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HomeMy WebLinkAbout0079 GOAT FIELD LANE - Health r;r 79'CGoatfield Lane Hyannis, MA A 248 258 23 1 TOWN OF BARNSTABLE LOCATION .GOO kk -r k d E.C,^'k- SEWAGE# ) 0 — U VILLAGE � S ASSESSOR'S MAP&PARCEL a INSTALLER'S NAME&PHONE NO. SC EA E�1 SEPTIC TANK CAPACITY e k l S+ OCU LEACHING FACILITY:(type) (f Sk t%k 9; (size) NO.OF BEDROOMS 13 (>,�6K O n kl OWNER PERMIT DATE: I � a/�1 COMPLIANCE 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) 4 -e Feet i Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY - � � sw � � � � i �. .fir, w 1 _ � � , �� �., :� � r� �.� � . � .,. �� No. 10 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zfppfitation for Misposal 6pstem Construction Permit Application for a.Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ��dividual Components Location Address or Lot No. 75 Owner's Name,Address,and Tel.No. Al Assessor's Map/Parcel �`� `t C`�1 `S V d t "� d��o Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. 5cd$�cc,,, V_ C�3 0�� Y�,��-moo cfj tw G 0 Type of uilding: 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) Affi4. 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 'o Nature of Repairs or Alterations(Answer when applicable) \�p�G�. �K(�Sr� t� (��)Tt c(� QQ- 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 Rhvironmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this Board of Health. Si Date Application Approved.by Date Application Disapproved by Date for the following reasons Permit No.., go in — i D y Date Issued 3'Z61 7,01 °� ,Ca •,a;.�t�',�.-�7.��a�f� ...�y_k.��'�*r�h`,�"'�i�,�„"e�',.+-yti.ev��iti,r'1r'�Y�.+t;�e�'�'a%'e-'SJ�1'^:'�:MY�"rG�.`�.i" �.'`�`.�;�`.% '�"�4"`�'1C��'1'. -.} No. Z9 m 1 0q �, Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: c0 Yes PUBLIC HEALTH DIVISION -.TOWN OF BARNSTABLE, MASSACHUSETTS - . 2ppfitation for -Misposal 6pstem Construction Permit Application for a Permit to Construct( ) Repair �Upgrade( ) Abandon( ) ❑Complete System Np Individual Components Location Address or Lot No. 75 &6rj Cj L ' t,04— Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 2Sy � 0 Installer's Name,Address and Tel.No. Designer's Name,Address,and Tel.No. 0\J `fir r--o Vh. !-W �. �� MM !SIDk ary 066 " 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 L 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) 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. Signed Date Cl Application Approved by C"' E/ Date .[ z1� 7,iq1 C1 Application Disapproved by Date for the following reasons Permit No. 7-0I°1 t aq Date Issued J 1 ZJ�' (I t THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(� Upgraded( ) Abandoned( )by at C^S no. I-L' d. �rc.n1 'C�� ` L tit' Chas been constructed in accordance with the provisions of Title 5 and the.for Disposal System Construction Permit No.0) 101 dated Installer Cc, V 'C"(4 Designer #bedrooms Approved design flow gpd The issuance of this permit shall not be construed as a guarantee that the system w'-11'fiTnction •desi to Date �/' �`�</ '7 Inspector �\ -- ---- ----------------G---- ----- - - ---------------- ------ ------------------------------ - ------------------------- ------- ----- -- No. Zo I — l Q-- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 30isposal bpstent Construction Permit Permission is hereby granted to Construct( ) Repair(\/r Upgrade( ) Abandon( ) ..System located at. �� G C 4,\ OZ-` W (_WA-�, 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:Cons pction must be completed within three years of the date of this permit Date ��/�lcJ Approved by COMMONWEALTH OF MASSACHUSETTS ' EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION / o' O,ef PY_ � L/ LB Jk 0�3 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION G� S�# /� .3�0 Property Address: / / COlr44 glcl 60 / Owner's Name: F !✓ rg H �e Owner's Address: < N -r Date of Inspection: ' a _ Name of Inspector: lease print)Company Name: -- TL—G hl — -V Mailing Address: ea p 3 01 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 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 Needs Further Evaluation by the Local Approving Authority Fai Inspector's Signature: - Date: 2 ®3 The system inspector shall sub ' 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 now 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. Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page 1 f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Owner: Date of Inspection: G 9 0 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syst sses: 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: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section repaired.The s ste hon need to be replaced or y m,upon completion of the replacement or repair,as approved by the Board of Health,will pass. I j 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: i 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 distribution box is leveled or replaced ND explain: 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: Title C inennrtinn Fnr.n�/1 a/'lnnn 7 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFIICATION(continued) Property Address- Owner: r �� Date of Inspection: 6 ,2 p 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 s stem is failing to protect public health,safety or the environment. y I. