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HomeMy WebLinkAbout0005 LI'L LANE - Health 5 Lil. Lane Hyannis A= COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONmENTAL;'AFFATRS' c • DEPARTMENT OF ENVIRONMENTAI,..PROTECTI,ON t'. .._. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTE M FORM PART A // / CERTIFICATION • Property Address: J V1 e Owner's Name: Owner's Address: �� G✓1✓1 Oaf601 SZ" Date of Inspection: 1 Name of Inspector:(please print) ar o lf-e Company Name: Mailing Address: P0 x -°q 5,1 ." Id Ood 6Z111 Telephone Number(So — (� 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 _ Fails Inspector's Signature: Date: -z p 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 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 0 ' Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: -S z/z Z -17 h-e- Owner: /�`�,N, $,� Date of Inspection• Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Syste asses: 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: ZOne or more system components as described in the"Conditional repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,ewill 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 struc unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent System turally 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 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: Titlo �irenPrtinn&'nrm(,/1 Shl1An I y Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / CERTIFICATION(continued) Property Address: -S Zi L �L G $I (nG✓IN/S� J`/ Al O-Z`O/ Owner: A 0"� f -0 Date of Inspection: of 0S C. Further Evaluation is Required by the Board of Health: /vFu Conditions exist which require further evaluation by the Board of Health in order to determine if the syste is failing to protect public health,safety or the environment. m 1. System will pass unless Board of Health determines in accordance with 310 CMR 15303(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 system is functioning in a manner that rotects the ublic heal Supplier,if any)determines that the P p 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: T41. Tncnnntinr. T.nr.w L/1GNAAA I Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: LI L [-" Owner: 671�- , Date of Inspecti - D. System Failure Criteria applicable to all systems: You must indicate`Yes"or"no"to each of the following for all inspections: Yes No _ �ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or or cesspool g 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 V J-iquid 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 f times pumped due in clogged or obstructed pipe(s).Number /o v Any portion of the SAS,cesspool or privy is below high ground water elevation. ►ny portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface ^ater supply. 5ny portion of a cesspool privy is within a Zone 1 of a public well. � or p ' 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 sesIfvolatile 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 crittas eria exis 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) ys o — 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 H 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. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: J Z"L N Owner: /7 ��� Date of Inspection: -d 49 �n(- Check if the following have been done.You must indicate"yes"or"no"as to each of the following• Yes -- 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? r/Has the system received normal flows in the previous two week period? — ---Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) 1/ _ Was the facility or dwelling inspected for signs of sewage back up? ✓ — Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? ✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: 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 15.302(3)(b)] T;tlo i rncnartin»Fnrm r,1i cr,)nnn 5 i Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: vt� Owner: 4ti Date of Inspection: d RESIDENTIAL FLOW CONDITIONS Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: 0 Does