HomeMy WebLinkAbout0021 PENELOPE LANE - Health 21Pene16pe Lane
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BOARD OF HEALTH
TOWN OF BARNSTABLE
01ppYication ff or Yell Con5truction Permit
Application is hereby made for a permit to Construct(t f,, Alter( ), or Repair( ) an individual well at:
a� /'e�cloPe L ,y �o7-u t �
Location 6ddress Assessors Map and Parcel
J r wt. G�e r� pe) .)/ ?e•�je6e< I-po cry f i
Owner Address
D &�a Nw-e l/ /oF De.G raa /?J ^44S4,oec eMu 06 V 5
Installer-Driller Address
Type of Building
Dwelling
Other-Type of Building No. of Persons
Type of Well y�L)(-- Capacity
Purpose of Well
Agreement:
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well Protection Regulation-The undersigned further agrees not to place the
well in operation until a Certificates mpli ce been issued by the Board of Health. Z /
Signed s- 'Z
Dat
Application Approved By 2/
Date
Application Disapproved for the following reasons:
Date
Permit No. ?, rD3�— Issued
Date
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BOARD OF HEALTH
TOWN OF BARNSTABLE
Certificate of Compliance
THIS IS TO CERTIFY,that the individual well Constructed(4< Altered( ), or Repaired( )
by DcfN/V/S SC CG rOAVE l/
Installer
at off/ PeN eto✓'e L,� t'� bt
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private We r ection
Regulation as described in the application for Well Construction Permit No. I Q,0711 ��� Dated Z
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
�a
q�
No. _ _ Fee
�� ._.__-- ..- BOARD OF HEALTH
l � TOWN OF BAR STABLE 9 � s
J� r rication -for Yell CpMruction Permit
Application s hereby made for a permit to Construct(t j, Alter( ), or Repair( ) an individual well at:
al �l�e •�c1oL ,J ��lu
Location- Iddress - -- Assessors Map and Parcel F`
Owner Address
/G 9 `/?j mGSh ✓-1a C) y�
Installer-Driller Address
Type of Building ,
Dwelling
Other-Type of Building 1 No. of Persons
Type of Well ��t�, !/�(')L Capacity
.I
Purpose of Well /l-r I g a /-. t
Agreement: I
The undersigned agrees to install the afore described individual well in accordance with the provisions of the
Town of Barnstable Board of Health Private Well,Protection Regulation-The undersigned further agrees not to place the
well inoperatio until operation a Certificate of Compli ce /s been issued by the Board of Health.
Signed
Dat f
Application Approved By
Date
Application-Disapproved-for the following reasons:
Date.
Permit No. R" tJ� Issued l
l Date
w BOARD OF HEALTH
TOWN OF' BARNSTABLE
Certificate of Compliance
A
THIS IS TO CERTIFY,that the individual well Constructed(!.)! Altered( ), or Repaired(
by
Installer
at -'j C/o,Pe- L Gar u/
has been installed in accordance with the provisions of the Town of Barnstable Board of Health Private_ Wjel.l Pro�ection
Regulation as described in the application for Well Construction Permit No. € '� � Dated ;> �f�� 1+/
f� r
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL
SYSTEM WILL FUNCTION SATISFACTORILY.
Date Inspector
BOARD OF HEALTH
TOWN OF BARNSTABLE ,
Ivell Construction permit f f
No. U i Fee: C --
4, Permission is hereby granted to SCCowAye//
t Installer
to Construct( Alter( or Repair( an individual well at:
No. ez d e �w 6O
Street
as shown on the application for a Well Construction Permit No. �"7�' s Dated
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Date U l j Approved By
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE,OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
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TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUB$UR=FACE;1SEWAGE DISPOSAL SYSTEM CEIVED
PART A
CERTIFICATION
t , pp AUG 5 2002
Property Address: 21 PENELOPE,L`ANEtCOTUIT, MA 02635 03q U"12— TOWN OF BARNSTABLE
Owner's Name: KRISTEN MONTEIRO
HEALTH DEPT.