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. — The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. — The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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 and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: I T41. Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: (S'OaT rf 4J L ItX Owner: Date of Inspection: 6 9 Bj D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No l ackup 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 ,,dogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or es spool _ uid depth in cesspool is less than 6"below invert or available volume is less than%:day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number ,,--'of times pumped . — 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. y 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. f This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] (Yes/No)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. 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) yes n 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—]WPA)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. T;tla G Tnennnt;nn 1 ..... �/i ei�nnn d Page 5 of l l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: .99 6`laoh <e61 c Owner: ea H jDate of Inspection: Co.z,4.-9 Lor Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes o Pumping information was provided by the owner,occupant,or Board of Health C, 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? rl ave 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? 1,1�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: Yes _ 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(3)(b)] Titlo C incnortinn 17^r Ail ciInnn 5 S Page 6 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: (T O4i�g /,j Z— �/ ✓�I ,51 /v Owner: Date of Inspection: (o 02 RESIDENTIAL F OW CONDITIONS Number of bedrooms(design): 3 Number of bedrooms(actual): DESIGN flow based on 310 CM�15.203(for example: 110 gpd x#of bedrooms): Number of current residents: Does residence have a garbage grinder(yes or no): /G0 Is laundry on a separate sewage system(yes or no):- [if yes separate inspection required] Laundry system inspected(yes or no): ,(/D Seasonal use: (yes or no):�Q Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no)- 4-p Last date of occupancy: /f/ COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgketc.): 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/use: OTHER(describe): GENERAL INFORMATION Pumping Records / Source of information: /C 7 P4 •,P--� Wass stem y pumped as part of the inspection(yes or no): If yes, volume pumped: gallons--How was quantity pumped determined? Reason for pumping: T�YPF SYSTEM SepUc 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/Altemative 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) d source of information: V H Were sewage odors detected when arriving at the site(yes or no). Titla 'q incnant;n V--«. [/Icilnnn ! - f Page 7 of 11 i OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Dr,/7/c Z-/;/ Cr All Owner: 1".'I . Date of Inspection: G a9 0 BUILDING SEWER(locate on ,site plan) Depth below grade: a 9 Materials of construction:_cast iron _" PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): ------------ SEPTIC TANK:_(locate on site plan) Depth below grade: Material of construction:— ovE ncrete metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: 02 Distance from top o�sludge to bottom of outlet tee or baffle: m Scu thickness: LLess Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: �/e �Q devl C Comments(on pumping recommendations,inlet and outlet to r baffle condition,structural integrity,liquid levels as elated to outlet invert,evidence of leakage et�f.): A1.6 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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): T41. 1Z 0..— C/I ci'%nnn 7 f Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C q SYSTEM INFORMATION(continued) Property Address: � Owner: I oa I'GI „I, Date of Inspection: C- p 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/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: L' Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into 95 5,0�t of box,etc.): /f-0 S / J PUMP CHAMBER: K (locate 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.): Titles c i.....,o..r..., r„_.., ctici�nnn R • Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INNFORMATION(continued) Property Address: 9,9 6fBe;5 17, Z,/t/ L Owner: l of Date of Inspection: (O ot q Q� SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: s Type x leaching pits,number: 6 leaching chambers,number: leaching galleries,number: / J'EJ ne— 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.): © // / / 7 sip / 0 v+cd I V1 r C ivy q 7— 4 � �9 CESSPOOLS: /V (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 or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY:4/—(locate on siteplan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): T;t1a ; Tnc—t—T:'..