residence have a garbage grinder(yes or no): /moo Is laundry on a separate sewage system(yes or no);N� [if yes separate inspection required] Laundry system inspected(yes or no):Alin Seasonal use:(yes or no): 67 49s Water meter readings,if available(last 2 years usage(gpd)): Sump Pump(yes or no):_4! Last date of occupancy: COMMERCIALANDUSTRIAL Type of establishment. Design flow(based on 310 MR 15.203): and Basis of design flow(seats/persons/sgf4etc.): 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 Was system pumped as part of the inspection(yes or no): If yes, volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: TYP YSTEM eptic 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 kno")and source f information: Were sewage odors detected when arriving at the site(yes or no): /O T41a 4 Tncnnn►,-.. V--...eiier1"nn f. i ` 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: iA P� Date of Inspection: ola�07 BUILDING SEWER(locate on site plan) Depth below grade: -?y Materials of construction:_cast iron —�40 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) d � I �►s a �P�t�4 ,,,.,.— Depth below grade: � Material of construction:—concrete—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) s. ,� Dimensions: Sludge depth: 6 'r Distance from top of sludge to bottom of outlet tee or baffle: d Scum thickness: 3'' 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: 5-" How were dimensions determined: 60/c Ile Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as lated to outlet invert,evidence of leakage,etc.): 1 e. Ah 4, crk eet i r (go GREASE TRAP:4 (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, as related to outlet invert,evidence of leakage,etc.): in'�liquid Levels Titers 9 Tncno.-tinn p. — </IG/7AAA 7 t Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S zr ` Lit HL J'AlQ04,1s, Od6ol Owner: o"w,5, Date of Inspection: TIGHT or HOLDING TANK: /V (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: xallons/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: t (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert.4 0,1--7-n L ✓y eti L to v e„- Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakag into or out of ox,etc.): oA T eve /. /lio So/�s //iv .�e-r 4-s PUMP CHAMBER:/V (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.): ` Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTA RY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: S /I L `//� O�-6of Owner: l�Gw,(,h,.s�,�- Date of Inspection: ova 0 SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: � Type e leaching pits,number:� leaching chambers,number: leaching galleries,number: w SO tic leaching trenches,number,length. L, leaching fields,number, dimensions: /�Gis Ado Top p overflow cesspool,number: innovative/altemative system Type/name of technology. Ce k1i ev, L Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, (over. etc.): I, // /_ /� ,/� �^ �✓�J. �i � by JI vlJ O i q v1 r2-, 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:/f/ (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.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PA RT C SYSTEM INFORMATION(continued) Property Address: J L, L L,�✓t c_ Owner: G►^L yr Date of Inspection: J b0 — 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 b ' ding. -33 �3 3� f O 9 ` � �l3e(,o✓ y('H cad r C Title S incnnrtinn Anrm lii ai�nnn 10 f " Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C / SYSTEM INFORMATION(continued) Property Address: S L...i L LA y 09-60/ Owner: #004 Date of Inspection• SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ep ground water s 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: Checked with local excavators,installers_(attach documentation) - Accessed USGS database-explain: You mus,,descpbe howyou established the high jround watel elevation: o�� � 02 3 �- LCO, f !1 c w, y LA � O 'p O o c9 O C7 rU Tifla G TTCTOf*1nf1 Fnrm�/1 GNnnn i l No..ILl:: f(.,is THE COMMONWEALTH OF MASSACHUSETTS --�� BOARD F HEE LT ..................OF......, A..l...tf,- Y4..2...._.....--..................