Owner's Address: 21 PENELOPE LANE COTUIT,MA 02635 5� r (A
Date of Inspection: 7/22/02
print) N1,' '`JOHN GRACI
(P
Name of Inspector: lease rent SEPTi�C INSPECTIONS 1 Y\�J
Company Name:
Mailing Address: P.O,WX 2119 TEATICKET,MA.02536
t
Telephone Number: 508-564 6813 FAX`508-564-7270
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CERTIFICATION STATEMENTrported
I certify that 1 have personally inspected the sewage disposal sy n at h was performed based onis address and that thermyttroa ning and below is
true,accurate and complete:as of;the, time,of the mspectioinspection
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
?' 'n 1,5.340 of Title 5(310 CMR 15.000). The system:
inspector pursuant to Sect
X Passes
_ Conditionally P ses
_ Needs Furth valuation by the Local Approving Authority
_ Fails
Date: 7/22/02
Inspector's Signature:
r .
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
0,000 gpd or greater,the
30 days of completing this inspecti n. if the system is tshhe appropriate ed s e regionalm or has a soffi e of heign now of IDEP.The original should be
inspector and the system owner shall submit the report
sent to the system owner and`copies sent.to the buyer, if applicable,and the approving authority.
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Notes and Comments
SYSTEM PASSED TITLE V.INSPECTION. RECOMMEND PUMPING ONFUL'f1ZATORSo YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE`i RECOMMEND RAISING CO
g
****This report only deseribes.condilions al the time of iuspecl10 I 'IIId nder vider tlil samele onditi different of Ilse conditions at that ,of use-
inspection
w
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perform in the
does not address,how•he y st.em ill
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'r{rl:. : lict�rrtinn Firm (.11 S/'JT1(1(1". _ �
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
v CERTIFICATION (continued)
Property Address: 21 PENELOPE!LANE COTUIT, MA 02635
Owner: KRISTEN MONTEIRO =.'.
Date of Inspection: 7/22/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Sectioa D
A. System Passes:
X 1 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: yj+
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE. RECOMMEND RAISING COVER TO INFULTRATORS. ,
B. System Conditionally Passes:
_ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,
ass.
it as approved b
upon completion of the replacement or repa pp y the Board of Health,will p
Answer yes,no or not determined'(Y,N N6) in'the for the following statements. If"not determined" please explain.
n/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.:avail able.
ND explain: n/a
n/a Observation of sewage backup or b'reak+out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneve''distribution box. System will pass inspection if(with approval of Board of
Health):
`'x brokeh pipe(s)are replaced
g`obstruction is removed
'distribution box is leveled or replaced
ND explain: n/a '
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 ofthe Board bf Health):
_broken`pipe(s):;' replaced
_obstruction is'removed
:i
ND explain: n/a
Page 3 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
40 , PART A
s , •CERTIFICATION(continued)
Property Address: 21 PENELOPE LANE COTUIT,MA 02635
1.
Owner: KRISTEN MONTEIRO
Date of Inspection: 7/22/02 '',,,
F
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require fu'rAhe 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`13oa�r'dof Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner,;yvhich %ill protect public health,safety and the environment:
_ Cesspool or privy is within 50!feet of 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 tai k+and SASInd the SAS is less than 100 feet but 50 feet or more from a private water
supply well". Method,used to determine distance n/a
"This system passes if th'e''d'tvater 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- 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:
n/a
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Page 4 of 1 l
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
` PART A
CERTIFICATION(continued)
Property Address: 21 PENELOPE LANE COTUIT, MA 02635
Owner: KRISTEN MONTEIROt`.,',.:
Date of Inspection: 7/22/02
D. System Failure Criteria a'pplica'ble'to all systems:
You must indicate"yes"or"no"to eacli''of thee'following for alLinspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of:effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool I , '
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/2 day flow
_ X Required pumping more than 4 tin-less in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped NO PUMPING INFORMATION.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool'or privy-is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or,privy is within a Zone 1 of a public well.
X Any portion of a cesspool:or'privy is within 50 feet of a private water supply well.