—4/1 9Mnnn 9 i Page 10 of 11 • OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: /:"r 010 � Owner: O�6oJ Date of Inspection: 6 5 9� o SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. A ' S j - 02 r 3 Titles Tno —;r n Anrm Aii cnnnn 10 n Page 11 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM nINF/ORMATION(continued) Property Address: �Q pc'`/-r-WIl/e� /yl Owner: !G, Date of Inspection: 6&21 ,06 SITE EXAM Slope y Surface water Check cellar Shallow wells Estimated depth to ground water d o p feet f_W C� / Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: 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 hoyv you Fstablished the�igh ground water elevation: G�Qw4 Y -4 a /s a o w► p Le�,o of i S 6" Titla rZ Tno-t;n T7­4/1 CMAAA 11 L`O.0 A't ION SEWAGE PERMIT NO. 'Lo -9 Z3 GoA-I 5 f ,�f Ln,,,e, 271- --M VILLAGE 1 ' INSTA ULER'S NAME i ADDRESS W1aC oti{ irh, \�S R U.1 L D E R OR OWN ER DATE PERMIT ISSNE'D Li DATE COMPLIANCE ISSUED �� _�� e3, --. � � X � , bk y S � � --� �� �-- �J� � Lr �, a,=.;, r'�. 9 � - ;. '} ;> ._ __ _ oB ... � . FEB......cI...�............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............OF...........,. ................................. Appliration for Rgpasal or utudrurtinn permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal el System at. ................••• •-•-----.......... .............----- ..... ...... Lo ion-Addr,ss or No. e � .. � -.. e...........�. C `.L............................................ �`�_ Owner -.. Ad ress ............* -3... �a� ................................ ....... Installer Address U Type of Building 3 �� �y�Size Lot_._ ...............Sq. feet Dwelling—No. of Bedrooms............................................Expansion Atticl�Y('l Garbage Grinder k-c4'O '4 Other—Type of Building .. 1 a g /rV � No. of persons........_______________ showers (Z.). — Cafeteria ( ) QOther fixes ........../Jf�l� =-------------------------------------------------------- W Design Flow....._._._�. ...........................gallons per person per day. Total daily flow....._.__.�.3.0..................gallo s. I: Septic Tank—Liquid'capacity/Wd..gallons. Length..... _:_. Width.....:_..... Diameter................ Depth..... Disposal Trench—No. ./l�Ql!�.. Width.................... Total Length..............._.... Total leaching area...2-C6......sq. ft. Seepage Pit No.---- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( ) Dosing tank ( ) rr '~ Percolation Test Results Performed by... ........ ... .. �l!B.. ............... Date...._ .1. ...� 3..-. Ate.... . ,/. - z a Test Pit No. 1................minutes per inch Depth of Test Pit...../............ Depth to ground water..yrflc% „ f%----------—Test Pit No. 2.................minutes per inch Depth of Test Pit................•... Depth to ground water........................ - Descriptionof Soil......... ..--- --. 1/._`.�!L.............................................................................. W ----------------------•----••-----••-•••-•••--- -----•------•---•- ......................................................-............................: till 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 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. Sin C '�j�� "•- r ------.910.1 3 -......`.............. ate Application.Approved By•••••-•-•••-•...... ............. I ,Pate Disapproved for the'f ollowing reasons:----•------------------••------•-------------------.....-•---------•------------—.--•-•--------....-•---.... ..................•-...•-•--••.••••••••--.............-•••-•••••••••••-••....-••••••............._........--•...•••-•--••-•••••••....•-••...-•-•••-•••••--•••----...---••---------------------------•--•- ` Date Permit No.............•----•-----•-- __ Issued........................................................ Date y ov.............. FRP............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..............OF............ . ................. ................................. Appliration for Uhipwial luo anstrurtion Prrutit Application is hereby made for a Permit to C6nstruct an Individual Sewage Disposal System at, ............................................ . . ....... .......................... .......................................... L i Add ............ea�.m.*C,4..... ................................... .......................................... Owner r SS .......... ............................ ............t..T../ meff, ......... ....... Installer Address Type of Building Size 'Lot... ......Sq. feet U —No. of Bedrooms... .13 ................ Garbage Grinder ktoo�() Dwelling ......................... Expansion Attielk/0 aOther—Type of Building _4W ............ No. of persons--------6............... Showers Cafeteria. Otherfixtures .............vo.....�p............................................................................ .. ................................... Design Flow..........S.]i..................... ....gallons per person per day. Total daily flow.......................0..................gallons. W pe Ix Septic Tank—Liquid'capacity,�Odd_gallons Length.....&Z Width.....6 Diameter:_-------------- Depth.....6...... Disposal Trench—No. 41al?Z.. Width.................... Total Length.................... Total leaching area...2_',C,&...".sq. ft. Seepage Pit No...................... Diameter.................... Depth below inlet........