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HomeMy WebLinkAbout0079 SANTUIT ROAD - Health 79 Santuit Road NNWA=.021--089. Cotuit un 17 1512:56a p.1 Commonwealth of Massachusetts 9//0 Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments uw 79 Santuit Road Property Address Richard Bartlett ,. Owner Owner's NameM. " information is required for every Cotuit MA 02635 6-16-15 page_ City/Town State Zip Code Date of Inspection 1«.�9 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important When rms A. General Information on l the comng out oputer, J�I 1 (�l n ``�o``�iI"OF:�t1 use only the tab t ! I Ul y� .•.:q�,' keyto move our 1• Inspector. cursor-do not JamesD_Sears JAMES use the return Name of inspector = ' key. C_apewide Enterprises,LLC "o •� Company Name i 153 Commercial Street 1E����``�� Company Address ► I Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License 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 irspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails y ❑ Needs Further Evaluation by the Local Approving Authority I ` J 6-16-15 pector's Signature Date i The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30-days of completing this inspection. if the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ***"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. V I5ins-3113 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Pape 1 or 17 • j i Jun 171512:56a p.2 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Forrn -Not for Voluntary Assessments 79 Santuit Road Property Address Richard Bartlett Crooner Owner's Name information is required for every Cotuit MA 02635 6-16-15 page. Cityrrown State Zip Code Date of inspection B. Certification (cost.) 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: j The system is a 1000 Gal.Tank D Box and pit. B) System Conditionally Passes: Q 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. i Check the box for"yes","no'or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years oJd*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. Q' Y ❑ N ❑ NO(Explain below): i tsirs-3113 Title 5 Orrrcial Inspection Farm:Subsurface Sewage Disposal System-Page 2 or 17 Jun 17 1512:56a p.3 Commonwealth of Massachusetts U_-____--_ Title 5 Official Inspection Form - - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a 79 Santuit Road Property Address Richard Bartlett Owner Owners Name information is required for every Cotuit MA 02635 6-16-15 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): i ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y Q N ❑ ND (Explain below): i i i I C) Further Evaluation is Required by the Board of Health: El 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(t)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: i ❑ Cesspool or privy is within 50 feet of a surface water j f❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh i i isms•3113 Title s Official Inspection Forth:Subsurface Sewage Disposal System Page 3 a117 i i i t i Jun 17 1512:57a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 79 Santuit Road Property Address Richard Bartlett Owner Owner's Name information is required for every Cotuit MA 02635 6-16-15 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) 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 ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 fleet or more from a private water supply well**. I Method used to determine distance: •*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 must be attached to this form. 3. Other l I i i i 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 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 emospW is less than 6' below invert or available volume is less than Yz day flow AiT . t5ins•3113 Tille 5 Official Inspection Form:Subsurface Swage Disposal System•Page 4 of 17 Jun 171501:09a p.2 Commonwealth of Massachusetts ., Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Santuit Road Property Address Richard Bartlett Owner Owner's Name information is required for every Cctuit MA 02635 6-16-15 page. City/Town . State Zip Code Date of Inspection B. Certification (cunt.) Yes No ❑ ® 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. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. 1 ! ❑ ® 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. El ® 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 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•3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Jun 17 15 01:09a p.3 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments G 79 Santuit Road Property Address Richard Bartlett Owner Owner's Name information is Cotuit MA 02635 6-16-15 required for every page. Cityrrown State Zip Code Date of Inspection C. Checklist . Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as NIA) 0 ❑ was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? I� ® ❑ 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? 