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HomeMy WebLinkAbout0052 SCHOONER DRIVE - Health 52 SCHOONER DRJ COTUIT A = ooq- ova.- oo3 i No. 0 L G' FeeTHE COMMONWEALTH COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for �D 05"' 9ppstem Construction Permit Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or.Lot No. S Z ��+� r1q X. Owner's Name,Address,and Tel.No.Ck"v"'d 64 d A/4t L hC if Assessor'sMap/Parcel ® ® Q12.(003 S2 (4c'-/' Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. rAj Type of Building: Dwelling No.of Bedrooms I? 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) C e r S+ ,'h ew-74, 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 no lace the system in operation until a Certificate of Compliance has been issued by this Board of Healt �e� J 'f Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit.No. Date Issued _ No. a` 0 I_7 ` Y/ Fee � �� ... THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes T(pplicatlon for MispoBaf .*pstent Construction 3dermit Application for a Permit to Construct( ) Repair("Upgrade O Abandon( ) ❑Complete System ❑Individual Components F Location Address or Lot No.'51: Owner's Name,Address,and Tel.No. Assessor's Map/Parcel G�} �l l-.Q t�.•Q a 000�2.�•� (�0 f CA( 1 Installer's Name,Address,and Tel.No.�O� �/ �/���f' s'�� Designer's Name,Address,and Tel.No. Type of Building: c"^��"r an �,••r Dwelling No.of Bedrooms I? 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 A Nature of Repairs or Alterations(Answer when applicable) C -bate last inspected: r 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 o place the system in operation until a Certificate of Compliance has been issued by this Board of Healt —� '�� ,Signed C Date 1,4 Application Approved by o—A t 6,e7� tie__ ft-�--- Date P � Application Disapproved by r Date for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS (Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(Y) Upgraded( ) Abandoned( )by D i,6 k,0 4 O <C.,J'-�+-� e.,-. at -_ S G-. �,C_A Q-A ,,�� 0It has been constructed in accordance _ with the provisions of Title 5 and the for Disposal System Construction Permit No. dated 16 Installer Designer #.bedrooms 3 Approved design flow gpd The•issuance of this permit shallnot /liee construed as a guarantee that the system willl fu cction as designed. / Date ,(c) I "1 // Inspector 1 V - --_ - _ --------------- ---- - No.. t7�V 7& Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction i9ermit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at ion eh 0 D 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 must be completed within three years of the date of this permit. Date (� C Approved by 6 } Commonwealth of Massachusetts by / - D/lI2- 00 A 7 Title 5 Official Inspection Form 04 a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 52 Schooner Dr Property Address David lance ay4' Owner Owner's Name = information is required for every Cot uit Ma 02635 10/30/171 page. City/Town State Zip Code Date of Inspection 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 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain reb Company Name 35 Content Ln Company Address r Cotuit MA 02635 City/Town State Zip Code 508-364-9587 S 113522 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority J 1/30/17 spector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****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. t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 f 17 CJ/� VS Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments GSM 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. Cityfrown 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: System contains a 1,500 gallon septic tank. As well as a concrete distribution box and two concrete leach pits. 6xl0 Pits had 32" of seperation at time of inspection. 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. 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 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. City/Town 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): ❑ 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 ❑ N ❑ ND (Explain below): 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 Ej Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. City/Town 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. ❑ 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 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: 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 cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. CityTTown State Zip Code Date of Inspection B. Certification (cont.) 