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HomeMy WebLinkAbout0110 THANKFUL LANE - Health 11'O Thankful Lane Cotuit A= 039- 039 3 1 I } ,, III TOWN OF BARNSTABLE 1� LOCATION do -TYiah�'^�oI Gdl ! SP VILLAGE /%tV;' ASSESSOR'S MAP&PARCELOn'039 H� (R'S NAME&PHONE NO. -CLIC c��I SEPTIC TANK CAPACITY ISUU LEACHING FACILITY:(type) 6 3:� M'C''C4L1yf5 (size) NO.OF BED OOMS 3 OWNER PERMIT DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leap ' ' 'ty) Feet FURNISHED BY f ! f f ! r f ! r r. f'i r.i r r .• f f ! f J f f f r r r r r f f . i !J ! ! r r f r f r I / ! / f / ! ! \ \ 4 4 4 \ \ 4 t 4 t \ \ 4 \ \ \ 1 \ \ \ 4 4 t 1 f / / Water \ ♦,\ \ \ \ 1 \ \ \ \ \ \ r r f r I r Service \ \ \ 4 4 \ \ \ 4 , \ \ \ \ \ \ \ ♦ \ \ \ \ 1 \ l \ \ \ \ 4 \'4 4 1 4 4 \ \ \ \ \ 4 \ 4 37 f r f r f I f F f f f f 52 30Q �r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments •°- 110 Thankful Lane Property Address Floyd Cormier Owner Owner's Name' information is required for Cotuit. MA .02635 Julie 15. 2009 every 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. Important: A. General Information `. When filling out forms on the . computer,use 1. Inspector: 551 only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return. key. Septic Inspection Services Co. . Company Name r� 189 Cammett Road Company Address Marstons Mills MA 02648 renm City/Town State Zip Code. 508-428-1779 Sl 12855 Telephone Number License Number B. Certification I certify that i have ipersonally 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 June15 2009 Irisp ctor'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 DER 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. 09-106 Cormier.doc-08106, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage bisposail System Form -Not.for Voluntary Assessments' •° 110 Thankful Lane Property Address Floyd Cormier Owner Owner's Name information is required for Cotuit MA. 02635 June 15, 2009 every page. City)Town State Zip Code, Date of Inspection B. Certification cont. Inspection Summary. Check A,B,C,D or E L always complete all of Section,D A) System Passes: ® f 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: Tank scheduled for inspection, leaching system shows no evidence of saturation pumping .following or surcharge: B) System Conditionally Passes:,, ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system;upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes,-no or.:not.determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally.unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing,tank is replaced.with a complying septic tank as approved by the Board of Health A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of.Compliance indicating that the tank is less than 20 years old is available: ND Explain: Observation of sewage backup or break out or high static water level in the distribution box due . 'to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.System will - pass inspection if(with approval of Board of Health): ❑ broken,pipe(s) are replaced ', obstruction is removed 09-106 Cormier.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System+Page 2 of 15 Commonwealth of Massachusetts _ _ Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form - Not for"Voluntary Assessments 110 Thankful Lane Property Address Floyd Cormier Owner owner's Name information is Cotuit MA �-02635 June 15, 2009 . required for every page. ' City/Town State Zip.Code Date of Inspection B. Certification (cont.) IB) System Conditionally..Passes (coot.): ❑ distribution box is leveled or replaced ND Explain:_ El The system required pumping more than 4 times a year"due to broken or obstructed pipe(s). The, system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced'., ❑ obstruction is removed ND Explain: 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 El Cesspool or privy is within 50 feet of a bordering vegetated wetland or.a salt marsh 2. System will fail unless-the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has aseptic 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. 09-106 Cormier.