0 Z 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)1310 CMR 15.302(5)] D. System information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17 Jun 1715 01:09a p.4 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 79 Santuit Road Property Address Richard Bartlett Owner Owner's Name informrequired is Cotuit MA 02635 6-16-15 requirEd for every page. . Citylrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal.Tank D Box and Pit. i Number of current residents: 0 E Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): 2013-36,000GaI 2014-35,000Ga1 s Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy. Date I Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpa) j Basis of design flow(seats/persons/sq:ft, etc.): i i Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No i Water meter readings, if available: i t5ins•3113 Title 5 Official Inspedion Form:Subsurtaor.Sewage Disposal System-Page 7 of 17 i Jun 1715 01:10a p.5 Commonwealth of Massachusetts @ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Santuit Road Property Address Richard Bartlett Owner Owner's Name information is cotuit MA 02635 6-16-15 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: NA Was system pumped as part of the inspection? ❑ Yes N 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): t1ims•3113 Tille 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 8 of 17 Jun 1715 01:10a p.6 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Santuit Road _ Property Address Richard Bartlett _ Owner Owner's Name information is required for every Cotuit MA 02635 6-16-1 a page. citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1979 Permit# 79- 568 6-2015 New D Box and lines. Were sewage odors detected when arriving Yes No g rs ng at the site. ❑ Building Sewer(locate on site plan): 2' Depth below grade: feet y Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: fleet Comments (on condition of joints, venting, evidence of leakage,etc.): Pipeing is 4" PVC SCH 40. Pipeing to and from D Box new 6-2015. Septic Tank(locate on site plan): . Depth below grade: 1 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: 1000 Gal. Precast H-10 - Sludge depth: 2„ 15ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Pago 9 or 17 Jun 1715 01:10a p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Santuit Roadlug- _ Property Address Richard Bartlett . Owner Owner's Name information required for every Cotuit MA 02635 6-16-15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 28 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 17" AsbuHow were dimensions determined? Sludge -Tape . Sludge Judge Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank at working level. Tank at 9" below grade. Inlet tee, outlet tee. No sign of leakage or overloading. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date 15ins-3113 Title 5 Official Irispection Farm:Subsurface Sewage Disposal Syslem-Page 10 of 17 Jun 17 15 01:11 a p.8 Commonwealth of Massachusetts Title 5 official Inspection. Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Santuit Road Property Address Richard Bartlett Owner Owners Name information is Cotuit MA 02635 6-16-15 required for every page. City/Town State Zip Code Date of Inspection Q. 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.): Y Tight or Holding Tank(tank must be pumped at time of inspection).(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: .gallons per day Alarm present: ❑ Yes ❑. No i l Alarm level: Alarm in working order: ElYes ❑ No y Date of last pumping: Date Comments(condition of alarm and float switches, etc.): �I 4 I Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Mns•W13 Title 5 Offidd Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 i i I Jun 1715 01:11 a p.9 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Santuit Road Property Address Richard Bartlett Owner Owner's Name information is Cotuit MA 02635 6-16-15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): D Box is 16"x16"-38" below grade w/one line out. Box is new 6-2015 w/cover at T. f I Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* i Alarms in working order: ❑ Yes ❑ No* i Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): i *If pumps or alarms are not in working order, system is a conditional pass. Sail Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins+3M3 _ Title 5 Official inspection Form:Subsurface Sewage Disposed System•Pa 12 of 17 � 9 P Y 9e Jun 171501:11a p.10 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 79 Santuit Road Property Address Richard Bartlett Owner Owner's Name information required for every Cotuir MA 02635 6-16-15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number ---- ❑ leaching chambers number. s ❑ leaching galleries number: i t ❑ leaching trenches number, length: I ❑ leaching fields number, dimensions: ---- f ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: -— Comnients(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, oondition of vegetation, etc.): Leaching is a 1000 Gal. Precast Pit w12' stone. Pit at 3' below grade w/cover at 20". T water in pit w/no high stain line. } Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration --- Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool -- Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No 15irs-3113 Title s official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Jun 1715 01:12a p.11 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Santuit Road Property Address Richard Bartlett Owner Owner's Name information is required for every Cotuit MA 02635. 6-16-15 page_ City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I Privy(locate on site plan): Materials of construction: Dimensions Depth of solids — — I Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i 15ins•3l13 Title 5 OKdat Inspection Form:Subsudace Sewage Disposal System•Page 14 of 17 Jun 17 15 01:12a p.12 Commonwealth of Massachusetts -- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Santuit Road Property Address- -------------------------••------------._--_----------------- Richard Bartlett Owner Owner's Name ---- --____._—__--•— -- _--- ------ information is required for every Cotuit MA 02635 6-16-15 page. City(Town State Zip Code i Date of Inspection D. System information (cost.) 