Loading...
HomeMy WebLinkAbout0019 KENNEDY CIRCLE - Health 19 Kennedy Cir': -Hyannis A=267.179 1 � v 0 i i FLOORPLAN Borrower: RONDA DAWSON File No.: 02020002 Property Address:19 KENNEDY CIRCLE Case No.:KENNEDY19 is HYANNIS State: MA. Zip: 02601 Lender:CAPE COD& ISLANDS MORTGAGE LLC i 36.0' Bedroo is Bedroom m 4 r N s; e� i r i i j Wood Deck i i 36.0' Bath Kitchen i b JFP I N Dining Room Living Room i I i { 36.0' Sketch by Apex IV WindOWSTM i AREA CALCULATIONS SUMMARY LIVING AREA BREAKDOWN i Cod® Description Size Totals Breakdown Subtotals ...... Fu$.....` ............... THE COMMONWEALTH OF MASSACHUSETTS 9,4 -.--}� BOA RD OF HEALTH 1-- :��...................OF.... v SLI 9''s.Q.. ................................. Appliration for Disposal Norks Tonstrurtiun rnmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -4 /77!P4-'0 ----- ---.... ..........-• ----------------------------------•------------ G ............%VM .....--•- . Location-Address or Lot No. v O er Address RA 4 ,. :. Installer Address ' UType of Building Size Lot....7-fio.___.....Sq. feet Dwelling—No. of Bedrooms___.......,_...........................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building No. of persons............................ Showers a yP g --------------------------•• P ( ) — Cafeteria ( ) dOther fixtures .:__.... W Design Flow__.... ..Q1Q._ .............gallons per person per day. Total daily flow.__.... ........................gallons. WSeptic Tank—Liquid capacity.k ).gallons Length.......:1....... Width....... ....... Diameter................ Depth............. x Disposal Trench—No. .................... Width.................... Total Length.................._..Total.leaching area....................sq. ft. Seepage Pit No.....__l............ Diameter......_...4,�...__. Depth below inlet........,,........ Total leaching area....IJ'-...sq. ft. Z Other Distribution box ( ) Dosing tank ( ) i aPercolation Test Results Performed by.... ............................. Date_: Test Pit No. 1...........:....minutes per inch Depth of Test Pit.................... Depth to ground water..__�.�1LU= (s, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ x -------------------•-----------------------------------...----------------.....------....---------........---...............------•-•----•-•••............. O Description of Soil............�L"� 5?L�lcl &N-'0- ------------------------------ v -••--•-•-•••-••-----••••-••---•••-•--•-•....--•------------•---•--••••--•--------•---------•-•---•••.....----•-••-•---------•-••------••---•---•----•-•--•---••••-•---••-------•----•---•---•......--•-- W ------•---------------------•-------------------------------....---------------------------------------------------------------------•---------------------------------------•--••......•--------••••- 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 t e sys m in operation until a Certificate of Compliance has bee issued b the board of health. Sie -- . .. .. ..!t.C.. - --•---..................•-•-. / ._..... Application Approved B . -- ....... ..................................................... Z_Z_7Z� ............. Date Application Disapp for he following reasons:.._..---••----•---•-•---•-------------------------------------•---••-•-•--------•-----•-......-----.........•••. ------------------ tne oar" --------•-----••-•----------------------------- Date PermitNo......................................................... Issued........................................................ Date `Nm-J�y...._ FEs..... v............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH tU r')I ................... --...............OF...-..Y` 1�-.�1..`* 4.0 .- ,.. .................................. Appliration for DiiposFal Hlorks Tanstrurtion ga`mi# Application.is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ld G T �` �( Location-Address .............................. ---------•-----............--- Owner Address W _..•••--••---•-•---------•....•••----•. .....a.:1:......... . Add ess a Type of Building Installer SizerLot___a._�,©g....5 feet Dwelling—No. of Bedrooms............ ___________________________Expansion Attic ( ) Garbage Grinder ( ) U yP g 1 q I aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures r •-------------......................... W Design Flow______ �1.g __� .......gallons per person per day. Total dail flow_______ �3_4?.........................gallons. WSeptic Tank—Liquid capacityl gallons Length_..9........ Width....... Diameter________________ Depth___.......... x Disposal Trench—No_____________________ Width.................... Total Length.....................Total leaching area....................sq. ft. Seepage Pit No.______-............. Diameter.........Z...... Depth below inlet........ ........ Total leaching area....�1 .sq. ft. Z Other Distribution box ( ) Dosin tank ( ) '-' Percolation Test Results Performed _____________________________ Date._$A � —::......... Test Pit No. 1................minutes per inch Depth of Test Pit______________._____ Depth to ground water_._ J � a P P eP � (i Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ P ----------•------------------------------------------------•---.....--•-------------•••••••••_•••••......................................................... 0 Description of Soil----......_ ' ti --•--- < _if 1.d. i• �� ��I\1 x 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 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. /� Si ed...................................................................................... ------ ate Application ApprovedeBsy� ` ---- - -Date Application Disapp or�.the following reasons:................................................................................................................ ..............................:f="E: =-�-'----•-----._...---•---------------•---------•---------•------•-------------------•---------------•------------------------------------- ................. Date Permit No......................................................... Issued_............................ ........................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... (Irtifiratt of TompliFanrr 7IS 0 CERTIFY, That the Individual Sewage Disposal System constructed or Repaired by --•---•.............••_•••• ------....-----.............---..........._....--------•-----...................••-•-----•- � Installer at......- •--•--••---/----• G .e tw :.. -------•- t ------- ---------••-------------........ has been installed in accor nc with the provisions of TITLE r of, The State Sanitary Co j.a described in the s application for Disposal 'or s Construction Permit No.9.9______ __ __________________ dated2../y/ZF-----------_----_----- THE ISSUANCE F THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL FUN TION SATISFACTORY. DATE__... .... 3................................................ Inspector•••• ••- = -----•--•---------------...•--....•••.._......-••......••_•••--- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ' f ...........................................OF..................................................................................... No.____.-_- =.._...... FEE.A/"10............. Dillpo alYorkii i nstnuton f ermi# Permission is ereby granted/�.�................................ ........Z................................................................. to Constru ( ) or Rep�a ( ) an ndividC Sewage Disp at N St •sp Street as shown on the application fo osal Works Construction ermit No............ ate'd-7-,-'' ...................... i oard of Health DATE...................................... -•--------- •- ... FORM 1255 A. M. SULKIN, INC., BOSTON LatATION SEWAGE PERMIT NO. ,6 7 AN-2Y i� 6 VIUlAGE INSTA LER'S NAME V ADDRESS BUILDER OR OWNER DATE PERMIT ISSUED DATE C ® NAPIIANCE ISSUED s�1�/Y13 �-'�, -- �6 o / / / -S Q �\ ~yL �� �. i� � � ^ � 4 �� .