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of_1.5 Commonwealth of Massachusetts Title 5 Officiad Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 110 Thankful Lane Property Address' Floyd Cormier Owner Owner's Name . s; information is " required for Cotuit MA 02635 June 15, 2009 every page. City/Town State Zip Code -' Date of Inspection B. Certification (cont:) C) Further Evaluation is Required by the Board of Health (cunt.): ❑. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well** Method used to determine distance: ._ **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absentand 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: a" A D), System Failure Criteria Applicable to All Systems: You indicate '. or"No" to each of the followin for all inspections; „y g Yes, No t ^ ® t Backup of sewage into facility or systemcomponent due to overloaded or clogged SAS or cesspool Discharge-or ponding of efflueht 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 , 0. ® Liquid,depth in cesspool is less than 6" below invert or available volume is less than dayflow, Required pumping moretlan 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 A100 feet of a surface.water supply or , tributary to a surface water supply. 09-106 Cormiecdoc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 15 a Commonwealth of Massachusetts Title 5 ®ffici7l Inspection Fora Subsurface Sewage Disposal System Form =Not for Voluntary Assessments w, 110 Thankful Lane. Property Address Floyd Cormier , Owner Owner's Name.' information is required for Cotuit MA. 02635 June 15, 2009 ` every page. Cityrown State Zip Code Date of Inspection B.. Certification (cont.) S D System Failure Criteria Applicable to All Systems Cont. Pp ( )Y Y Yes No ❑ .® Any portion of a cesspool or privy is within a Zone 1 of a public well.. ' Any portion of a cesspool or,privy is within 50 feet of a private water supply ^ ❑ ® well: ❑ ® Any portion of a cesspool or privy.is less than 100 feet but greater than 50 feet from a`private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of.arnmonia nitrogen and nitrate nitrogen is equal to,or less than 5 ppm,. I' 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 r ❑ ❑ 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.`fhe system owner should contact the appropriate regional office of.the Department. 09-106 Cormier.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pages of 15 Commonwealth of Massachusetts . Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 110 Thankful Lane Properly Address Floyd Cormier Owner Owner's Name information is. Cotuit MA 02635' June 15, 2009 required for every page. City/Town 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 P ® ❑ 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? i] ® 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 breakout? ® _ ❑ 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, t 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 ® El approximation 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)]_ . j i p 09.106 Cormier.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 i I Commonwealth of IMassachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments 110 Thankful Lane Property Address Floyd Cormier Owner Owner's Name information is Cotuit MA 02635 June 15,2009 required for every page. CityfTown ,State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 31.0 CMR 15.203 (for example: 110 gpd x#of bedrooms):` 330 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage,system?[if yes separate inspection.required) ❑ Yes ® No Laundry system inspected? El Yes ❑ No Seasonal use? ❑ Yes ® No N/A Irrigation Water meter readings, if available(last 2 years usage (gpd)): system. Sump pump? ❑ Yes,® No Last date of occupancy: Currently . Occupied 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.): Grease trap present? ❑ .Yes ❑. No Industrial waste holding tank present? El Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,Jf available: Last date of occupancy/use: Date Other(describe): 4 I , 09-106 Cormier.doc•06/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System Page 7 of 15. t Commonwealth of Massachusetts Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments „ 110 Thankful Lane Property Address Floyd Cormier Owner Owner's Name: information is required for Cotuit MA 02635 June 15, 2009 every page. Cityfrown :. State Zip Code bate.of Inspection D. System Information coot.); . Y _ General Information Pumping Records: P 9 Source of information: None Was system,pumped as part of the inspection?'