- Appliration for 01sposttl Works TonstrMt"ton Permit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at' . 7 !1 Lord ion• dreaa � ... Addreea irl, �l �Q.of�SGT_L[21 .............-.... .r.ly.. ataller Addreea Type of Building Size Lot..........................Sq.feet Dwelling—No. of Bedroo s...........*3......... .... .....Expansion Attic Garbage Grinder Vye> p t _ Other—Type of Buildin P_/J7#r...... No. of persons............................ Showers (Z4—Cafeteria ( ) dOther fixtures ...................................................................................................................................................... W Design Flow............:F_ ..-..._ gallons per person per day. Total daily flow.-....�..�J.v....................gallons. W Septic Tank—Liquid'capacity./T.Mgallons Length................Width................Diameter................Depth............... Disposal Trench,—No.....................Width....................Total Length....................Total leaching area_......._..........sq.ft. ...... ft. 3 Seepage Pit No.................... Diameter....14t)-"..... Depth below Inlet...4............Total leaching areazt�i�! sq. z .Other Distribution box (I ) Dosing tank ( ) .. . *.."Date..... . ..... .a Percolation Test Re ults Performed by.....................................................T................... �.* ..-. Test Pit No. 14"5.....minutes per inch Depth of Test Pit.....�� ..._Depth to ground water..,p.. Tg Test Pit No. 2., .........minutes per inch Depth of Test Pit..._.. »'Z...._Depth to ground water. ................... a ....................................................... ................» . K ...... O Description of Soil.,0-�......4nPAIY\ Z.: . M. . �J .'t-4 : ........ V ................lt.."". _Z......... ......'yr7TT�' ...._..............................:.................................._................... .. ................................................................................................................................................................................................... 0 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 OP until a Certificate of Compliance has been' ueQh oard of health. / ned.. ....:........................................../�!/ . . 2......_.... Application Approved By.... ...... .. ......................................................................... :..K .. . ;;J.......... Application Disapprov or a to reasons:........................................................................................................_»__ ..........................................................................Date.._.......... PermitNo.......................:............-........._.._-.-. Issued...»............................................._. Date - --...-----. Date - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF..................................................................................... Tntif irate of Tomptittnre THIS,.'. / ERTIFY,That the Individual Sewage Disposal System constructed ( or Repaired ( ) by..........::::...::.......:.. ......... - . ..................._»-.... - • meta at........................ ... ....... .... ......... . ...... ............. - _ has been instal ed in accordance with the provisions of TITLE 5 of he State Sanitary Cod bed in the application for Disposal Works Construction Permit No.........1._.......... ........ dated-.�i..:'y....... ..... . THE ISSUAN E OF THIS CERTIFICATE SHALL NOT BE CONSTRU AS A GUARANTEE THAT THE SYSTEM W)� �CTION SATISFACTORY. Vj DATE...I..... ......................................................_......._ Inspecto .................................................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH J�(� OF................................................................................. No...G.'.. ............. FEE...................... �is�rnstt o � vn r�tr#tnn Permit Permission> reby granted.........:..::.::..... t ..to Construe,( or Repaiy(/) an Individ Sewage Disposal System atNo....:'.... '._._..,. ............'