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. ❑ ® 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 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form R ... i; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Schooner Dr M Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ 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)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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 ears usage d 176 Gpd 9 ( Y 9 (gp ))� Detail Sump pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): a 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: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. City/Town 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: Not provided 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 co of the current operation and 9Y copy P 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): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 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: 1994 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ® cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1500 If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts WTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 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 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. Cityrrown 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.): 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 Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. City/Town 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 New installed 10/23/17 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 6x10 ❑ 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.): Na 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts . W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. Cityrrown 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.): 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.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: 15+ ft 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: 11/18/94 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: Test hole data on plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 10/30/2017 Assessing As-Built Cards `55�4 wweTOWN OF BARNSTABLE LOCATION 1l9 ScAcohlr 9,1✓j SEWAGE 9y- 387 bo 9.:ei0-44� VILLAGE Cot.f ASSESSOR'S MAP& LOT INSTALLER'S NAME& PHONE NO. 19 `f.28.9S 9Y 1J)SEPTIC TANK CAPACITY /S do 0. LEACHING FACILITY-.(type) a= /0(�10 11°a (size) b'X lot NO.OF BEDROOMS L PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER JO4„ Sfa.ilos�+ DATE PERMIT ISSUED: 9- 2-2- 9`1 DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No c- ' 34 A-p r Yet,3;, C- E _ 47' H e= 44" C. : 2s c _7 , e 0 http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=009012003&seq=1 1/2 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 52 Schooner Dr Property Address David lance Owner Owner's Name information is required for every Cotuit Ma 02635 10/30/17 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ' r ! oO of©01 V 08 - COMMONWEALTH OF iN1ASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFF DEPARTMENT OF ENVIRONMENTAL PROTEC ONE WINTER STREET, BOSTON MA 02108 .1(617) 292-55,00 t . O TRUDYIC9 *, Set?. ARGEO PAUL CELLUCCI "i%AVID BA, HS Governor Co stoner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM L PART A CERTIFICATION Property Address: S2 . ')�Dvi1�- ✓� Name of OwnerV� C'D l'" r Yi 1VA, c�6 3s Address of Owner: -ly A9el Date of Inspection: — 99 016 3 s Name of Inspector(Please Print) J041 19, 171, /!y 1 am a DEP approved s em i r ant to action 15.340 of Trtie 5(310 CMR 15.000) Company Name: o h � p� //.vic> Marling Address: Telephone Number: CERTIFICATION STATEMENT 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 inspection. The inspection was'performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _!/Passes _ Conditionally Passes r Needs Further Evaluation By the Local Approving Authority ti F JsZ Inspector's Signature: Date: S-L�— �q r The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ro NOTES AND COMMENTS V1SOCl 9/2/98 Page I of 11 r: a. i= Primed on Recycled Paper.; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A J n CERTIFICATION (continued) Property Address j`Z St`roOh�✓ Y�'� �/ �o/use/ ��. Owner: �Q y S7`e, Date of Inspection:-•S—2 g y, INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES:, I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure criteria not evaluated are indicated below. COMMENTS: 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. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or the septic tank, whether or not metal,is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. x is due to broken or obstructed pipe(s) w k r breakout or high static water level observed in the distribution bo p p _ Sewage backup o g or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 revised 9/2/98 Page 2of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:`` p, Cto/-t� // /�'ik• , Owner: �OGrh ..STAv7 /o�. Date of Inspection: 2 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 the public health, safety and 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 THE PUBLIC HEALTH AND 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., � t ` 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than-100 feet but 50,feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance (approximation not valid). 