` El .,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 esspool ❑ 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) ❑ Tight tank: Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Compliance date: 5/20/98 Were sewage odors detected when arriving at the site? - ❑ Yes ® No" 09.10.6 Cormiecdoc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15 f. �I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal;System Form.-Not for Voluntary',Assessments 110 Thankful Lane Property.Address Floyd Cormier Owner Owner's Name information is required for Cotuit MA 02635 . June 15, 2000 every page. cityrrown .State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron E 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:. 2' 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: 10.5' long x 5.8'.wide 1500 gal. Sludge depth: Distance from top of.sludge to bottom of outlet tee or baffle 30" Scum thickness Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 2 How were dimensions determined? Measured 09-106 Cormiecdoc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts Title 5 Offici71 Inspection Form Subsurface Sewage Disposal System, Form -.Not for Voluntary Assessments' 110 Thankful Lane Property Address Floyd Cormier Owner Owner's Name information is Cotuit MA 02635 . June 15,2009 required for every p9 a e. City/Town State Zip Code .. Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are intact and clear,liquid level was found at bottom of outlet invert. Tank was pumped after inspection. Recommend pumping every 2-3 years. 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: a Date 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 grader Material of construction: ❑ concrete ❑ rrletal ❑ fiberglass ❑ polyethylene _' ❑other(explain): j 09-106 Cormier.doc OBI06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 r t Commonwealth of Massachusetts. Title 5 Official Inspection Form Subsurface Sewage,Disposal System Form - Not for Voluntary Assessments ` 110.Thankful Lane Property Address Floyd Cormier Owner Owner's Name information is required for Cotuit MA 02635 ' June 15, 2009 every page. Cityfrown state Zip Code Date of Inspection ; D. System Information (cont.) . Tight or Holding Talnk(cunt.) 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 Distribution Box(if present must be opened) (locate on site plan): o„ Depth of liquid level above outlet invert Comments,(note if box is level and distribution to outlets equal, any evidence of solids carryover,any: evidence of leakage into or out of box, etc.):' No solids or high stains present. Liquid level at bottom of outlet pipes: - Pump Chamber(locate on site plan): Pumps in working`order:'. ❑ .Yes ❑ No Alarms in working order: ❑ Yes ❑ No ' 09-106 Cormier.doc•08106. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 • Commonwealth of Massachusetts Title 5.Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w 110 Thankful Lane Property Address Floyd Cormier Owner Owner's Name information is required for Cotuit MA 02635 June 15,2009 every page. Cityrrown State Zip Code Date of Inspection D. System Information (coot:) Comments (note condition of pump chamber,condition of pumps and appurtenances, etc.):. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type:. ❑ leaching pits number' ® leaching chambers number: 5 Infiltrators. . ❑ 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.): Stone and soils were probed no signs of saturation or hydraulic failure were found. , 09-106 Cormier.doc r 08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15 Commonwealth of Massabhusetts Title 5 Officicil Inspection Form Subsurface Sewage Disposall System Form- Not for Voluntary Assessments w 110 Thankful Lane Property Address Floyd Cormier. Owner Owner's Name information is required for Cotuit MA 02635 June 15, 2009 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and 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 inflowEl Yes 0`No 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.)