. ._......1:..! ..............__.................................................................. . ..-... .........._...... street as shown on the application for Disposal Works Construction Permit No........... ... . Date ...:...:_� ............. - ' .................................. �_.. ........_................_......................._ IV07'E /F E/TNER THE SEPTIC TANK OR 20 F7. M/N- 4--,4C.NltYG PIT ARE MORE 77AfAlV IZNBE40W IO fT• M/N .'iR^�E, A.24�D/�tMETER CO/yCRET� COVER SNA L L eE B R041GN T TO 4.T,4 L?.E.�,4 N EXTRA CONCRETE 4-P✓C P/PE hrE.4VY CA ST/RO/Y COV4 Sf�ALL :L3E USES M/N. O/TLN /F/lyr OR/VEwi4 Y F ya" COVERS OFR fT. --r 2K. MIN. CDNCR�TE Qr ADS CO✓ER CLEAN SANG &A CA. 2 LAYER 3 �RCK P/PE o CJIF l8 fB y MlN.P/TtN 0 O GAL. ° •;,� . • . . • . .. • e. .eo WASHPD STONE . D/ST, • PER r T. SEPTIC TANK31.4 . . . • . . . - •-=. BOX v � � $ • • • •. � . •i . M = :- , • •• pipTly . • • • o ASHEP STONE o ti • • * ••• � Leo . 470 18B x 2,S=. s • s . • . • • • o PRE445 T SEE.PAOC • P/T OR EQUIV. IMM&A-r CLEV-4T/D/Ys p�T cr+r°�" �r7 GR4�D�Y /NYERT AT av/LDING SEE TABUL.AT/ON� INLET SEPTK' TANK FT- O.fA/►s.. C C OUTLET S EPTI C TAKN GROLIMD:i1QQTfiT Ti4DLE /o �79. � ur N a FT INLET OISTR D BOX-Z SECT/Q OF - N ounzrol37;T,A rr/oN BOX -7'-•7-,Fr. INLET LEACHIM49 /PIT ?1:.`_FT SEl�NAGE OLSP0ISAL SYSTEM 7i44ffULA7*1G0N LEACH!/VG o!T o/MENs!cN A 4 FT. DES/GN CRITERIA SCALE VJ/MjER OF e9EL>Ro4M5 3 - D/MENS/ON C_ FT•M r^�' GARCA6ED/5PO5 AL.uN/r f SOl.L LOG TOTAL E.?TII+lATEO P'400V 3 3 �+ o.4t./DAY SOIL TEST AEI SOIL MST*2 Sa�L '7rE3T / NUMBER QF LEACMING PITs_Ll r �^EtEY. �P•' I -AmA-4 GATE of -So,,I- TEST z` SLOELl'ACH/NG PERP/T Sit I:T. 0-01 RESULTSJt//TNESSED dY'�RE �� `�''`�4 9oTTOMLr64CN/NG PER P/T �� $Q. iT I-PAA' 0- PERCOLATION RATE JVJIVI//VCH - TOTAL LEACH/NG �4REA Zl 6 SQ. FT. T`lP:sG'-L - PEMCOLArlON RATE!k 2 ' 'y MI N•�/NCH �-(- 6 2 , _ 6 z v RESEKVE LE,4C'N/N6 AREA SO. FT. M F n s R p- d9 O ZM �����{OF At, 3 # / oat Oft yG Ql AL�(�j i U�} �nr/r RSE H 3 ! w No.10951 O 4 L DREDGE r EMVA RIAWT C�/NG.. E �o�s • 712 MAIZV Sr.ONA e`,t.I�Y+Rf1N/S.AM Al Su NO dT0VV0 YYATLE Tr N - SS. Q GM U/VD wA7 EA=R AT FLE✓. JOB NC: U✓ S SHEET 2 Of Z L '-L'EF KC - w 115` MIQ. LaT 0, a EA f' tee:7 P.d'c- 105 -r- Mwim,iM FQ�wTAe c- v�A�•���r� P�� P�A1��—N �� ran RD -Pz:� Lo 5.F . To'_,�I� 2ouiu(o {L�(.y7LfCnOL.�i �1'L'ncl� �., I cf4P.PTE2. ILL, J-F. 1 10oit vt ,ryre��Wa" ''' 0- 7Q e rJoR?71 ��, �'K •o �-or t ^Nt o Nht fpya� 0 All ^rn 4 Po�T �► SgrS' Gy,� o: 1 o\`i 1p '20,0 _5 ti Sys°vv'oo e.o µE►� :3 Irs p ALB RSE h /�° A4 I I 1 �- S / Q o' ,S•MIT I �-IE-. °ggFGI5TEQ6�QWS RFSSIONAV WE CERTIFIED PLOT A.40._ 7zoLd'r � b,n.y�r�scv'3;.T f � E I N S7-P V✓ g� (4c y�r vuOEFrr Jab P�. '�� Ti MY 7:,"l SCALE, /"f-lo' DATI (�LORfOGE ENGINEER/NQ CQI�NBC► OF I CERTIFY THAT THE SHOWN ON THIS PLAN �EGISTERED RI:OIST6RED �nbS. ON THE GROUND AS IN[ CIVIL LAND ' I '*"""'�^ CONFORMS TO THE ZOi ENGUIFER§ SURVEYOR pR°NYI!f�; AS ClL.�YI OF ,BArei✓srn� .� 712 MA,IN'STREET„ 4 • a �:t9 >t�,. "�� i� �a.'6� � ">+ B�9�Ia�a ��-•� a �*�I .S y rx �r � 4 Y t D��a 1t+ • V,4 �t RE): gof ., f �.rhi�,�, �...i ;a tf#i 4>•I r`t l�{�3 f..�€}1l:� ���A e- - .. •� l �l L.. a S � jd yr'�-,��a .. ! , I .r a k, cq}f€3y I z'� 111w vi a:= f f ; # i t�iF K +#• 5 j{�:�. Xt �,-• � rl -Yd� a !I.�1'i + I a- ?p i.Fi,j#.•S•�� �� � a �"4 � ! � , Y �Tirp' 11 rt 11l �t iak•�E�'�i"5 R'��� Pi Grog� t � i ,. 5 � Si♦'fr i1 s ,# rbi iA. �;�} r �'ry-� `�f .F � � ik. Rh a.f i k t �r g ' itf 11 t5{rp#A{ `rFa 4 }C�rS�����p, ;r J HfC4 ;Ul n u.°#*dddd ;' �jii9►► �'n..�# ftt 4izTs#a v t�1 L `; s dSp �j��; fwi } a � a �, Yam(•1 . _ u<,�r, :t,-- a♦�, �fj. +A icicv�rf* r}a l.teS �� �ep�' t��f; ,�: .�,{ro �w:, 1� � � E i ti 'S. .b� �I�•,ckl � _'CIA.>..:d:ayreE ` TO OF BARNSTABLE LOCATION S•� .pis �?'r1.2- SEWAGE # VILLAGES ASSESSOR'S MAP& LOT INSTALLER'S NAME&PHONE NO. r SEPTIC TANK CAPACITY LEACHING FACEL=: (type) (size) NO,OF BEDROOMS ...� BblffiDER-6R OWNERC4W4-;-% 0W -�.