-, �: �_, t TOWN OF/BARNSTABLE LOCATION �� ea S� CIS!e SEWAGE # VILLAGE /S1�l�l�rll5 ASSESSOR'S MAP & LOT 7f INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY lvOad !:;;r LEACHING FACELITY: (type)1-f� s�'m^4 L���-(size)O NO.OF BEDROOMS 3 BUELDER OR OWNER ge-e.)O ,5 PERMPTDATE: 3 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) 7/ Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �S ti th IN No. 9'r, L Y Fee �15_6e> THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS ZIppYtcation for Zigaar *pgtem Construction 30ermtt Application for a Permit to Construct( )Repair( V)Upgrade( )Abandon( ) O Complete System e Individual Components Location Address or Lot No. /,? Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 7 7/- ✓z Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( d Other Type of Building 141AA No. of Persons Showers( ) Cafeteria( ) Other Fixtures �> Design Flow �� gallons per day. Calculated daily flow `7�� gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank O D fe 1_;�Irlsxleo Type of S.A.S. T9 G4�1�G� Description of Soil 4 417' 1?/& ',4 �0 z, 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 Certifi- cate of Compliance has been issued by-this Boardof alth. l/ Signed Date /7,7 f—g7 Application Approved b Date Application Disapproved for the following reasons Permit No. Date Issued G7 No. re' 1' Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Mioogal *pgtem Congtruction Permit Application for a Permit to Construct( )Repair( ✓ Upgrade( )Abandon( ) O Complete System M Individual Components Location Address or Lot No. / 7�r /1�����y Owner's Name,Address and Tel.No. Assessor's Map/Parcel ' )4/ew�!®-� ® / Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. � BQr�`oLo�`i CD�sr 771 Type of Building: Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( CJ Other Type of Building No. of Persons Showers( Cafeteria( ) Other Fixtures fly/ Design Flow gallons per day. Calculated daily flow `7`7Q gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank /QQO 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 Certifi- cate of Compliance has been issued by this Boardof alth. Signe Date /Z7 fg Application Approved b Date 1-7— Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS' ,;a 2b 7—/79 r ~ BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired(�pgraded( ) Abandoned( )by O % at _ � /9/1IS has been constructed in accordance with the provisions of Title and the for Disposal System Construction Permit No.YX--1 gVdated Installer Designer The issuance of this permit shall n t be construed as a guarantee that the system will functioonn as.,designed. Date_ . ��S'' Inspector THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS igogaipgterrt on.truction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at W- A� g and as described in the above Application for Disposal System Construction Permit. The applicant recognizes 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 thi IS rmit. r� Date: 17" Approve 1019197 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT ENGINEERED PLANS) I, ejel7` ,r f�Dl�Tc®� � , herebv certify that the application for disposal works constructionp g ,permit signed by me dated 310-1` Q9 , concerning the property located at �/0� C<� meets all of the P —�— following criteria: �/There are no wetlands located within :00 fee:of:he proposed leaching facility :/There are no private weils within !:0 :get of:he proposed septic systern Ahere s no increase in :low and/or:aange in-ise or000sea t ner a are no Variances requested or needed. If the proposed Teaching tacJity wiil 'e iocatec-within tee:or my wetlands. the boacm of:h.e proposed leaching faciiiry wiil age he 'ocated:ess:han :burtetn above ,he max:mum zdiustee groundwater tab elevation. Please complete the following: A) Top of Ground Elevation(according:o the Engineering Division G.I.S. map) B)Observed Groundwater.Table Elevation(according to Health Division well map) `0 SIGNED: DATE: ` 7 f� LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER [Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan, this plan should be submitted]. IF bulb Ibldee Oat !: �ry CJ.`s fl � � t .. S 4 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION , TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: Owner's Name-6-4- Owner's Address: ` / Date of Inspection: ,5j— /D 1 �60GG Name of Inspector: please p int Company Name: Mailing Address. ,Q �P� NSIPBLE F A Gad �NO�gNO�P�. Telephone Number: �O NEP 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 eeds urther Evaluation by the Local Approving Authority 0 1 Inspector's Signature: / Date: / p —�S� 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. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at-that. time.This inspection floes 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 Page.2 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM .PART A CERTIFICATION (continued) Property Address: • M , Owner: Date of Inspection: l Inspection.Summary: Check.A,B,C,D or E/ALWAYS complete all of Section D A. _}S stem Passes: V I have not found an. information which.indicates that a P ' e y any of the failure.cnt_r�a d�scnbed to 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments , B. System Conditionally Passes:. n One or more systern 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 Infiltraiion 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 distfibutioh 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Q Owner:0 -y-6 2/a Date of Inspection: 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. I. System will pass.unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)fhat 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 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 aseptic 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: 3 Page 4.of I] OFFICIAL INSPECTION FORM—NOT:FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: ado Owner: Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes NI ti 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 '/z 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 SAS,cesspool or privy is below high groundwater elevation. Any portion of cesspool or privy is within I00.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. [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_fre.e 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 3.10 CMR 15.303,therefore the system fails. The system owner should contact the Board of Healthto 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 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 ILof 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. 4 Page 5 of 1.1 OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.,FORM PART B CI•IECK ;IST Property Address: . 0I Owner: Date of nspection: ZQ11 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? J� Has the system received normal flows in the previous two week period ? ave large.volumes of water been introduced to the system recently or as part of this inspection? t�.. Were as built plans of the system obtained and examined?(If they were not available note as N/A) t/_ 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 thew 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 no 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 15302(3)(b)] 5 Page 6 of 1 l OFFICIAL INSPECTIOMFORM-=NOT FOR VOLUNTARY: ASSESSMENTS SUBSURFACE SEWAGhJ=DISPOSAL SYSTEM INSPECTION.FORM. PART C - SYSTEM INFORMATION Property'Address: - 14 Owner: Date of I spectiow. D FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): .. . Number of bedrooms(actijal):_ DESIGN.flow based on 31 0,CMR 15.203 (for example: 11.0 gpd x#of bedrooms): Number of current residents: a Does residence.have.a garbage grinder(yes or no): -- Is laundry.on a separate sewage system(yes or no if yes separate inspection required]. Laundry system inspected(yes or no Seasonal use:(yes or no - Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no) Last date of occupancy: AZoLP/ho� G��v COMMERCIALANDUSTRIA Type of establishment:: Design floe(based on 310 CMR.15.203): gpd ' Basis of design.flow('seats✓persons/sgft,etc.): 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 ��2Source of information: Was system pumped as part of the ins ction(yes or.no�� If yes;volume pumped: gallons--How was quantity pumped determined? Reason'for,pumpingc , TYP�'OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool _Privy Shared system.