__.......... Total leaching area..................sq. f t. Z Other Distribution box Dosing a Percolation Test Results Performed by--- _j ............................ Date..._: Test Pit No. 1_4��._minutes per inch Depth of.Test Pit--- . . ....... Depth to ground water-..,- , .1d fZ4 Test Pit No. 2......:.........minutes per inch Depth of Test Pit....................�. Depth to ground .......d.... ... ....... ...................................................................... 1---------------------- 0 Description of Soil........ ......4�0..... ....................I................................................................ ............. e.. ................................................................................... U - ------------------------------- ..................................................................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable............... ..................................................................................... ........................................................................................................................................................................................................ Agreement: The undersigned agrees to install the aforedescribed. Individual Sewage.Disposal System in accordance with the provisions of T I T IS 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. S1 Ar -3 ---------------------------------------- .............. .... ------- Application Approved By..................... .......... ............... ---------- D I /<-V. 1 Application Disapproved for the following reasons:................................................................................................................ ......................................................................................................................................................................................................... Date PermitNo......................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS .BOARD OF HEALTH A ..... ..................OF.............. . ..... .. ............................ THIS IS TO CE;8h it the*idual..Sewa e Disposal System constructed or Repaired by----------------!...................... A... . ...................................................................................................... /ns t�11 a ............ .4. Ai,—,/ at.... ..... ....... . . ................................................ .. ..... ......................................................... :'..has been insta�ed in accordance with the provisions of TIT5d The State Sanitary Code as described in the V 4 ,. application for Disposal Works Construction Permit No.--- �17....... ..!-dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.................. ....................... ............. Inspector-----------f ....................................................................... THE COMMONWEALTH, OF MASSACHUSETTS BOARD OF HEALTH ....... .........OF...... .................................. of No4.7... FEE.... ............ Disposal IV rkii (90. 9trnrtwn Vamit Permissionis h reb granted.. ................................................................................................................... to Construct (�03 R &V In ual Sewage Disposal Syst V .. ..- . I A ,* ,o~W;&�at NO..",...3......... ........... ............. . ..... ..........Cam!-------.............. Street as shown on the application for Disposal Works'Construction Permit No._. Dated.._........._....__._..................... oard of Health DATE..-.. I. .... .. ........................7---------------------- FORM 1255 A. M. SULKIN, INC., BOSTON OF A141. v�`'P yid (0 000 66ERT ELLIS �10 1 o.29874 Q �G�sTgf �p� No SOR��' oT 22 . . tt 4A V 7�� qa �Loa,o2D • d soil 7TCS7- �y k. .losellN Whit�.l �� LEGEND CERTIFIED PLOT PLAN EXISTING SPOT ELEVATION OxO �P�IN oF�ygs -EXISTING CONTOUR •--- 0 FINISHED SPOT ELEVATION T' d3 V14u Av, �4y IS' FINISHED CONTOUR 0 ERG y' IN No. 366 A APPROVED , BOARD OF HEALTH TONAL E .g A g kl S E A S!.1,.W ASS. DATE AGENT SCALE# 1 - 0' DATES 2213 �S LOREDGE ENGINEERING CO. IN CLIENT. I CERTIFY THAT THE PROPOSED EGISTERE REGISTERED JOB NO. �3042 BUILDING SHOWN ON THIS PLAN CIVIL LAND DR. CONFORMS TO THE ZONING LAWS ENGINEER URVE R —�— OF BARNSTA LE, MASS. 712 MAIN STREET. CH. BY' K 02j, 5 � ,��. H YA N N I S, M A.$S. 2 9 �4 83 SHEET. I OF DATE G. LAND SURVEYOR oMMO � y � .00y 14� Z 2o2Q ^ Z : N o �AC D b N y h -V3C�' o � � o, 3 ^ � Y n � � po q Dyys a V,p �a7ai ? Z n sill Z O Z m N C• 3 N 11 coM,yory� W � CD f1 LA it •y ti IN y T] y y `1 Y �► � RI A 0 �1 qo PhCA VI , k. k. 0 �G o OJD n 3 o C o ti m S � � o boo a . . . . .IN . . . ofj ,yam 2b1 7 yyN y �` o o C 0-s CQ eeo , o• ;•�e °�= `•�' ' Z CA r- y `A � y i I o D t, ' n TOWN OF ARNSTABLE �. � % cexi f, 4�L.C�Ci�TION a SEWAGE # VILLAGE 46 1 I P"i ( ASSESSOR'S MAP & LOT aVf' R STALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �m O LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE 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 leaching nfacility) ' Feet Furnished by J u e.c;Qo�' ?U/ O ISWI err 11ZQ 7F 44 ai • S - �J