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HomeMy WebLinkAbout0116 OLD KINGS ROAD - Health 116 Old Kings Road Cotuit , i No. r q t �' �EALTH GAA Fee/ THE COMM OF MASS HUSETTS Entered in computer: PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippfication for Misposal *pstem Construction permit Application for a Permit to Construct( ) Repair() Upgrade( ) Abandon( ) ❑Complete System EE Individual Components Location Address or Lot No. f/(y ol-a /do Owner's Name,Address,and Tel.No. 1.14& Assessor's Map/Parcel p L2 G V Installer's Name,Address,and Tel.No. payZ;xc.�ov/r7 Designer's Name,Address,and Tel.No. _ 1z c Type of Building: dl6a t l/ 7 7 6W�7JelI Dwelling No.of Bedrooms Y 11 Lot Size F 4" !4�q-ft- Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) I WS'TAW_ 1S'CZ q1 rPCAY c. TAN k taw+a lJtw Dig-3 c,crA,1.►st��6 `� ',3?,LS 'tntb Iotx> Q L-6Az.1 o NIT r572 RgAsL wit- '�S`ff1` rA , —' (75Sjzj65 — 1—Avt-�IWL�-� f3 Full 6AT14 Date last inspected: ` Agreement: The undersigned agrees to ensure the construction and maintenan o the a ore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environm ode and not to ce the system in operation until a Certificate of Compliance has been issued by this Board of He ~ Sianed Date Application Approved by Date 0 Application Disapproved by Date for the following reasons Permit No. -11!(J '" Date Issued = — No /� �' (n R.. �Q(I�1 �LJ ! �1/1 Fee (/U THE COMMONWEALTH Of MASS HUSETTS Entered in computer: Y�� y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es 2pplicatlon-for -isposal 6pstrm Construction Permit l Application for a Permit to Construct( ) Repair 0() Upgrade( ) Abandon( ) ❑Complete System Individual Components Location Address or Lot No. //& 04,0 ,(tlivGs *To. Owner's Name,Address,and Tel.No. I q 2 vG Y , M17266A/6 Assessor's Map/Parcel Z2 GoTc.'T Installer's Name,Address,and Tel.No. p19 V-M.6 %x c,jwn-7 Designer's Name,Address,and Tel.No. P. o FSO-E `1T- LS `iSw Type of Building: 1 i�-7 _ Dwelling No.of Bedrooms Lot Size A` '-s fl—ft Garbage Grinder( ) {_ Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd 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) S` A L ANO NSw 00-1 t �r��f.���F,A �0 �v4ST�R3�-1 LrsA - ?a Ii�A�L EPriG � M 2�,C�S - LA�iU�iZ `� R� {v T� �i�ll 94T14 ' Date last inspected: Agreement: ` The undersigned agrees to ensure the construction and maintenance of'2eatore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme ode and not to he system in operation until a Certificate of Compliance has been issued by this Board of Hea Signed Date Application Approved by Date / Iq 0 Application Disapproved by Date for the following reasons Permit No. p/(J Date Issued _ko - - - - ----------------------- - - -- ,- - -- - --------------------- ----- --_ _ -_ _ f === = = _ _ - -------- THE COMMONWEALTH OF MASSACHUSETTS �sC.r _�J� m BARNSTABLE,MASSACHUSETTS Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(AA)y Upgraded( ) Abandoned( )by_AS,-=.T, 761- at & of h k-1�j&,7 has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 0/0 -/ q dated 4 I u z. Installer 4:1 r Designer A #bedrooms L Approved design flo� yV o gpd The issuance o thip permit shall not be construed as a guarantee that the system ill fiition as deslgned. Date (J Inspector No. rJ - // Fee h 0 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon( ) System located at (o 0I_DIC i w6 s Q.D- r CM )`j•T and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construc ion ust be completed within three years of the date of this permi . Date Approved by "Y - � � .. G �O � �� _ r `_ � r a � c �� s- ,. t� � ��.;1� } � ._ �4 - .: , - , . New Page 1 `' Page 1 of 1 TOWN OF BARNSTABLE (\� LOCATION r°" SEWAGE _ VILLAG MAP A LOT INSTALLER'S NAME A PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(tnm f (size)— NO. OF BEDROOMS _PRIVATE WELL OR PUBLIC WA BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No YOITT- ' r i H O v s e1 i http://www.town.bamstable.ma.us/assessing/2010/HMdisplay.asp?mappaY=022094&seq=1 6/3/2010 TOWN OF BARNSTABLE LOCATION �l OLD jW SEWAGE# Z" 716 9 VILLAGE 77' ASSESSOR'S MAP&PARCEL 0 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY /5 0Z CJ LEACHING FACILITY:(type) 10M q) (jet ) (size NO.OF BEDROOMS �� 77 ) OWNER rVtLJ PERMIT DATE: - —f 4 COMPLIANCE DATE: k 0 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 lea m li Feet FURNISHED BY Al Z A-L Z Al 3Z fn y 5z 7- � z . G z33 2-7 TOWN OF BARNSTABLE LOCATION ' ,/ ,ti f SEWAGE # VILLAGE ASSESSOR'S MAP 6z LOT t�- �j y INSTALLER'S NAME PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) � (size) NO. OF BEDROOMS�_PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER 422 DATE PERMIT ISSUED: -7 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No I � O u's TOWN OF BARNSTABLE LOCATION NO O OLD• k-jNb5 JW SEWAGE# ZO D VLLLAGE e,6>L'�T ASSESSOR'S MAP&PARCEL - 0 01 INSTALLER'S NAME&PHONE NO. PAWAM SEPTIC TANK CAPACITY 5" LEACHING FACILITY:(type) CJL7b (size NO.OF BEDROOMS OWNER - PERMTf DATE: ! -J,0 COMPLIANCE DATE: b#sk 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 lea li Feet FURNISHED BY �►Z `i Al 3L Z l 7-7 8z � . $3 Z1 I .. tali Commonwealth of Massachusetts Title 5 ,Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27/10 Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. A. General Information 1. Inspector: Frank Nunes III Name of Inspector saa Company Name 25 Deer Ridge Rd Company Address Mashpee MA 02649 Cit !Town State Zip p Code 508.272.6433 Telephone Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and--Maintenance-of on�ite 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 ❑ Fails w ® Needs Further Evaluation by the Local Approving Authority -0 �! I~ C- 5/27/10 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 31["days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and 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. I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments °Y 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27/10 Cityrrown State Zip Code Date of Inspection B. Certification cont. 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: Pumping suggested every 3 yrs to prolong the life of the system 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 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. ❑ 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: n/a El 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 r ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27/10 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: n/a ❑ 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: n/a 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. 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. i� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments '< 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27/ 10 City/Town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ 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 indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or Tess than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form:: 3. Other: 2 systems were identified at this home. The one in the front yard is in compliance w/MA Title 5 and local BOH pegs. The 2"d in the rear of the home is a single cesspool. This system is not in compliance w/local BOH regs. All plumbing in this home must-be tied into a compliant system in order to be cosidered a"Pass,, l D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes ` No Backup of sewage into facility or system component due to overloaded or El 0 clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ® Static liquid level in the distribution box above outlet invert due_to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow 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. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,..°� 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27/10 City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cont.): Yes No ❑ ® 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 system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- ❑ ® 10,000gpd. ❑ ® 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 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 ❑ ❑ 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.11 of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.3,04. The system owner should contact the appropriate regional office of the Department. a ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments M s 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27/10 Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.,Yo,u 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 ® 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? El ® 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 El available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage backup? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding-the SAS, located on site? ® _ Were the septic tank manholes`uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions,depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the-proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example; a plan at the Board of Health. ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] i ` 1 ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5127/10 Cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): n/a Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: 1 Does residence have-a garbage grinder? ❑ Yes ® No . Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 yearn usage(gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: occupied Date Commercial/Industrial Flow Conditions: Type of Establishment: n/a Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title.5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): n/a ti Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27/10 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: front pumped 3 yrs ago Was system pumped as part of the inspection? ❑ Yes ® No 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)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1973 per age of home Were sewage odors detected when arriving at the site? ❑ Yes 0 No Commonwealth of Massachusetts 9-3 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: >10'feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No -------------------------------------------------------------------------------------------------------------------------- Dimensions: 1000g 2,. Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle >12' Scum thickness 1" Distance from top of scum to top of outlet tee or baffle >211 Distance from bottom of scum to bottom of outlet tee or baffle >211 How were dimensions determined? measured ' Commonwealth of Massachusetts Title 5 Official Inspection. Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M s. 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 -5/27/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping suggested every 3 yrs to prolong the life of the system Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a 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: bate Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): n/a or Tight Holding Tank tank must be pumped at time of inspection) (locate on site plan): 9 9 Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): n/a Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -,Not for Voluntary Assessments ti 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27110 Cityrrown State Zip Code Date of Inspection D. System Information (coat.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): n/a *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 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 solids carryover, any evidence of leakage into or out of box,etc.): No D-Box Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No 1 ' ' Commonwealth of Massachusetts-; Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27/10 Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): n/a Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 � ❑ 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, etc.): Leach Pit is 2''below grade liquid level is 18 below the inlet pipe. Stain line 12" below the inlet pipe. Pit has 2-3'stone surround. No signs of backup a ' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for.Voluntary Assessments 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27/10 City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration1 Depth—top of liquid to inlet invert 3' 611 Depth of solids layer Depth of scum layer 0 Dimensions of cesspool 6'X6' Materials of construction precast Indication of groundwater inflow ❑ Yes ® No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Cesspool is 2' below grade,1/2 full at this time, 2-3'stone surround 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.): n/a �• Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 116 Old Kings Rd Property Address Harvey Owner's Name Cotuit MA 02635 5/27/10 Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 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. G -� z 3 -r o !a (D �9 A • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments < 116 Old Kings Rd Property Address Harvey Owners Name Cotuit MA 02635 5/27/10 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high groundwater: >12' 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: pate ® 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) z Accessed USGS database-explain: You must describe how you established the high ground water elevation: see above TOWN OF BARNSTABLE } LOCATION /O b . r.; SEWAGE # VILLAGE ` ./ASSESSOR'S MAP 6t LOT 1 ©� INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY '` _— :.: � , LEACHING FACILITY:(type) O NO. OF BEDROOMS�_PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER ,1 . DATE PERMIT ISSUED: DATE COLIPLIANCE ISSUED: VARIANCE GRANTED: Yes No Y l � ovse� 4 1 1 Apr I ` lwSp� ;e N6 _11 W FimH.... .. .................. THE COMMONWEALTH OF MASSACHUSETTS BOARD HEALTH �1 ... ..... ......... f. 41--A .........OF..........�..QA�Vz� Appliration -for Rtipoiiat Workii Tomitrurtion'Prruid Application is hereby made for a Permit to Construct (L4<r Repair an Individual Sewage Disposal System at: .........arl5z ........... ........ Location-Address or Lot No ................ ........... .�V,4­ _!?�O.......Z:..................... ------------- ------ ---- Oywner () Address .................. ......... ............................................................................................ ---Wae..s4A installer, Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms.-.-. -------------------------------Expansion Attic Garbage Grinder 04 Other—Type of Building ---------------------------- No. of persons_-------------------------- Showers Cafeteria P4Other fixtures -------------------------------------------------------- .................................................................................... <� 4Y"_V W Design Flow.................S-0.................gallons per person per day. Total daily flow._---- --------­------------------gallons. P4 Septic Tank L Liquid capacitv/�_gallons Length................ Width.----........... Diameter..._--....._... Depth---------------- Disposal Trench—No--------------------- Width...._.-_.---- . Tota� Total leaching area--------------------sq. f t. ------- _Length Total leachingarea3�P-:2—sq. it. Seepage Pit No......./----------- Diameter- osio, e4&�� n tank 1 Other Distribution box )osin tank ( ) Percolation Test Results Performed by..._--....._............................................................. Date----- ------ Test Pit No. I................