X 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 laborator ,tlorKcoliform 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.]."`
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(Yes/No)The systern1ails. Lhave determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fail'ss 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 now 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`4in addition to the criteria above)
yes nor.,
X the system is within 460 feet of-a surface drinking water supply
X the system is within 200 feet o,P tributary to a surface drinking water supply
:,x h,\
X the system is located in a'nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of.a public water lsupply well
If you have answeredye.s to any question in Section E the system is considered a significant threat,or answered
" Ut
yes" In SCl'lllln D above the Iar c 5 si qm huts"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.'f he system owner
should contact the appropriate regional office of the Department.
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Page 5 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 21 PENELOPE,LANE COTUIT, MA 02635
Owner: KRISTEN MONTEIRO 4
Date of Inspection: 7/22/02
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No w .
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system eomponents.pumped out in the previous two weeks
X _ Has the system received normal flows in the previous two week period
X Have large volumes of water been introduced to the system recently or as part of this inspection '?
s .
X _ Were as built plans of the system ebtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up
X _ Was the site inspected for signs of break out'?
X _ Were all system components,excluding the SAS, located on site?
X _ Were the septic tank m 11 anholes 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?
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposalf'systems ;.
The size and location of ttie Soil Absorption System (SAS)on the site has been determined based on:
Yes no
X _ Existing information' For example,a plan at the Board of Health.
X _ Determined in the field(if any:of thee""failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CM 15.302(3)(6)] ,
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-Page 6 of 1 t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
`SYSTEM INFORMATION
Property Address: 21 PENELOPE LANE COTUIT,MA 02635
Owner: KRISTEN MONTEIRO
Date of Inspection: 7/22/02
jo ).;t;,
FLOW CONDITIONS
141
RESIDENTIAL 1.•`
Number of bedrooms(design): 3 Niunber ofbedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 4
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or,no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):-tM— C) Cl'600
Sump pump(yes or no): NO C) DCD
Last date of occupancy: n/a 4
1
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR415.203): n/agpd
Basis of design flow(seats/persons/sgft;etc.): n/a
Grease trap present(yes or no):`NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the f itie 5 system(yes or no): NO
Water meter readings, if availablb: n/a
Last date of occupancy/use: n/a r,
OTHER(describe): n/a
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4GENERAL INFORMATION
Pumping Records
Source of information: NO PUMPING INFORMATION
Was system pumped as part of the inspection(yes or no): NO
If yes, volume pumped: n/agallons--How was quantity pumped determined? n/a
Reason for pumping: n/a t
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool , �}
_Privy k J f
_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): n/a
Approximate age of all components,date installed(if known)and source of information:
1996 BY OWNER
Were sewage odors detected when arrivirg at the site(yes or no): NO
6
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Page 7 of I I 4
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE:SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 PENELOPE{LANE COTUIT, MA 02635
Owner: KRISTEN MONTEIRO
Date of Inspection: 7/22/02
BUILDING SEWER(locate on site plan)`
Depth below grade: 12"
Materials of construction:_casteiron X40 P,VC_other(explain): n/a
Distance from private water supply well.or suction line: n/a
Comments(on condition ofjoints,venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 6"
Material of construction: Xconcrete" metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age Zc All'ntied by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 150OG L 10' 6" H 5' 6.Y;W.5.' 8""'
Sludge depth: 2" "
Distance from top of sludge to bottom of outlet tee or baffle: 32"
Scum thickness: 1"
Distance from top of scum to top of;outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):`
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY'TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
.FE
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction: concrete metal fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom to of scum bottom of outlet tee or baffle: n/a
Date of last pumping: n/a z
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
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'Page 8 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 PENELOPE LANE COTUIT,MA 02635
Owner: KRISTEN MONTEIRO: = '
Date of Inspection: 7/22/02
i
TIGHT or HOLDING TANK: (tank must'be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A ,
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
t
DISTRIBUTION BOX:2 ff present must,be.opened)(locate on site plan)
Depth of liquid level above outlet invert:LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribufion to outlets equal,any evidence of solids carryover, any evidence of leakage into
or out of box,etc.): °I:�,9 i , ,
D-BOX IS STRUCTURALLY t7UND. cl
PUMP CHAMBER: _(locate on site plan)_(171
Pumps in working order(yes or no). O
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Ul
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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: 21 PENELOPE LANE COTUIT,MA 02635
Owner: KR[STEN MONTEIR O ,.