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 where public water supply enters the building_ Check one of the boxes below: hand-sketch in the area below fAR e f�. t5:ns-3113 Title 5 MaW Inspection Form:Subwrfaw Sewage Disposal System•Page 15 of 17 Jun 1715 01:12a p.13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Santuit Road Property Address Richard Bartlett Owner Owner's Name information is required for every Cotuit MA 02635 6-16-15 page. City/Town State Zip Code Date of Ilispection D. System Information (cont.) Site Exam: ❑ Check Slope Q Surface water ❑ Check cellar ❑ Shallow wells N� Estimated depth to high ground water: 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: 6-15-79 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database.-explain: You must describe how you established the high ground water elevation.- T.H. on Design plan 6-15-79 no G.W. at 12'+. Bottom of pit at 3'+above T.H. Depth. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Jun 171501:13a p.14 Commonwealth of Massachusetts R rp Title 5 Official Inspection Form 'I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 79 Santuit Road Property Address Richard Bartlett Owner Owner's Name information is required for every Cotuit MA. 02635 6-16-15 page. citylrown State Zip Code Daenspection E. Report Completeness Checklist ® inspection Summary: A, B, C. D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed E ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t I i i i 15ins-Y13 TRW 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 a 17 No. F Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in com ❑ter: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ftphLation for -MispoBAf 6pstem Construction VPrmit Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System ,X Individual Components Location Address or Lot No.1019 $41 Y1 O t'Y RT> 400XU11- Owner's Name,Address and Tel.No. PUCKA" * -C41XkEiJ BAICTLEIT Assessor'sMap/Parcel ©y'L( ®S (>O1a0,1� (("7d <-O`[UI-r Installer's Name,Address,and Tel.No. $0$-1+1'7 -0$7Z Designer's Name,Address,and Tel.No. e�4gEce�t�s E1� 2P,2ts LL-Cc i J/A 53 Gt5od Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) —to l� Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health- Sign Date '�9 Application Approved by Date (_ r Application Disapproved by Date for the following reasons t— Permit No. � J-(r' Date Issued ..} _ No. Fee Entered in co4uter: 'f THE COMMONWEALTH OF MASSACHUSETTS Yes PUBLIC HEALTH DIVISION -TOWN bF-BARNSTABLE, MASSACHUSETTS application foe Disposal *pstrm Construction V it� ti Application for a Permit to Construct( ) Repair(A Upgrade( ) Abandon( ) ❑Complete System ,X Individual Components Location Address or Lot No. r'79 5AL1Tv 1- 'RD COTut T Owner's Name,Address and Tel.No. RtC1�kA" 4� r_AZXkF_W BA'X-T 57 Assessor's Map/Parcel 0;Q /Q'gq ((03 <_01TU(_r Installer's Name,Address,and Tel.No. S 0,9-4-1'7 -$Ss 7-1 Designer's Name,Address,and Tel.No. eApEccxvE ENTeR?A1se-C L4_C_ NIA 1.53 Ga G40_t4(C Z'T- b}PEs:, Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Buildin,F 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) Red C,A-CE9 il�? DEB - 4A&c E EROW 5<Vr(C 77E6e.k—' 17,) D-60K Artib -9--iW44 D-► aV, 'try I Cr s�Sr4-u- OuT LEa— -t-5F- Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title'5'of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health Sign �i1 Date 57 C)- a011 Application Approved by l3` Date Application Disapproved by Date , for the following reasons Permit No. I ) Date Issued T,Z o f s THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( X) Upgraded( ) Abandoned( )by at 7� �5�s�?U!% �� ��V(� has been constructed in accordance with the provisions of Title 5 and thefor Disposal System Construction Permit No.�to (f 0 c �� dated � � Installer C P&OcDC 1JSE'5 Designer I J #bedrooms � e���tj ..�" .. Approved des' ow -A n l�_- ti r The issuance of th per it shallnot be construed as a guarantee that the system wil�Cky as design . Date � ) Inspector ,., > t � -------------------------------------------------------------------------------------------------------------- --------------------- No. V S Fee �Uo THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS Disposal 6pstem Construction permit _ Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( ) System located at '7 9 S 6tJ-ru tT A0,Vt> 01 y Cr 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:Construction m +st bg completed within three years of the date of this permit. r C/ O Date S I Approved by /�- . i i AsBuilt Page 1 of 1 N y�� L—D� SEWAGE 1, — '57PERMITNO. J N-t I� 4 �! r VILLAGE o � vj +. INSTA LLER'S NAME i ADDRESS vi f� r ■ UILDER OR OWNER DATE PERMIT ISSUED jo — 77 DATE COMPLIANCE ISSUED �p_aG - 7,7, I http://issgl2/intranet/propdata/prebuilt.aspx?mappar=021089&seq=1 5/20/2015 { LO CATION SEWAGE PERMIT NO. Z e-,7' 5, VILLAGE IN ?STA LLER'S NAME i ADDRESS UILDEIII OR OWNER Cam- L,> r, DATE PERMIT ISSUED �3F�1� -- 79 DATE COMPLIANCE ISSUED ����,� �� �,� j� ��_ 74 No........ . ....... ' ........... .............. THE COMMONWEALTH OF MASSACHUSETTS ok BOAR® O HEALTH bIOF.-.......: 1�.................................................... Pip,` ' Appliratinn for Biipnsal Works Tomtrnr#iun Vamit Application is hereby made for a Permit to Construct (Vo or Repair ( } an Individual Sewage Disposal System at: ,D T GC iT /��• — • /Z .. �r�. s .f........ ......2 .. .- - -- - ._...._. L cation-Address or Lot No: ---------------------------------------- Owner Address .. ....._�..n�j-Q. ....................... ........................................•------------......--------------------------•----------• Installer Address Type of Building . Size Lot.x P/,__9__d_7.Sq. feet U Dwelling--9/No. of Bedrooms.........01................--------------Expansion Attic ( ) Garbage Grinder .(1.