- PERMUDATE: 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 facility) Feet Furnished by Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS_ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C /SYSTEM INFORMATION(eootlmud) L Property Address: S L, Z- Data o[Impectlom dJ SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a shteh of the sewage disposal system mciudiog den te u least two permaxat mfereoce landmarks or benchmark.Locate all wells within 100 Seat Locate where public water supply eaten the iGa.. Al- d 7, lt3 -.33 ' A• wDvi � l�le✓ /S./e w of to T:N.i I.w.,:,u,Cn„n R/1 Gr1Mr1 Ivo.. : .-3 „ Ra Fms......5a.............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® E HEAL 00,J 01 ...................OF........- , 00 3 liration for M-4 u.4Fal Workii Tamitrurttnu Urrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at• ^� LocStion- dress or o. - _ OwneAddress ............../---...1� `� I L ....... Installer Address dType of Building Size Lot............................Sq. feet V Dwelling—No. of Bedroo s............................................_3 .__..Expansion Attic ( � Garbage Grinder ( C7 P4 Other—Type of Buildin e_(..i#e_-------- No. of persons............................ Showers ( Cafeteria ( ) P-1 Other fixtures ...................................................... W Design Flow.............. -------------------gallons per person per day. Total daily flow------3•--{-O.....................gallons. WSeptic Tank—Liquid capacity_!P Ilons Length................ Width................ Diameter.--------------- Depth............... x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area----------_.........sq. ft. Seepage Pit No...r______________ Diameter.___/&........ Depth below inlet.•_j�p............ Total leaching areZA0......sq. ft. Z Other Distribution box (I ) Dosing tank ( ) Percolation Test Results� Performed by.................................................... i.................. Date----- a Test Pit No. 1 -- minutes per inch Depth,of Test Pit----- `�.-- /----•• Depth to ground water__ ___. Test Pit No. 2 :rt_....minutes per inch Depth of Test Pit------�_'�.�.... Depth to ground water ___................... ........................................................ --G. f-^'�.p_'•---------•--------- - .-------------...-------------- -�----}....................... O Description of Soil = r � "; �------.... . �---- -----• .. r` D- I"fl Y v_-----------•----- c.> -------------------------- ------ Z -----d . ...0 �� p w -------------------------------------=--------------------- ------------------------------------------------------------------------------------------------------------------------------------ VNature 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'TT. p 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been ' ued b h oard of health. ned---;. -- -------- -- - -----------------------••------•----------------•- •-- -- -----••-----•------•- ApplicationApproved By---. ---••-• •. .....---•••••-•--•-•---•-•-•--•----•-•-•--•-••-•---••--••=••-•-•--•---••. Date Application Disapprove for a following reasons---------------•---------------------------------....---------------------------•--------------------....••.•---- ---•--.....•••••----•----•-•-•••-----•••••••••••--•-••---••••----•-••-••-••••---••••-••--•---••••--••--•---•-••-•-••-••--------•--•••----••----•••------------•--•----•------•-•-----•---•-•-•••-••---- Date PermitNo.......................................................... Issued....................................................... Date k No..!2.. ..: .C.r �_ - FEs....... .............. . . THE COMMONWEALTH OF MASSACHUSETTS 1Y 2 BOAR® E HEALTH Appliration for Diapaii al Workfi Tnnitrurtinn Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: .j _ -. ,/ t� ' iI jq j _ �i,� t � c �� 7 fastJ�i ('j � lf �t ........... ......... 1.... 1..:.. ..... -•-••��--- �f .................. Location-Address f or/ f lyU`'��7" 1 / 1 f r'r --•-�� �•.....`.....�............-_ram_...---... Owner s �Address�/✓' �.._......._._...................... `em ... ... . ......................... Installer Address QType of Building j Size Lot............................Sq. feet aDwelling—No. of Bedrooms.............. ...........................Expansion Attic (//,p Garbage Grinder p, Other—Type of Building.'