3) OTHER r 4 revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART A CERTIFICATION (continued) Property Address: � -��-- -�- Owner: 1A s/AN Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 cesspool is less than 6" below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E. LARGE SYSTEM FAILS: You must indicate either "Yes".or "No" to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM, PART B CHECKLIST Property Address: S2 5C h'. W✓ ✓/vP Gv"'i �j /�,�. owner: ,7o�H STaN7a Date of Inspection: 99 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yew No _ Pumping information was provided by the owner, occupant; or Board of Health.. _ None of the system components have been pumped for at least two weeks and-the system has been-receiving-ntrrmal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with N/A. _ The facility or dwelling was inspected.for signs of sewage back-up. _ The system does not receive non-sanitary or industrial waste flow. _ The site was inspected for signs of breakout.. All system components, excfv Kg the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: _ Existing information.,For example, Plan at B.O.H. _µ _ Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [15.302(3)(b)) The facility owner(and occupants,if diffe_reni from owner) were provided with information on the proper maintenance of SubSurface Disposal Systems.., A s revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM , PART C SYSTEM INFORMATION Property Address: Owner' JdA., Date of Inspection: 9F FLOW CONDITIONS RESIDENTIAL: Design flow:�g.p.d./bedroom. l� Number of bedrooms (design): .S Number of bedrooms(actual):_% Total DESIGN flow 1S;V Number of current residents:•� Garbage grinder(yes or no):4_ 0 Laundry(separate system) (yes or no):Ale; If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use (yes or no): NO Water meter readings,if eve able (last two year's usage(gpd): Sump Pump (yes or noO , Last date of occupancy: OGC✓VJ,/ COMMERCIAL/INDUSTRIAL: Type of establishment: - Design flow: qpd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged,to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: AlVe, AlvJ- ne•ej-d , System pumped as part of nspection: (yes or no)—AP If yes, volume pumped: gallons 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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed(if known)and source of information: )h A'./ P 9 CJ Sewage odors detected when arriving at the site: (yes or no)/moo revised 9/2/98 P2ge6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "r PART C SYSTEM INFORMATION(continued) Property Address: Owner: JOL,.., sravr Date of Inspection BUILDING SEWER: (Locate on site plan) t Depth below grade: 30 Material of construction: cast iron— 0 PV _other(explain) Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage,etc.► SEPTIC TANK: (locate on site plan) Depth below grade:2O Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal, list age_ .Is.age confirmed by Certificate of Compliance_(Yes/No) Dimensions: Sludge depth: tr ,j•+ • Distance from top of.ledge to bottom of outlet tee or baffle: Scum thickness: S a t""&'t d a tOAt1''r Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottompyf ou at tee or ffie: O How dimensions were determined: V15 Ati Comments: (recommendation for pumping, condi 1 of inlet and outlet tor baffles, depth of liqu ,lev I I I relption�p.outlet invert, structural integrity, evidence of leakage, etc.) Gfl�r No, ut > s fR /c�� y GREASE TRAP: (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) revised 9/2/98 Page 7of11 II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // SYSTEM INFORMATION(continued) v Property Address: ,sue Se hG1vh-!r �/�/ im CO/k Owner: -To y y 570"Ir "/ Date of Inspection: i 7 TGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection) (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm present Alarm level: Alarm in working order:Yes_ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:_ (locate on site plan) r/ Depth of liquid level above outlet invert: 0 Comments: (note if level and distn dory.