-. 09-106 Cormier.doc 08106 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 • Commonwealth of Massachusetts Title 5 Officil'I Inspecti®n Form Subsurface Sewage Disposal System Form -:Not for Voluntary Assessments.:. 110 Thankful Lane. Property Address Floyd Cormier. Owner Owner's Name is 02635 ..-June 15 2009 information MA required for COtUit every page. CitylTown State Zip Code Date of Inspection . D. System Information (cont.) Sketch.Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties permanent reference landmarks or benchmarks. Locate all wells within 100 feet. _. to at least two p Locate where public water supply enters the building. Water - e '/`!'�`-`�'�`�`!`'`'` Servic <'/`!\�`'`'`'`'`'�`, ,,,,,,,,,,,,,,,,,,,\,,, - - - .. \!\/,,♦!\/\,\�\,\',\,\,\,\/\;\!\,\,\,\./`/` /`!`/�/`/`gyp/(`�,/�Q`y/`/`/`/ / , /`I I 4- 37.. 52 30 - °Ttiankfuy Lane. Commonwealth of Massachusetts Title 5 Official InspeCtion Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w, 110 Thankful Lane . Property Address' Fl oyd d Cormier Owner Owner's Name information is Cotuit MA 02635 . June 15, 2009 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope - ® Surface water, ® Check cellar . Its . II Shaw we o 20V Estimated depth to.ground water: feet . Please indicate all methods used to determine the high ground water elevation: Q Obtained from system design plans on record If checked,date of design plan_reviewed: pate �® Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: • IF ' Checked with local excavators, Installers (attach.documentation) '® Accessed USGS database-explain: USGS topo map and town GIS. i You must describe how you established the high groundwater elevation: Town groundwater contour map shows water below el. 25:and topo map shows property above el. 50 i 091 Cormier.doc 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15. TOWN OF BARNSTABLE C • �� �� LOCATION I�a'� 4:1tEa((C-�zl t L ►( . EWAGE # VILLAGE [�..-,!"trC-� i'� ASSESSOR'S MAP & LOT _ c� INSTALLER'S NAME&PHONE NO. tt-Lev i 4fe-&d—r- 7T L•013" SEPTIC TANK CAPACITY LEACHING FACILITY: �t�t[l_6� la t�11_i�h l {type) �� (size 11 k 11 N BEDROOMS ' BUILDER OR OWNER '= cr— PERMTTDATE: � OMPLIANCE DATE: Separation Distance Betweenrthe: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water SupplyVell and-Leaching Facility (If any wells exist on site or within 200 feet of leaching,facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) / Feet Furnished by ' G1 o. a 4 d ti i i No. Fee �— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIpprication for 30igpool *pMem Cougtructiou Vermit Application for a Permit to Construct( L-)Iepair( )Upgrade( )Abandon( ) CRComplete System El Individual Components Location Address or Lot No Owner's Name,Address and Tel.No. Assessor's Map/Parcel .39 c ` o t Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. y44 N ee $ j r✓e Cam,%1 i-t-A^#'S c,�►t -�, 4u Sm' 1 -335�i'ku,r c�•riv►S �LfS Type of Building: Dwelling No.of Bedrooms Lot Size Ab,�,�1S sq.f. Garbage Grinder(W Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures C� Design Flow 381 I gallons per day. Calculated daily flow gallons. Plan Date aO"4 7 Number of sheets Revision Date Tr9� Title • Size of Septic Tank O Cr Type of S.A.S. S In r1-Tha-W Q.S Gv �✓ S /�-2 s�Lk-sf 6NvS i ►X3 Description of Soil b' Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreementi 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 Certifi- cate of Compliance has been iss by t 's Boar of Heal Signed t l�Ld'i 1 L Date Application Approved _ Date Application Disapproved for the following reasons Permit No. �- _ Date Issued r` TOWN OF BARNSTABLE ...LOCATION _LirS'� 1 �,(k+LIL Kf 013SEWAGE # 17--L�F( :.ILLAGE L_.r!"