!?!L'b.& -___-_- No. of persons............................ Showers (,7) — Cafeteria ( ) a Other fixtures ........................................ W Design Flow............. _................•......_..gallons per person per day. Total daily flow__....?:._ s.6)........_......___._gallons. WSeptic Tank—Liquid*capacity_!Y'..-.gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..______.._.__......sq. ft. Seepage Pit No.___�..-_-._-__-_-- Diameter.._./.t_____..... Depth below inlet--__,!.._........ Total leaching area!=,�!/.___.._sq. ft. Z Other Distribution box (/ ) Dosing tank ---• Date...----'/•�= r�......--�"---- Percolation Test Results Performed by..................................................................... `� Nest Pit No. 1 .�''____._minutes er inch Depth of Test Pit._.__.f. Depth to round water_ ' 1 I p Pit f P gent _ Gz, Test Pity No. 2., V..:......_minutesper inch Depth of Test Pit...... Depth to ground water._................ fYi -----------------------------•--------------------.-...---•--•-•------•-------•----._....-----...-•-•-•------------.----------.--.--••----------------- O Description of Soil )=-''' .. %t f ••--` '= j - .P�1)- -- ._ t ! -��----....:..- 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:TTL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been/i ued by h oard of health. l� t Z .ate_ Application Approved By ........-- =`f Z.----------•-----•----•--. ................z Date Application Disapprove for,fihe following reasons----------------------------------------------------------------------------------------------------------------- .......-•---------•----------••-•••-•--••---••-•---------------------•-•••••-•-•-•------•------•------.....•-----------••--•-•---------•••---•---•---•------------------•-------------•---------.......•. Date PermitNo...........................--........................... Issued.!..................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................................1........OF..................................................................................... �� Tntifiratr of Tuntpliattre THIS/,b3 rERTIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( ) by.......... �.._....---•� ---. f --•----..----•----------•--••--------- ;' Insta er �� at. ---- - t -•----- -------------- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Cnd as s ibed in the application for Disposal Works Construction Permit No.__ .. _.:.-�1.__��..._....._. dated_..(__' .................... THE ISSUAN E OF THIS CERTIFICATE SHALL NOT BE CONSTRUE AS A GUARANTEE THAT THE SYSTEM W /L: �CTION SATISFACTORY. DATE.....:... ..... p Ins ector----- -------=--------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH r v ...........V FEE........................ . . ,. , �" Permission is reby granted.........: .:........:. to Construct ( ;)//or Rep#-( ) an Individ 1 Sewage Disposal System atNo...... ...h..�. ..... � ............................St- ------------------------------------------------------ .............. Street 7 as shown on the application for Disposal Works Construction Per No.__..__._.._ ... . Date fG :��/.............. '-f -• r Board of Health DATE--------------------------------------------------- - ---- ... FORM 1255 HOBBS & WARREN. INC., PUBLISHERS I /VOTE /F EITHER Ts/E SEPTIC TANK OR ?O FT. M/IV• --ACHIivG P/T ARE MORE 7-14A,"/ /ZNBELOW /O MiN I �RAOE, f� 24'O/AIN ETE�' CONCRETE COVER • SNAL.L BE B/YOUGNT TO G1;AOE.�AN EXTR/4 r GON.CRLTE i'•!ER V y CAS 7- /R O/Y C O{/.ER Sf/.4 L L .OE U S FO � . CO M/N. PITCH /FIN 0R/V,=WAY - „ r•- �B oFR FT. -•' ( CONCRE•TE 2•i�. M/N. c0 VER C,L EAN SANG - :: 2-LAYER 4-CAST !mO o e o I N P/PE e 1. o .. + MIN.P/TCX j— GAL. / • e • • e • + > 4 �/ASHFD S7VNE %4"PON/T, S.EPT/C TANK � • • • + + � a .'• 60X n � t 8 • • • • • � .•• • �. • / • w \7 • + • • DEPTJ+/ • t • • • • WA5,Y-FP STONE 97 _ e e i e + • • • • • • • o PRECA5 T SEf_PA6L' -79'x +.° _ • a P/T OR EQU/V, IN�/BR'T ELEY.