�s equal,/evjd�encel of��ds carryover, evident of leaks into g�yi-f out of box, etc.) /70}� ptts rf i�N d� Q4wu 4b Re//O•rIvrg Sa /s 4c r�v-7 PUMP CHAMBER:_ llorate on site plan) Pumps in working order:(Yes or No) Alarms in working order(Yes or No) Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) revised 9/2/98 Page 9of1.1 J s i • SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORMATION(continued) , / r Property Address:// Owner: J0hvJ s�Gl7lp H Date of Inspection: 9 C SOIL ABSORPTION SYSTEM(SAS) (locate on site plan, if possible; excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number: 2 leaching chambers,number,_ le aching galleries,number: leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, sins of hy raulic failure` �f Jondir}g, dart�p soil, cRn�ition of vegetation, etc.) r r.t i ` ek G JY i Ir are : /00D , ArNAlG /C v V . CESSPOOLS:_ (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY:_ (locate on site plan) Materials of construction: Dimensions:' Depth of solids: n Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C ` SYSTEM INFORMATION(continued) Property Address: s1� C4oah.ev Owner: To" Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 �r 4 2° �occvl�f r rocoi1r / � / � 3z6,� cv�.lr revised 9/2/98 Page 10of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5-2 �1104, Owner: jol,ti STh*� Date of Inspecvon: NRCS Report name Soil Type_ Typical depth to groundwater ` USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water + Check Cellar l Shallow wells ti Estimated Depth to Groundwater 33 Feet ° Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record _Observed Site(Abutting property, observation hole, basement sump etc.) Determined from local conditions _L/Checked with local Board of health Checked FEMA Maps R Checked pumping records __L,,-thecked local excavators, installers ✓Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) �al1N COH r• . 17 revised 9/2/98 Page 11of11 � 1 `71'`' ' OIT6WN OF BARNSTABLE LOCATION SEWAGE # 6,0 VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME PHONE NO. 19 .95 (`.)SEPTIC TANK CAPACITY /,: -00 t?a . !' LEACHING FACILITY:(type) s2 = /OVO L It's (size) �'X /O t. NO. OF BEDROOMS_ I PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: 9- DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No C— .8 � , y ' ye C � - N7 d •"` G�F Z� j.�,,•�_F � 5S, G z i f� f, _...... OCR -0o j .. No.-.•--- _....v FILE..... .. ( THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiun for Dic.,puuttl lVarka Tomitrnrtiun Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: o ----.�v C 0�IV �'® Ct�U ----'-'--------------- .................... ........... --•----------•--•----------------......------------------.....-------'--'------....------•. L ation Address or Lot No. Owner Address W Installer Address Type of Building Size Lot______----__..............Sq. feet Dwelling—No. of Bedrooms-------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Q' Other fixtures _______________________________ _ _ W Design Flow............................................gallons per person per day. Total daily flow..------------------------------------------gallons. 1:4 Septic Tank—Liquid capacity...._.._...gallons Length................ Width---------------- Diameter---............. Depth................ W Disposal Trench—No. .................... Width_-----___._.____---- Total Length.................... Total leaching area....................sq. ft. x Seepage Pit No--------________-._- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by----------------__...................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water_--__-.-__--_-_j - GT4 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water. ................... . P4 •-•••---•----••-------------••••••••--•-••---------'--•'.•-•---••--•••••••••-------•---------'-'_'---•-•------------•------_..... .. ..----------- - Description of Soil ----- •... 1 . -••• . -' . V W -'--••-••••••---------------••--••••....••----•-•--••--•-----------.._._.........-•-•--....-------------•-------- ------------......-- -- -------••-------••--- . ................................... UNature of Repairs or Alterations—Answer when applicable-------------------------------- -_ _-__---.___----_----- _..._._...............__............. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a&tificate of Compliance has n ' sued by the board o health. �ign(d ............. . ... ....... ..... . -.. ...... -", .'. .Application Approved By -------- ---------------------. .-...-_-. ---_-------..-----..-----.-....- ....--..--.---_Da[e-----.----------.- Application Disapproved for the following reafo r -- ------------------------------------------------------------------ -..-------------------- ------------------ -------------------- ---------------------------------------------.-.:------- re '...-. � �-_-Date Permit No. .....- ............. --------- Issued ......-�. ... ............................... a[e olc�_ -oo3 NO.. 3?7 Fss.. o THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allp iration for DioVwial Works Tomilrnrtion ratnit' Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal Y System Si._��Qz__soo�.. U----- --•-L•?ation-[\ddress -•----•-----•----------------------------or Lot No. . Owner Address W Installer Address UType of Building Size Lot............................Sq. feet t t Dwelling—No. of Bedrooms---____________----------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures -.__-•------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity_------.