Date of Inspection: 7/22/02
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
INFULTRATORS leaching chambers, number: 1
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a >;` 1'l :,innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
DID NOT EXPOSE INFULTRATORS. NO INSPECTION COVER RAISED. INFULTRATORS APPEAR TO BE
STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM SHOWS NO SIGNS OF FAILURE.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a `
Depth of solids layer: n/a
Depth of scum layer: n/a '
Dimensions of cesspool: n/a +•
Materials of construction: n/a
Indication of groundwater inflow(yes or no):-NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
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Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 21 PENELOPE LANE COTUIT,MA 02635
Owner: KRISTEN MONTEIRO
Date of Inspection: 7/22/02 ,
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two perr lanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply.enters the building.
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'Page 1 I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
` PART C
,.SYSTEM INFORMATION(continued)
Property Address: 21 PENELOPE'LANE COTUIT, MA 02635
Owner: KRISTEN MONTEI,RO,, 1
Date of Inspection: 7/22/02
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+feet .
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain:;n/a
You must describe how you established the high g ground water elevation:
HAND AUGER- 10+ FT.
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TOWN OF BARNSTABLE
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LOCATION v 7 /l"�e� ° XV, SEWAGE # Q
VILLAGE G��Ll/?` ASSESSOR'S MAF&LOT '
INSTALLER'S NAME&PHONE NO. 4/�OL4l�/^
SEPTIC TANK CAPACITY ✓��®
I LEACHING FACILITY: (type) (size)
ei
NO.OF BEDROOMS �J
BUILDER OR OWNER ��c57�"15� ®�L�rJ`LG✓S
\PERMTf DATE: COMPLIANCE-DATE:
® Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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ASSESSORS MAP N —
(� / PARCELNO'
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Uhi-p sal Works Qlaustrurtiort Vrrmit
Application is hereb made for a Permit to Construct (k ) or Repair ( ) an Individual Sewage Disposal
System at
.............!!VJ. --��-�......................................�� cf l Et.o = 'L` _ ...................................
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.-- Location-Address �j�!'� ��� �Ior'Lot No.
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O Address
W ................. ... .........�. ...........................................
Ins Address
Type of Building Size Lot...�?-__ a.�.....Sq. feet
.. Dwelling— No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ------------------------------- - -
Design Flow..................6.5..................gallons per person per day. Total daily flow................35.o................gallons.
WSeptic Tank—Liquid capacitv.15v 0 gallons Length..� .__4__ Width.1_...$.-.- Diameter................ Depth....
x Disposal Trench—No. Afi`iKMS........77�1_ Total Length.... Total leaching area_.._!!ke'3.....sq. ft.
3 Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......� .-.G'!'r°��!-................... Date........8...... s.......
Test Pit No. 1...___.!!�.Yminutes per inch Depth of Test Pit-------A.�" Depth to ground water......
Li, Test Pit No. 2................ �inutesper inch Depth of Test Pit__.____A_ �� Depth to ground water----.P ..4.......
........-•------•---•-•-----...----•..............•--•-......_....... ----•-•-•-••---•--...-------"---------'•---•••--'............-'-....................
0 Description of Sofl.•CV.O..:.a-3."------E= ........ .......ti e". -t-5A-W.-->--------3-_'•,�/(.00—"--Mfi50- Z4&A
►Yr �a..1_ .�., .. MEYI-(.21_��A?11}J�_...... .9.71~_.._ r�.8•....E...�.._...._ e��t"`® Q - `' T•......
V �.
W I�oaw.�..5,�a►+sP------...!i i_5 y"... '' ..4V..oft. 5'`'
UNature of Repairs or Alterations—Answer when applicable.......:.......................................................................................
..----••-•--••••--_...-•--••••.................•...--•-•---..._..........••••-••••••...........................-••••-•--••-••-•-•-••----••-•----•--•-•--•-•--------•------......•-•...----------..-'-•--
Agreement:
The undersigned agrees to install the aforedescribed In ' •dual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environ ntal C de— e undersigned further agrees not to place the
system in operation until a Certificate of Comph ce as een is ed the o d health.
Signed/ ...... .. ..... ................ .....¢......................-----.....