�IT/®IYS p�T C�^�°I' c�'� G R� D y' "Ole 0 INYERT AT B//!LD//VG Xo S'_FT 6.FT IMAM. 3 FT.. PIAM., �C CSEE T.ABUL AT10N> INLET .SEPTIC TANK f n , FT, CUTLET SEPTIC TANK /NLET D/SPRiA&7YON BOX 7_FT. SECT/ON OF GROUNv i tTEX TADLE OVTLETD/sTR/Burioni BOX -7 9.•7;_FT. .SEN�AGE OI.SPOrS'A L .SYSTE//►� INLET LEACN/N!r PIT -7q:�_Fr. TABULATION LEACHING P/T p/ME/V.3'/0N A 4 FT. DF.S/G/V CRITERIA SCALE 01.rIeN51ON $ 61 FT. NUMBER OF BEDROOMS 3 _ D/MENS/ON C 4 FT.M I^!' or✓ C•AREAGED/SPOSAL UN/r nr SOIL LOG SOIL TEST • TOTAL E3T//44rED FLOA/ 3 3 6 GA1-1,0AY S0/1- TEST AI SOIL MST#2 NUMBER QF 40ACN/NG w/T,g/_ fELEK �D �"ELFY. ®ATE OF SOIL TEST 7 S/OE 4eACH/N6 PER®/T 5)9 PT. O-2' RESULTS 8Y R-E. Gi�F'r�r"fry Lod ? PE�tCOLAT/ON /LATE TOTAL. LEACH/NG AREA 7-1- 6_SQ. 'FT° v�suic PERCOLAT/ON RATE RFSEe�{iELEr4CNlN6AREA �-�' h SQ. FT. �•� 2 6 � �,..D M FD S� ✓O I t flFM,t�� f -Vk OF � O N vA •' z ORSE - RLUS " No.10951 o e ELOREDGE ENGINE R/�/G CO,/NG. 712 MAIN ST. , HYANNiS. MASS , O tj✓ rSIONAI Sul ® ND rROUNO yrATER E/VCDUivTfR6o CL/ENT: L�3 4 �1. GRO UVO N/ATER AT ELE✓ - J08 ND: t�O S- SHErET 2.OF ` Assessor's map and lot num e!5 r".�,e7 C . 1. .�• v t ¢ THEro Sewage Permit number .....F.3..-... .:$. 3 INSTALLED IN ���'} �� � � sAuSTADL House number ...............................................I........................ KAGIL WITH +°o TITLE i6341639 •+ _ .sue ' t:., 9 V I�N�.s� l�Tl�,,L TOWN . OF E ABL BUILDING ANSPECTOR APPLICATION FOR PERMIT TO" ................ ..2� .LL.lI "„� �A.... TYPE OF CONSTRUCTION ........(,rl � ............ r �- /. .`. .......................................... .... .......................19.. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to .the following information: Location .... . ff ....Y............ .l.r-��•,,.c... .. .. ........ ......... /..............� ProposedUse ..... ..` .1. .U C ..................... ..� .. ............................................................. Zoning District ......K......P... ..........Fire District �! T .. ./.................... ................ PP � Name of Owner ..... ...... �...�. ...... . ...Address ...A.. .�... ��� ..... .......... .. Nameof Builder .......... ........Address ............................................................... ` .......... Name of Architect 4'.i'4..... .�,t.1.1�.1..Y.......Address .R7_1v...... © Number of Rooms .............. ..............................................Foundation ..Pe.<ZZO. ... r Exterior . ... ....... ......... ,..:. ......�y?� (..� �.Roofing ........ ( .�,? .4!? : ......�,� -r... � �1 Floors ............ ........ ..... .................................................Interior ...........! I. f...0 (.Z... c Heating ......... ...... ......... ,...........................Plumbing .. ....V-47T..L.A,17................................................. Fireplace ................. JY �—� .................................. .Approximate Cost .........C ? ... ........ Definitive Plan Approved by Planning Board __________ 19______. Area .... ... .. ..............� Diagram of Lot and Building with Dimensions Fee . ��.................... SUBJECT TO APPROVAL OF BOARD OF HEALTH �'J f Ll fr cam' FofJ� i f.'�r1c;= } :5 �' RIB �07.17", «F3 .I1' � . .. AV 0 ^o: 20 Q�c-ALA-nc�c_i nc� 1 n " °[ k ILL; J ter. D Lo r - - . - - 4Y ��r• to � �0�,,��•.� ' ' � - r�, f T Mf,. �E� IOpa wi�. � � •r\ rp - tik. , tII FNp EL B4.SNr ` V art �';"` `: 83.6 , R� S 3 s 1; , 7, �• QJ, SS � v.pALB Q t�•W 46 un�, 3� frsl� �Ly � 1104 t�� / RR. P� fl�` 0.. { o RSE � h M , 11 o•vJ.• �1-4 Tw. No.1095 44�Q FSSI001-�a v �jE55, Zc�►.l .,� j , . .. ..moo, CERTIFIED PLOT PLAN MUM .� •� (.� ,etL•O VV IN ia SCALE / "-= 0 DATIE < <1���� 3�� � a •,a � ( LOREDGE' E/YGIIYEERIMO Cp.//dr' '; `r'�� �,�J�'� oF ,�'� I CERTIFY THAT tHE Drr� ;L '3 . SHOWN .ON THIS PLAN Id, LOCATE w EGISTERED REGISTERED _ �, „ ,r �• �, a, x 0�' ' . '" ON THE GROUND AS INDICATED ANt,) CIVIL LAND COAIFORMS TO THE ZONIN® LaS ENGINEER SURVEYOR DAB®'t�l!�''. '.. `„ ®' �0 4 OF °;��+ i✓sTA�L:E „ A38 - Pr °''; A� 0 � r � S , 712 M A 1 IV STREET'..< } Dv�' „ �