-----•--••---•----•--•-•-•---•••....•••-••--•--•••••-•--•----•--•-----•••------••---___._ Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH !...:...............................OF.I....r?r:...............o..............r....................................... (9rdifirtt#r of Toutph atta THIS IS TO CERTIFY, That;the Individual Sewage Disposal System constructed ( ) or Repaired ( ) a� / ._.....� !i �f�v_ ....._._ Installer at ...........-••••-__.....- ----•-------------------"-•-------••----------------•-----••-----..-•--....-••-•-...... has been installed in accordance with the provisions of T TLE r of he State Sanitary CodeAs scribed in the application for Disposal Works Construction Permit No._ ._�_ ............. dated...I,ly-'.--- _ " ._._.___._....__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUAiANTEE THAT THE SYSTEM WILLFUtj&ION SATISFACTORY. DATE....... -.L ............................................... Inspector.......... -----...----....-•----------......----------•--......_..-•-----•---- THE COMMONWEALTH OF MASSACHUSETTS �----' BOARD OF HEALTH f' ........................OF...... ?r�r/ ri/.�l �. No.. FEE......:.'r............ Disposal Works Tonstrurtivit frrutit Permission is hereby granted...._ --•-••---"--•--I-••-•-••---•----••..............•-•..............••-•......_........._............--••.....---- 01 to Construct ( ' ) or Repair ( ) an Individual Sewage Disposal System Street as shown on the application for Disposal Works Construction Permit No.__.__ _:_'__�Da -_� ............ ................................ ......................................._ r y DATE_ --------•------••--•-•-------•-•..........................................••--- ,/ Board of Health ,FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS r r- G Ea.!E2 D.L. N 0TF-15 (D--AI-L ESE%/' gNo � w 1.9,A�2-F M E AaP SE�► L.E�d1EL BASED Ct t.l C3+�sa�, rr. 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