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-----__-57 ---------------------------------------------------------------------------- -------- -------------------------------------------- X ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 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 Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b sued by the board of health. Signel;g 1< 7-3................ ..... .. --- ............................ ------ Application Approved By-----a -- -- -------10,...... Application Disapproved for the following reasons:--------------------------_---V_------------------------- ------...... .................. .. .............. ......................................................................................................................................................................................................... Date Permit No. Issued-._;;�/........................................................ Date' ........ 9 - .. ,...fix.:•".. . � AIT No...... �'`".'CY'"__..- E 4},:���m _r F;.. FEE............................. T4E COMMONWEALTHI-O.F MAASSACHUSETTS :BOARD. HEA 0. OF'.. ...... .� s firtttin� f�irr .i ru tt1 aark Cn t r�tstiexn -- remit Application is hereby made for alPermit to Construct ( Repair ( ) an Individual Sewage Disposal Systein at Location ress T j .fir or Lott No. .. i`Y �" ,-F3_•---•--/ ---�M-"-"-..7..... ........................... - ---�J/la- ',,,r7 ..--•� •i+�- --� ' j--~/_----••___-----•--- Ownrei/ Address Installer i Address Q Type of Building n Size Lot----------------------------Sq. feet U Dwelling—No. of Bedrooms-_---__. ..._.Expansion.Attic ( ) Garbage Grinder ( ) U ,�' .. PA Other—Type of Building ____________________________ No. of persons---------------------------- Showers,( ),— Cafeteria ( ) ,A . Other fixtures --------------------------------------------------- ---------------------------`------ ---------------_---------------------------------------------- d,W W '+ Design Flow................ gallons per person per day. Total daily flow....._._.. e _________..__._..gallons. WSeptic Tank--Liquid capacity � allons, Length________________ Width.__...._. .._. Diameter................ Depth.- ----_ .-. . x Disposal Trench—No. __:_________________ Width------------------- Total ength....... ._. Total leaching area_---.--_---_-_----sq. ft. Seepage Pit No........ .__....__. Diameter....f :__....___.'*... Total leaching area.--340-;;tr ft. z Other Distribution box ( ) Dosing fank ( ) Percolation Test F:esults Performed by-------------............................................................. Date...... Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-.----------------_----- rX, Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground,water__.--.-_-_-.-_---------- -------------- .. ----•------------••-----------....---------......... -•-•-------•--- D Description of Soil-----------„ ----_ ' .0 --------------------------------=------------------------------------------------------------------ ------------------------------------••----------------------------------------------------:- ...... 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee • ued by the board,of health. 1 s Sign e _ r'!► ••------- �i�� tt.'a_... Application Approved By---... --- --- Y, te - '.. Application Disapproved for the following reasons------------- -------------- --------=-------------------------------------------------•----•-•--......-•--••••-- e' Date f PermitNo...............................................-.......... Issued---- .................. e Date THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH ... .j/ :E .....OF...... _.E'/ Trr#ifiratr of �Tampliartrr ` TrYSISY TO CERTIFY, Th the ndivtdual Sewage D,is'posal System constructed ( ) or Repaired ( ) by = // i' ih //( c ;t1` ./- - ''' - � ' has been installed in accordance with provisions of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No----------------------------------------- dated------------------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL. NOT BE CONSTRUED AS A,GUARANTEE THAT THE SYSTEM WILL-FUNCTION SATISFACTORY., DATE-_--------- -7--- '' -•-- -- Inspector -------------------- 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .............. ..L' ......OF... :^n z ................................. No......................... FEE........................ Binpniitti Warkii Tnni#ritr#ion rrrmi# Permission's hereby granted------------------------------------------------------ ---------------------•--------•----------------------------------------------.....--•- to C r/ or Rep4ir n,Individ`ua ewage Dip_o'sal�L System uc ' atNo'- ��---- ..... --------------------------------------------------------------------------------- Street as shown on the application for Disposal,Works Construction Permit No--------------------- Dated------------------------------------------ .......................................... Board of Health DATE-------------------------------------------------------------------------------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS e r - �1.,\sf�f1'• F/y.��'� M1�r 4 8 .w.8�w.{wy�`.jr'.(�'/''('J' ^^ff�r_, _Y.(w.j�./{ ,.J./�.�t�.�. • •,. , r �'���� rMi,-+y Y!� r�� •��� �•--ins„wn-.i++..� L±4+^Y'�o.'*^"'•"_ ,4.' _ > •. �r * + ' • ', � ' _ ,' - '�" • : Y � .�.-�R .. .(�` � , Try .. r _ , • . ', • " - . � :. . 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