Application Approved 1�........-�,7� +-- .... .. �....... .L. 2.Z. . . Y...J... G�'� .✓
Due
Application Disapproved for the following reasons: ......................................................................................................................................
.............................................................................................................................................................................................................. ...................................
Permit No. ��'�li. �4.. e
-•................. ........... ..........-----•----...---- Issued ...................-------------------� ...................
Dire
FEB
` THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE - --�
Applirtt#ion for DioVoottl Works Tonotrnr#ion lirrmi#
Application is hereby made for a Permit to Construct (k ) or Repair ( ) an Individual Sewage Disposal
System at:
'S ,7/.�
.............-•... ...........•--• ----------•----------•-•---------•--............... •---•------•... --
r Location-Address or Lot No.
...................... .......0 e.. 0 to h!✓ G t l % � Address (S_ .......
a
W1 !.� � -----•-•-•-
, �
h tallei Address
PQ
UType of Building Size Lot...31:... _P_J.._..Sq. feet
a Dwelling— No. of Bedrooms.........-•---•---.__--•-----------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
A4Other fixtures ----------------------------------------------------------------------- -------------- ..............................................................
Design Flow-----------------rz ti--_--__---.._--__--gallons per person per day. Total daily flow.........._...__3.�................gallons.
W -
WSepticr Tank—Liquid capacity-15�?gallons Length__ �'_ .. Width__ 4-s� _._ Diameter____.___._____ Depth___C_. ..
x Disposal Trench—No.�_! t !rz '?_FVIdtYl s._.......7_'.. Total Length.___:4 A ...... 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........ .............C-�'�_. � ................. Date........ '�,'�S
Test Pit No. I....... -minutes per inch Depth of Test Pit________________"__ Depth to ground water----_- r ..._.
44 Test Pit No. 2................minutes per inch Depth of Test Pit--.----�.3 2.'_ Depth to ground water.....�°fq._--_--.
R: f....
Soil c l�J --='= -- r 5 'z'' `-"
D Description of - n.z
U coL:"-'..!_ P:'...!..E_?.Gr1... ............. ..:�?—--,,--- ----------`----„_._E..........
._ vu ............................
47/ .....................................................
................. ...... -... .....�..-i7---....----.......-•-------......_....._.....................................
U - Nature of Repairs or Alterations=Answer when applicable...............................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with t
the provisions of TITLE 5 of the State Environmental Code—lThe undersigned further agrees not to place the
system in operation until a Certificate of Compli•ancerhas been issued by the oard of health. r
'1 �u Si ned (: rG 1� /•----- ��`� `.'I✓% I -
-------------------------- ----------...........................:
Approved --'-
-y - m
Application Disapproved for the following reasons: .._................_........................_..._..._._..._.---
............. ....... . .................... ................. ............-......................... ....... ...... ....._........ ........................................
Date
Permit No. �' ..... V Q
.. ... Issued .... 4- ....................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
LLQrtifirate of CIIlrt plianre
THIS IS TO CER`TyIFY, That�he Individual Sewage Disposal System constructed ( X ) or Repaired ( )
by fjc+ fc !i (( 6ivc
6 --A > i't
.... _.... - __..........._.... -
Insr II2.•r -
at .................. ..... ---------------
.......1....------ ;/'[---.-----------------------------------.---------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The Sta e Environmental Code as described..
�+ r Q `
the application for Disposal Works Construction Permit No. _.�,�^...��..._��._. dated�......�_........_e�_,./..
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................ --`� - Inspector ---------- �.`j
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No. _.
�t,.r ll �j e FEE........................
.•---••.......
Riploal orko �on�#r ion rrmi#
Permission is hereby granted_...__!r GB�` 11
�'
to Construct (k ) or Repair (7 ) an Individual Sewage�Dispos� System
at No...(aT 5� �!.. ��ti. /�. �•�...7........ °f --
....... ----------------------------------------
` Street
as shown on the application f Disposal Works Constructi fi Permly N ,.__,;._ t d..........
r..�-
= 1 /l --= �
- a7d of -i
� L Boa_d of Heal`
DATE................. ....................................
+ FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS
A rx44 ",X.o mpi% w > ,
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Job: Note: *` Ste dn .kichman
_ t 211 PENELOPE LN. Any dld"cnaesme a's,md/or anvwsiioes to the notes,
dimeraiew,and/or drawings shall be brought to the attention • y
CO=,MA of the designer prior to start of con"nWtion.&kq fanrcrd Des
ign
UP a GARAGE/FAMILY ADOM®N with oatORK1ion mwmutes mcePmnoe of these and any "
® s•_ Q:r dicrependa,errors.and/or mrisfaa become the so e `
responsibility of the building contr+aetmr ond/ar home amen.
All amtsh ction to cWOM to 7th edNion of tha Mons.building code phone: 508-280-5738
Title FLOOR PLAN e-mail: stefanrichman@hotmail.cor.
SEPTIC- PROFILE TEST HOLE LOGS
T.O.F. AT EL 411 (NOT TO SCALE) � `•
�4
ACCESS COVER TO WITHIN fr OF FIN. GRADE
ACCESS COVER (WATERTIGHT) TO
n� e' of FIN. GRADE
ENGINEER: OJ����T�.
�4$�MINMIUM .75' OF COVER OVER PRECAST /�^ -
J .__._ 2X SLOPE REQUIRED OVER SYSTEM
.__ _.______.�....__.. -_ __._..__-___. � WETNESS: _. _
RUN PIPE OR FIRST LEVEL 7" po....l✓irk b.>ds�irc'Y;- P6rl��•�'►{;�
;� HATE.:
PROPOSED ksow
I GALLON SEPTIC 4� SS _ r 4i},5 •sa _ y ___ '� Y4o„_ P F RC. RATE
--_
G 2 .
TANK (H___) _.
t,iASS SOILS P
(YX SLOPE) �' CRUSHED STONE OR MECHANICAi
�, COMPACTION. (15.221 [2])
DEPTH OF FLOW _ A SY'
TO I-.-1 jY DOUBLE WASHED SMNE
TEE SIZES:
(lc% SLOPE) (4R SLOPE)
INLET DEPTH ! o _ >< __ _.._._..._._._...__...._.
OUTLET DEPTH a 1 SIDES AND TjOTTOM OF LEACH INTERFACE TO BE SCARIFIED � /' N ._ � LOCATION MAP
1; ASSESSORS MAP ._.. PARCEL _
FOUNDATION— 10 - — SEPTIC TANK --__._ _-_ __ D' BOX -- ____-- - 1 _ __ _ _ LEACHING LAY
FACILITY /6JW ' d 3`r L i4d"' .f/l,+v�> FLOOD ZONE
4 2- 4Z.94 .wet
�rl "'06c.0 BUII DING 70NE: �
,{ SETBACKS: FRONT 30__
sin r 2 s' rz
SIDF -
r'
REAR
i
si /Ilo j,,�.¢ Cn/C ocJn GcF'
o ss. .c, Pt-AN RFF FRENCE.:
SEPTIC DESIGN- (GARBAGE orsPosER IS
DESIGN FLOW: 3 BEDROOMS (_i h GPD) _ 3? GPD
�' - ? t��►..ck" �A;1 .,+,1 USE A '?3_ GPD DESIGN FLOW QDU
�OU%clr� -
r+� _ _ SEPTIC TANK: 3 r� GPD (_Z_) �'o GALLONS 1 . DATUM IS _ -.--
o �? US+ A 1`5 e? GALL.ON SEPTIC TANK
- _ - 2. MUNICIPAL
1 , LEACHING: 3, MINIMUM PIPE PITCH TO RF 1/Fr PER FOOT.
{,���.t�. -�?1. ( �4) ZIP
4. DESIGN LOADING FOR ALL PRECAST UNITS TO BF AASHO-
SIDES: GPD -H__ �o
_ - 143 GPD 5. PIPE JOINTS TO BE MADE WATERTIGHT. u'
_F `+�?3 S.F. GPD 6. CONSTRUCTION DETAILS TO BF IN ACCORDANCE` WITH MASS.
1 .
ENVIRONMENTAL CODE TITLE V.