(yes or no)(if yes,attach previous inspection records, if any) _Innovative%Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank Attach a copy'of the D13 P.approval _Other(describe): Approximate age.of all components date installed(if known)and source of information: Were sewage odors'detected when arriving.at the site(yes or no): 6 ^ Page 7.of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: Owner: Date of Inspection, BUILDING SEWER(locate on site plan)L190- Depth below grade: Materials of construction: cast iron 40 PVC_other(explain),- Distance from private water supply well or suction liner Comments(on condition of joints,venting,evidence of leakage,etc:): SEPTIC TANK:Zlocate on site plan) Depth below grade: <S?Q Material of construction:_Zconcrete_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: Distance from top of sludge to bottom of outlet tee or baffle: 33 Scum thickness: y , Distance from top of scum to.top of outlet tee or baffle: 3 Distance from bottom of scum to bottom of outlet tee or baffle! How were dimensions determined: Comments(on pumping recommend`9tions, nnllet and outlet tee or baffle condition,structural integrity, liquid levels s related to outlet invert evidence of leakage,et . : apt °' GREASE TRAP ecate 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.): Page 8 of 11 OFFICIAL-INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ? SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART C SYSTEM..INFORMATION(continued) Property Address: Owner:• Date of Inspection: I 1 TIGHT or HOLDING TAP l./ '"_"(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 fast 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: Comments(note if box is level and distribution to'outl equal,any evidence of solids carryover,any evidence of aka into or ou of box,a c..): n . r� (/ t R PUMP CHAMBER: ocate 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.): • 8 r Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address: Owner: Date of nspection: ZO f SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located.explain why: Type . leaching.pits,number:_ leaching chambers,number: y'reaching 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, 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 or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.): PRIVY• ocate 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.): 9 Page 10 of I 1 OFFICIAL-INSPECTION FORM—. NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION,FORM PART C- SYSTEM IN.FORMATION,(continued) Property Address: g(4=A-11-9 Owner: Date of Inspection: 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. 0 / 41 b� o 6T1 I 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C . SYSTEM INFORMATION(continued) Property Address:/ �,�✓ Owner:� 101A Date of]inspection: SE/ ap SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water H feet 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: hecked with local excavators,installers-(attach documentation) Accessed USG.S database=explain: You must describe how you established the high groundwater elevation: 11 TOWN OF BARNSTABLE LOCATION 1 I �'elft4 CI - e SEWAGE # — .YaA. GE_/S��1II111I S ASSESSOR'S MAP& LOT 1 79 INSTALLER'S NAME&PHONE NO. �e& .T SEPTIC TANK CAPACITY /vOezp 1e r L- 1 w LEP►CHING FACILITY: (type, /fw � (size)/d X)d -A� 70 OF BEDROOMS 3 BUE bER OR OWNER gee-'; Q©S PEAMITDATE: 7M—Q�3 COMPLIANCE DATE: Separdtion Distance Between the: Maznum Adjusted Groundwater Table and Bottom of Leaching Facility 'fit Feet Private Water Supply Well and Leaching Facility (If any wells exist ' : aii'aite or within 200 feet of leaching facility) q ` Feet Edge of Wetland and Leaching Facility(If any wetlands exist `::j;within 300 feet of leaching facility) Feet F4stied by is 9'h Q!h SECTION - SEWAGE -- _ - —SEPTIC TANK — — "D"BOX — — LEACH TOP OF FDN r, —(+�' 3� MSL ii 47dTL '. RCMG.lV6 Aw.1Y utlic ut-T 1RP -1_+S } -_«- 4T Xa": y 1 r 4trr yFp$ 1"1 r (. ) 2 OF /8 TO 1/2., w 4•. tt, s �-;'.1k"4�-r• ... t�i50t�luC tcNTc2. lA.e!t T�}T Awry PPWGr WASHED STONE s` st r✓ k pti e 4S i' y S Q .tv d9 y�- tLirraS3y< '4•, un'rki CJ.F�►a:} caP�SB SA�+D. 4 _. wr x� 4 $#C; :a �Zln .Ty.: r ��a5 '"`x, �F -54 au ELM, # 4 ! V- I k: ri ` Cjl`eu J Fswi��32'" �§ Y 77 .G _ ski }b^ , t .. 