�L� ;r ASSESSOR'S MAP& LOT INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) !!T-4t tctd (size I 1 ;.:. BEDROOMS BUII.DER OR OWNER, 1Lr P) RMITDATE: ' 6 6-17 _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ; Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge:of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet .Furnished by ; I w ; I 'I E „-17 047 IV A 9P or � Q of I din,I No. ;F l Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes 4 PUBLIC HEALTH'DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS ipplication for Mfigpaal *p.5tem Conotruction Permit Application for a Permit to Construct( L,11epair 4 )Upgrade( )Abandon( ) complete System ❑Individual Components „� i• ltl , Location Address or Lot No I —r' w�J FCjL /�j Owner's Name,Address and Tel.No. '4 '» � G RfAerT (3e�rk2 Assessor's Map/Parml'';3 AlL.6/ � L t.: bcf Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7A Neee S IJ r Lkell c'IAnS,j(tANf. can irf-1, yu q /Zo ark Type of Building: Dwelling No.of Bedrooms _ Lot Size i3 'KYS sq. ft Garbage Grinder(Alp / Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 38 1 gallons per day. Calculated daily flow 3 gallons. Plan Date aO"R 7 Number of sheets Revision Date A 7 i `fe-I- Se a TA 1j 'Title w Size of Septic Tank t10 CO Type of S.A.S. Y i n r/4tRA'r0 R,S Gv-"7n 4►' 5IM,-rZ Description of Soil S 1 c��'$f G�h+1�S I y Se e 0 ' � r� Nature of Repairs or Alterations(Answer when applicable) Date last inspected: w 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 Certifi- cate of Compliance has been iss ed by t s Boar cj of Heal Signed r :� _ 1li'> c7-r► ri t T mate Application Approved _ r f Dater ' Application Disapproved for the following reasons ti 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 4,-'J�Repaired ( )Upgraded( ) Abandoned( )by at 3 ^1"h/l4 Nk EQ L Z_N has been constructed in ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No / dated Installer Designer V 4 N ee S v/✓e�, (' y-,C u c T A Ni7S' The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector No. l Fee /"Vj THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS Migooaf *potem Conotruction Permit Permission is hereby granted to Construct(pair( ,/)Upgrade( )Abandon( ) System located at h t _'1 _ and.as described in th We a pplication for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with itl�L5 and the following local provisions or special conditions. Uate: Li ed:€Cfonstructi t%tLbd)completed within three years of the date of this permit. ! Approved by ;- 'Town of Barnstable FIN I -7 Department of Health,Safety,and Environmental Services Public Health Division Date $ 367 Main Street,Hyannis MA 02601 BAMErrASM `�� 3 '4)N /�rFo�► Date Scheduled 12`s '"`�� Time � Fee Pd. l Soil Suitability Assessment for Sewage Disposal Performed By:�N) C J/�L_A Gam[ Witnessed By: J t�t �VN N N G \w�7) `LOCATION & GENERAL;INFORMATION Location Address LOT �r -RiA NK-rV L- L-i 1JF Owner's Name L, . '-L15 Vf L .L��•}, Address fb 7 (Or.�(J Assessor'sMap/Parcel: 3"1�3`� Engineer's Namevo"'-N 6AIP� NEW CONSTRUCTION V""' REPAIR Telephone# %5 L4 Land Use Slopes(%) Surface Stones Distances from: Open Water Body Tft Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes) . . i Lor y kt61--r 17 ^o �V Parent material(geologic) 0%-7 J Depth to Bedrock Depth to Groundwater: Standing Water in Hole: Weeping from Pit Fare Estimated Seasonal High Groundwater /yQ 6'N0TV— 7:70VN DETERMINATION FOY2 SEASONAI.Y-IIGH WATER TABT�E Method Used: Depth Observed standing in obs.hole: in. Depth to soil mottles: in. Depth to weeping from side of obs.hole: in. Groundwater Adjustment ft. Index Well# Reading Date: Index Well level Adj.factor Adj.Groundwater Level PERCOLATION TEST Time , t- Observation Hole# Time at 9" Depth of Pere �_-- �0 Time at 6" i Start Pre-soak Time© _�j N Time(9"-V) End Pre-soak Rate Min./Inch Site Suitability Assessment: Site Passed_� Site Failed: Additional Testing Needed(Y/N) Original: Public Health Division Observation Hole Data To Be Completed on Back— Copy: Applicant JC'tt)j (bJO J g�O,J Wc- DEEP OBSERVATION:HOLE:LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % to AZO DEEP OBSERVATION HOLE LOG'.' Hole#. �- -� : Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) I Consistency,(USDA) (Munsell) Mottling Structure,Stones,Boulderes. % 0.1(L DEEP OBSERVATIONOEE.LOC ;Dole#` Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling Structure,Stones,Boulderes. % 'DEEP OBSERVATION HOLE LOG Hole,# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. % DEEP OBSERVATION ... Y OG Io:sE# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulderes. %