7 TM� P1 AN Iri FOR Pl7f1F?n`;FI) W01RK ONI 'r' AND NOT T0 8E
.—._---� �i. r-tscrl:-1._ a.. I --�. ...,lr:...rr-..r r.:—,•— �, sue( r i�r.- r r,
USED FOR LOT IINE STAKING.
8. PIPE FOR SEPTIC SYSTEM FO CH. 40--4" PVC.
'` C.
Q
�+ y
6 T i / +rt_ \ 10. COMPONENTS NOT TO BE BACKF ILL_EU OR CONCEALED WITHOUT
ti, ` /' _ � INSPECTION BY BOARD OF HF-AI_TH AND PERMIS")ION OBTAINED
( / FR
OM M BOARD OF HEALTH.
/
11. IT IS THE RESPONSIBILITY OF THE OWNER OR THE OWNER'S
ZAV, / / AGENT TO CONTRACT WITH THE DESIGNER FOR INSPECTION AND
CERTIFICATION OF' CONSTRUCTION AND LOCATION OF SYSTEM
/ ? I AS PER TITLE 5 REGl.1LATIONS, c
12. VEHICUI AR TRAFFIC, PARKING OF VEHICLE S, STOCKPILING OF MATERIALS
1
--'• 1 d AND STORAGE: OF EQUIPMENT OVER I_FACNING AREA PROHIBITED AT
ALL TIMES.
FROM DATE OFf)13. SYSTEM AREA SHALL BE STAKED AND FI AGGE
`�9 INSTALLATION UNTIL CFRTIFICATF OF COMPI IANCE IS ISSUED, �1� 10�i' r
Z
SITE AND SEWAGE PLAN OF
j poAxn o� ,►LTH Ga `
IN THE TOWN OF:
PPR AOVF,D —DATE: MA �CDTG1/T +/T�f�T/ej e
se am�e �sam- n+s� r s�eaa xm x-a�saa a•+s��e�.+s• ®zavoa
PREPARED FOR:
..�� 0 •yo 6° /�O Feet
r 30 a DAT)Izvs .1G a✓r'- 2 /`f9S�
Lo7- -¢S down ca e en ineerin , ine. AOJALI� ti OJ L w
CIVIL
CIVIL ENGINEERS ►
LAND SURVEYORS
PHONE 508-362-4541 FAX 500-36?-WW X/
939 main st. yarmouth, ma - ARNR A. OJAI.A, �P F,., P.L.S. DATE
JOB .' ys 2-0
SEPTIC PROFILE TEST HOLE LOGS ,
T.O.F. AT EL 49
(NOT L
TO �E)
ACCESS COVER TO WITHIN a OF FIN. GRADE QJ�_ i D.C•E
_ ACCESS COVER (WATT WnGHT) TO vCorE1i
MIN F � OF FIN. GRADE
•� 2 MINIMUM .75' 0 COVER OVER PRECAST / 2% SLOPE REQUIRED OVER SYSTEM & it
7
I RUN PIPE Lf.VEI Zr poJ Pit.•>ic. 1•-��tci r �Q.(�>4 '�-:� I)A I F
Qo — I FOR FIRST 2' - ---- ,� - -.