3 Mp i�,} =r� M�,�•' " "ir4�,},,�.M;�';rxc�.a:'�`5�+-,>.:.v. 7�� .7 '' ➢ '4t4'i . W y .4 IN OUT- IN 1 4 (p (OLJG� OUT, IN SEI TIC _ �` �t t TANK _. 31•Gjp / „ C / f a 1 _ 4 '�y i 1C7 ELEV. ELEV. ELEV, ELEV. r i � ] pAckll An ELEV. ELEV. 4 - - .' �tf 1' -t 1 , 40 Lli v. 4 WASHED STONE 4 xj TEST HOLE LOG d , TEST BY BTQat ,}7 , —'t_ea► t GiF raii�7� t- I ' �, io•" �, C � TEST PATE WITNESS Z 7 8f�.(�Z DESIGN 3 BEDROOM HOU E IVi , r 33.E ° ° T.H. # 1 3.s T.H. 2 0 U 1 - . � � . ELEV, ELEV. - NO _ _ .�p•�ro. - L=I1a r --E�A•' .�' '. - ,, 33•G tT" •�lsa '` y ugh —95 2 DISPOSER DISPOSE -O tZ• 3z•5 PERC RATE MIN/IN. FLOW RATE 33O(GAL./OAV) fl Lp ( "� -..." c + \ t tQ, . _ to SEPTIC TANK 33c� li.�,)= LL t oc>c> t \T r'. G\.' 1'st: ' R r REQ'D SEPTIC TANK SIZE 1 ca©© _ 1' Z©c� Sq, LEACH FACI LIT ` SIDE WALL t�51�TT1(C')'IGO- 7 (2 rS ) -'S 1 G/D. cr '" IYt D. SAnaA BOTTOM 4.0� l I.o ) _ tCo.B G/D. t '± # TOTAL ICI .Co USE: �'t�G LEACHING , SI WATER ENCOUNTERED' 'at4' 33-I '= DOTES: (UNLESS OTH�RW)SE NOfiED.) fs 1 ,u I=DATUM(M$L). TAKEN FROMi �ch«(ti�t OF i* 'I QUADRANGLE MAP (3F �� u4 _ dg il24IVI.UNIC.1 RA.l:,WAT=ER t _.:_ _ .AVAILABLE "7t,� . . ' •a , �. '/a PER FOOT• ,. ,` � q� , � _ e ,. • 4 DESIGN L ADtNo:FOR ALL'PRE•CAST UNITS•:AASHq- _ 4q G O' ARNE " y R Rr ARNE H. 5 ,nar`rs.MIN:CaEOUfVD COWER OVER ALL SEVYAGE'FAGt1 fT1ES: (1),FT. � H. DISTANCE AS EIRt1fi1E �•• ,, ,., A .._, ,. ,, ..,. UJALA . r� } C D ,r'. INTS:SHA, is MAOE'LWA t a JALA '{ 6.,PIPE JO LL BE _.. TIER,TIGHT t , s -,a D; ` CIVIC _ ch +7. ON$T.RUCTIQN E AILS TO E`ACCORDAN E WITH GOMMi'OF MASS. 2,6348 a _} 4-,[ .; c e NO 1 HER BY CER I FYt HAT TH6; RF : 'r TE E•N•VIRO.NNIENTAL'CGOE tT" 5:' �0762. T . . 7 8U!•LDING P- s STA.. T LE. #: a w .• SITE SHOWN P ,., �s l' r ,! .<. , , _ .•, .., LAN.IS CATED O)V,�TkE:: � a� ,, t. ;., .:x r 7 . ._ • -- ., . � ON THIS. j,. LO, s k - > ,, , 1 Y ... 4 . , ,. =,r .x t� V.✓:\:: *'CIS Q '� , r, :� a d at' f T tJ GROUND AS SHOWN,HEF EON&THAT 1T t. g i a CONFORM TO THE ZONl It10v BY WS.�7F!THE, .� LA ^. - , • J C!'`"3.'... F`" F.. TOWN OF av ,RE .PROF'E t L ENGtNEE k G- _ WHEN CONSTRUCTf=D., ._, . 'i`E t,.'sf'" ,f a _,+..#,,.., »., ', +.y {, _ 7 f "Y •- , , .- a i' -4 6 .,' '� ! '.+.4 < ',I fJA. ,.,•,,, #` t C3 � 'y�.4 �J°�„ .a,a•i .,., �,. �1. ., .,e. ,.e .-, ,. ,., .,. .. r t •:,. ; t.', - 4 , .. ,. t. k' n"� M R�F' �♦ g . +,. ...-r _• G ... ,. ,', . -. - 4* .. 1 .. .. y', ri• t., - _ ', ., .... R Q�PQ a .. x K a r ,' ,# ,.x a . - •� , •.CI 4<S!." t t {-., ,,� y.. A - � : {.. c r ♦ s '� a. .# .R'. .. 3'f l r. l�:< r.„ :.s r,• z r.. n ., 4:• �, .r 7, s 4 t ,. .r• c R' y��•r� NEEf15. s, ri, .; Y i r. 1 { r t. • .. t '. ,, ..:. -;•� -�. '^r! �b,ry,M., io,�.-!'•- "r`.?., t.K Mai. —M4•rn'1;.:.� �.�„_: ��'.: . e- ,h•y ,.,., � <.37 :,: {; ,. : . .LA I�&UP311EYOR5 ;-+,, , a s. . N., #I o w.. s. r •e may:: ,. f! -> •s :. R s .S s .# t NIS StFRV' YC+.R`` i•:„ •., BOARD OF.H A TH'. � 's. ING < . .:-.-•'.- .: r, .._r-- 4,Iwa, q .. _. .. ,.. Y *. -t,4 rt ( y ,1��:r,, h. '✓ fS.X:S`T' �_ (,,-� (1 U ,S .. .� R - , SAC.. , . Ye moot ;$t 0 eeRs M %tyr ,. -.,.r... Y.L. 31,-r...,i t. y��{ ...,e$^, . ,.... ,�, ..... .. .... .! ,... , ., v . ,.: .. ...- � 6 ... a 4. n _ 1 �. .. � �- .. E•. 4- Q-. ;�' } d. .3...... ...... .... .. .. .,.,- ,.. .-;:. .. .....-<,"i.'!'•.z _: ..... �:...... ,... ./. wt:_.t:��...� ..I,,,.#..« .f.. L. {:.- . .. .,. _. .< ... s� fi yy mm,,, t ".. . t .Fa 'i } ,.. . , , -M .N. .. _�, a.' , Re.: '�.YM [':t,'° 3'r.. tt, •'p s/,.y x.r"� .;� ._,....k:.sailk..i. ,_�+L+,«ah '.+•i v .,r • 2.. R4 .. a , , t r . t .-. r i . .' ,„ •Fh�� +`'�, <; - K { :.,,.�..,.Ll.a i.,':.,...��:SR.r,.. ......_ a..'.,:.. �i, - _ .. .+_ ,.. .. •... ,w..<,..`.... .+ ..s r ^{g -..... ,s .... .«w.s.. _,'[._, r _.,,...,-,�a. ,.i._..... .._._....-_.._. ._._.,«.,.,._ ., -r t -.y< _- i'- .� ,..a... .. rz�...,..Fi..-a.�.a�..r.._:.:.®.�.-sd. d.�:.w .3.,.d»,t ...�+L-... J'� �s...v".....a-, -._.e.......,..-.�,.'l..s..:P:.9-•,1s..,_' ...L:."..:. ,....dt1.,,��,. a r 3 �1 9;ayt I 04 �vj(JJ(�: C`of f. _ a a