�4 Other—T e of Building No. of.persons.....................:...... Showers — Cafeteria p' Other fixtures ---------------- ----------- W Design Flow........,1'1'..........................gallons per person per day. Total daily flow.........d.-l..4......................gallons. WSeptic Tank-Z Liquid capacityJjA .gallons Length................ Width---------------- Diameter................ Depth................ x Disposal Trench—No..................... Width................__.. Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------/---------- Diameter./AX_j0...__ Depth below inlet........... ....... Total leaching area..*24.6...sq. ft. Z Other Distribution box (./ ) Dosing tank 6 �e y � fit- Percolation Test Results Performed b .._.__..._ ��ate..... ..'�S_.._'. Q._.__.. aTest Pit No. 1................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______---__-___---.-___- a .._...y . ._. Description of Soil-•-••-.� , 1. ---------- -------------------------•-- �'�' C .--------------------- x 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 TITL U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign .............. --•--•-----------------------------------•••---------•--•----•-•--_.. ................................ Date Application Approved BY = ----••--• I•• ......3j 'Z_/� O Date " Application Disapproved for the following reasons----------------------------------•--•--•-------------------------------------------------------•------•--------- •-••--------------------------------------------------------------------------------------------------•---•-•-•---•-------•......---•-••-•--•---••••------•---•---•-•--••------••......•--•--•-----•---- ' y Date PermitNo._-.....:..:............................................ Issued.................=--.....�-...... ---------_ ---- — --� Date 174 1 1 ' THE COMMONWEALTH-OF MASSACHUSETTS BOARD OE HEALTH .� ,: •A, f .-_ OF.......... .. ... !F ..................................................... y Applirtt i�a�t" or i ip" ai urkg Tomitrnrthin rrmit Application is hereby made for a Permit to Construct ( or Repair IN). ) an Individual Sewage Disposal System at AO 7- bC �"�" .. ... cation-Address or Lot No. : :...... .-.r , # . ..--•-----------------•-----.... .......... owner y Address W mv' 14�! 4 !.. -=- .......---••- ...•--.....-----•... Installer Address Type of Building. `� � Size Lot.- 44 0_',�...Sq. feet U Dwelling�No. of Bedrooms.•...._..tom.............................Expansion Attic ( ) Garbage Grinder (Y9lf 'L Other—T e of Building •-___..--•••• No. of persons............................ Showers — Cafeteria a Other fixtures --------------------------------------------------•---"------------------------------------------------------------------..•-------------------------- W Design Flow......... e.........................gallons per person per day. Total daily flow.......... _:-._..................gallons. WSeptic Tank l Liquid capacityV44 .gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No---------I-____-___. Diameter./.d_jt'. .... Depth below inlet.... _.___. Total leaching area..s�_6•�:..sq. ft. Z Other Distribution box (�) Dosing tank 0 � "� Y ! # f} � W.Percolation Test Results Performed b ._.._.. �._ ._� _ .�S!j.,, ��bate_...._ __.' aTest 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........................ •-•-••--•• ••. fJ O Description of Soil r! /"' rk- .. •-- _�__�...�~ U ------------------ -..................................................................................................................................................................................... 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 TITIL- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sign ..................................... pp. Date Application Approved BY `. ( V - ----------•---•- ....9'."..a ".�-11........ Date Application Disapproved for the following reasons:--•--------------------------------------------------------•---------------••......•-----. --•••••--••.•••••- .................•••••-•-•--••••-•••-----••-••••-•-••---••••...............••-•-•--•-•••-••--•--•--•...••••••-••••-••-••••-•-••-••••---•••••-•-••-•------------•-•••-•••••------•-•••--•------•••-•-•--- Date PermitNo......................................................... Issued......................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ......OF........... .....`................................... Trrtifiratr of TompliFanr THIS TO CERTIFY at the Individual Sewage Disposal System constructed ( or Repaired( ) by .. .................................................... --- -• --- -- taller ,+� _..... -C ♦ __ -� has been installed in accordance w' the provisions of T r of The State Sanitary C de as-descri •n the application for Disposal Works Construction Permit N __-�............ dated y._ ..._. ------_--'- ......... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE,CONST E® AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY DATE. ................, s ... . .�� -5 c�� �= Inspector....... ----- ----------------------------------- THE.. .a_..•.�. ; COMMONWEALTH OF MASSACHUSETTS " BOARD OF ALTH M (J ............... .... ....:....... ...OF...... ............................. (% No.......... .....•..... FEE................ or Tnns#rnrtion trod# Permission 11shereby granted :' ...----- ------•-----------•- -•------ to Cons tr (� p her ) an Indiv'du ► e`ra a ,sp sal yst / e Street as shown on the application for isposal Works:.Construction Permit Dated.." '�'" 'd" ..... ? �, • �" Board f Health DATE-------- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS i ! t: —a ! J 1 /// I/_+_.lN q./q. 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