- 1
PROPOSED _._. � --��___.._---- �
/ GALLON SEPTlc 4.� PF RC. RATE - _____-_____--
4 2-
TT
TANK (H �) ,_—__ _ c
1 -�- -
- --- .._ '4 E; -zx `' c'I A`,S - - — _ SOILS P S,Z LotD`' t�
(L-X SLOPE) 6r CRUSHED STONE OR MECHANICAL77
DEPTH OF FLOW - __ COMPACTION. (15.221 [211 --- T v T r
TO t �}�7
TEE SIZES: 3;FS f10t1P1 E WASHED STONE� � q
(�X SLOB E) (t1X Sl(7Pf I 9
INLET DEPTH .. ( o_ �
SIDFS AND BOTTOM OF LFACH INTERFACE 10 BF SCARIFIFD U P -
OUTLET DEPTH = -q_ - 3 3 --- - LOCATION MAP
G . , S ,, � I �
PARCEL
FOUNDATION— SEPTIC TANK J' aoX I � LEACHING AS
FACILITY
i 44 �E/4 tr_ SA �2 3G I L --- 4 z 9 FLOOD 7ONF -
I
1 ��. s•S*� Ga /i& BUII I)LNG 70NE: - _.�
LA"Q fide I G
;K.FT A : 4
S _ ET t S
FRONT
120'r 132.;
-� C-l.. 3G 'i 34 RFAR
j f 4 PLAN REFERENCE: Lc� ZZ"—d D
5
SEPTIC DESIGN: (GARBAGE DISPOSER IS .._N 'q�!C1___ _ )
DF51GN FLOW: � BF DROOMS (_I10 GPD) - � GPD
G-. „� USE A '� _=' GPD DESIGN FLOW ' :NOTES:_ --
�� d'� ► .—C - SEPTIC TANK: '� ?, GPD (_.=_) - w_o GAI I) )NS 1 . DATUM IS
--.- :
car �3 �. 11SF- A Lf�_ GALI ON SEPTIC TANK 2. MUNICIPAL WATER IS
,� LEACHING: 3. MINIMUM PIPE. PITCH TO RF 1/F' PFR FMT.
` 4. DESIGN LOADING FOR ALL PRECAST UNITS TO 8F_ AASHO H--1__..
GPD
1 f .3 GPF) 5. PIPE JOINTS TO BE MADE WATERTIGHT.
. � . BOTTOM:. - 4ti--��-� ------ ��`}-) � _____._
,> F1- '�� �� y =O TOTAi � � S.F. GPn 6. CONSTRUCTION DFTAILS TO RF IN ACCORDANCE WITH MASS.
F NVIRONMF N I AI CODE TITLE V.
/� \ \ \ •\ c P •+-ix��r`� !"' 'r r - ,f n. f i.r, r. ,r ��n..� t wnpv (1111 V Af4f) NOT TO RF
1.4
' - � USED FOR LUi, LINE STAKING.
r, -'�'-
� � t fi PIPE FOR SEPTIC SYSTEM TO SCH 40 4" PVC,
o T 10 COMPONENTr, NOT TO RE HACKFILI-F.D OR CONCEALFD WITHOUT
INSPECTION RY ROARO Of HFAL TH AND f'ERMISS40N ORJAINFD
61 FROM ROARIT Of HEALTH.
\ 11 . IJ IS THE RESPONSIBILITY OF THE OWNF_.R OR THE OWNER'S
' \ •.� o�� ✓�� / �y ��+ 2 o AGENT TO CONTRACT WITH THE DFSIGNF_R t OR INSPECTION AND
r CERTIFICATION OF CONSTRUCTION AND LOCATION OF SYS I F M
Ac, f ER TITI_F REGULATIONS
, IF �t Rci >
7/1
L9
� 12. vEHICUI.AR TRAFFIC, PARKING OF VFHICF.Ec.,, STOCKPILING Of MATERIALS
� �;, / AND STORAGE. OF f Q(IIPMFNT OVER LEACHING AREA PRONIAITFD AT
�, tix15'-: - .x' � ;• C/r� ALL TIMES
: " •y' - ' �' r.+ 1 .�. >YSTFM AREA SHAI L BE AND F I AGGF(� FROM DATF OF
f INSTALLATION UNTIL CFRTII-ICAIl Of �OMPIIANCF IS ISSUFF. IF Key
WAGE PLAN OF
SITE .A N_D _ .S��
4`.
Al
BOARD OF fi1RALTH ---_.^___— - _ _ _ _ _-- .------ --- -----__--
1N THE TOWN OFF
APPROVED DATE MA
�CDTG1/7"� �/'� /� 4✓I
PREPARED FOR:
fi"ri.. ..
30 0 Y G �70 Feet
- ----------
AS
Go7- 4S down cape engineering, Inc. � ARNE H. �y� ARNE
OJALA c3 OJALA i
CIVIL ENGINEERS CIVIL Na M48
mm
LAND SURVEYORS
1w1oaE soe-3es-4ssi FAX "-ae2-MM
939 main st. yarmouth, ma
JOB# z8 � ARN OJALA, P.E., P.L.S. DATE
9s-
...
... . . ...
_ _ _