-.-gallons Length................ Width---------------- Diameter................ Depth---------------- x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No...................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ a Test 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 waterF...__.__.___...____1j P+ ---�--- --. .--•-••------ 0 Description of Soil-----------------------------------------------------------------------•--•-•--•. ------------... t� t ,_/1V ap - -- -------- -- U -••--------•----•--•----••••----••----••-•••-----••------•-----•••••--••--•--•--•-•---------•----- 1' == - �t--------------------- W ••---•-------------------------------------•-----•---------.................................................... ---•--.oo--•-•••--•-•---o•...-•-••-•------------•--...... 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 TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a C rtificate of Compliance has been 'sued by the board o health. Signed . U.. ...... :............ .":-��......�I..............:......... .. d Dace Application Approved BY / ............:.�..........:..-...--------- -:. / ......... - ................... �- :_- s v �%. � ✓ � Dace Application Disapproved for the following reasons: ----------------------- ------------------------------------------------------------------------------------------------------ ------------ --- ------ - -------------------*...----------...------------------ .........----------- --------- --------� 1 Permit No. ---- �.. Issued -- D( --.1...-I Dace � ate� THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE CILIVdifirate of Tompliance THIS IS TO CERTIFY, That the Individual 11-- �. Sewagea Derispos alS�yste m constructed or Repaired by .... � .... at ..----k ..- - . ....o l / ................_.......--------................--------_..__.._(-------------)- has been installed in accordance with the provisions of TITLE V he She Environmental Code as described in the application for Disposal Works Construction Permit No. I ��__.._ ._.. dated .- __.-_---------.._-------------- ---- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRA/AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE /-.`~",/.-.. ..'.--...--. '... Inspector.- .: . .. --.. ------------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q :77 0 TOWN OF BARNSTABLE (2�_---- r �to�oottl ork� �onotr�rtion �rrmit Permission 's hereby granted..............................................------------......-----------...�----------------------•-----.....................-•-•--... to Construc ( or, it (-)(4 17 11 divi.\uj.l S age/ i posal S ,t at No..... r o �! o i/ S eet � as shown on the application for Disposal Works Construction Permit No. Y____B,.a,d . ... . . ated....... `.- ---1.-rl...... •--------------------•----------- ID..---------------------------------•-•--•-•-•-••._.... y.............................. of Health DATE.................. .---- - FORM 36508 HOBBS♦!c WARREN.INC..PUBLISHERS 5 A 'PGICff SF W L ETAND SULLIVANULLII/AN 56, 144 SF z u P I-A.. r> �r1 I d No 97 3 Coo. 03 2 S F t TOT A L- h) IST 4�E' C `s`r ow N 1-a T LJ 1 T Q I�1= Q = 52, 4' J / MAS+-tPEE � 4, �6 � , di 40 /54- J Ltry gi Lp 4. ok ' 4AS 1 ( 'k IZ20 f - atN\N r7o�wf0E - IL 1 \ 46 Mt \ rp2 � � . A" TB i mo 9-l.0 � \ A 'ISI O Ecl Ao �� 3EIJGH:M.FQrG is cl�S/du ¢ >< w vnwr _ (LG! sE PQoD�Qrt ceRw+CP ,• ` O W ATE SMvT C PP 1J�516 N -PAT-A 510,6U-z FAMIL`f .4 6,A43AGG GQINVEK 'PAIL'-( FLOW : 4 x 1 1 0 = 44c e-PD SEPTIC 1AI�I� 0 o ho.44 15 '7e = (o o GP D 5�E L/" P(� ati fblt�X of 7G 15oo e�AL S.T. LcT 'j /•� 21SP05AL FIT 2 - i o0o C-AL % I- Four SiaN� 51DEWALL APC-A Sc.t-Imo/--tcR- RISE 3 00 5F X 2 5 = SpI- BoTToM AafA I no Gi�D, M A-P *i 3 p L TaTX�L D�I6N = 850 6f!P, -TCTA,L DAILY rLDV = 44- GpD T�EP�aLATtoN QATE I " „_, 2 n.I ,NUT�s oe Ltss OF �fqS vi Of RI:TEM s H . 29874 0 o SULLIVAN FcjstER��� NO. 29733 IsTea�`� �J"S.IO A 1N4"L.L RISC-QS A5 O i0 W t Tl1 I N 11" 6 F F"1 14 T sr P - a238 F4. 40(- - 0G- 0-7 q4 TF s�,o / Left M �` P V. ram' Ao 1 Fj oo .NV 6Al. ,NV S4.a SKr• ,N,l 5i.,s S ric I QCG INV OCK S�.•S • S3.zz ITT r�u�c WIR Ie' . �j'1'Q•�[r ✓.0 1'w14 4. V • 'L r76QtC-6 DCES NGT d1 OO L�l �EQ p�J _ •BE i4"7.o •eS ITE SEW AbE pSPCShL GowSTRvC•nC•.1 EL 0 1 I•�� � 1 — fI f � a V�1.0 'Przo�ll�- C�T'l�l® pL1Tl' 12LA14 I o SGQL>✓ `' �.p 'IDt1 : t T- nn A ss —• 12 /'A�EL- 3b.5 �tiF11.E—% D4TEi b-j. Il•`3�}lro wn-T_-(4_ EL=21.1 Q fSorrnnn ca SA�-.+K. ; EDeza Qiy1=2 n -_.r PLAN 1 C FJzTI Fy T}4 AT T�{E - R�-�E RE�ICE' 5f�owtJ HezeoN coM'P� S WITA lAf- PLC, ®,= �nF., ,�, l � r Q 5lQ�V�E `�TeVPaLE , MASS. , F02 ALC)Eu eA P 1-t-A L. IS IJor 1-O�(�� T VA^T. �f�LE I Qm' DATE '. 1 I •12.9 3 �A�' �•I'L �4 NYE p�5510�1AL L�IJD 5uZVeyCe5 70K FLAW IS N 8 ,ED oN AN t�41 .MEt'i" L�v1�. c-+1GINE�.S 5uR✓eY AIJD THE OW>e'1'S 41�Out.T> u rr(' T3E o ST��Iu.E MASS . ... u5� 1-0 ESTAtBL.KN Rzcpe2-Ty U uL-5 I100I✓IcAI T ' J6H— 'Si�TarJ,ET �X.