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HomeMy WebLinkAbout0306 STRAIGHTWAY - Health 306 STRAIGHTWAY RD., HYANNIS A = _ i 0 un 271409:49a p.1 Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Straightway Property Address . Richard and Brenda Smith Owner Owner's Name information is required for every Hyannis MA 02601 6-23-14 page. City/Town State Zip Code date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important When A. General Information filling out forms \`����`►_jirk OF u, „11�i on the computer, `. �ZH �4S use only the tab • keyto move our 1. Inspector. ;sue- y ,�; JAMES , cursor-do not James D.Sears =�• -use the return Name of Inspector s v:• #`key. CapewideEnterprises,L LC o o Q Company Name e !.. ...•. � 153 Commercial Street ''��►%Su `"����` Company Address Mashpee MA 02649 Ciry/Town state zip Code 508-477-8877 S 1623 Telephone Number License Number B. Certification I 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 n�-ailtenance4 on site sewage disposal systems. I am a DEP approved system inspector pursuant t Mection ISM" C Title 5(310 CMR 15.000). The system: Passes ❑ Conditionally Passes ❑ Fai " t f w ❑ Needs Further Evaluation by the Local Approving Authority C .C211'1- 6-23-14 4 o r`1n pector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board. ofHealth 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 atrthority. his,report only describes conditions at the time of inspection and under the conditions of use b at that time.This inspection.does;not address how the system will perform in the future under .: ;the same or different;conditions of use. S ns•X13, THIe 5 official Inspection Fo Sub rfece Sewage Disposal System•' age 1 of 17 r Jun 27 14 09:49a p.2 Commonwealth of Massachusetts., Title 5 Official, Inspection Form y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner Owners Name information is required for every Hyannis MA 02601 6-23-14 page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 31.0 CMR 15.304 exist Any failure criteria not evaluated are indicated below. { Comments: Garbage Disposal,Per Donna Barnstable B.O.H: Recomend disposal be removed. B) System Conditionally Passes: ❑ One or more system components as described in the°Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the.Board of Health, will pass. Check the box for"yes", "no"`or"not determined" (Y, N, ND)for the following statements. if"not determined," please explain. The septic tank is metal and over 20 years old' or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltratiowor exfiltration or tank failure is imminent System will pass inspection if the existing tank is.replaced with a complying septic tank as approved by the Board of Health. 'A metal'septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND(Explain below): 15uu-W3 TUe5 Official Inspection Forrrr Subsurface Sewage Olsposal Syslem-Pege2 of 17 Jun 2714 09:49a p.3 Commonwealth of Massachusetts Ila Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information is Hyannis MA 02601 6-23-14 required for every y page. CityrTown State Zip Code Date of Inspection B. Certification (cunt.) ❑ Pump Chamber pumps/alar'ms not operational. System will pass with Board of Health approval if pumpstalarms are repaired_ B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if-(with`approval of Board of Health): i ❑ broken pipe(s)are'replaced Q Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): • i ❑ 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): ❑ brokeri pipe(s)are replaced _ ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, - safety and the environment: Cesspool or privy is within'50 feet of a surface water Cesspool or privy is within`50 feet of a bordering vegetated wetland or a salt marsh 15ins-3113 - TAe 5 Official Inspection Foffm Subsurface Sewage Disposal Sysiam-Page 3 of 17 �, Jun 2714 09:50a p.4 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information required for every Hyannis MA 02601 6-23-14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cunt.) 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 stank and SAS and the SAS is less than 100 feet but 60 feet or more from a private water supply well**. Method used to determine distance: *'This system passes if the well water analysis, performed at a DEP certified.laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered_A copy of the analysis must be attached`to this form. 3. Other: i D) System Failure Criteria Applicable toAAll Systems: You must Indicate "Yes"or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or clogged.SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters ® due to.an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in mispag is less than 6" below invert or available volume is less than %`day now F1(111A.,' t5ns•3M3 Title 5 Offidal Mspootion Form:SWsudace Sewage Disposal System Page 4 of 1T- I ' i Jun 271409:50a p•5 Commonwealth of Massachusetts Title 5 Official! Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information is Hyannis MA 02601 66=23-14 required for every page. ckyrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑_ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no'other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form j ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 101000gpd. ❑ ® The system fails. l have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system'owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a;large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No f ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 16.304. The system owner should contact the appropriate regional office of the Department . Page 5 or 17 151ns•3113 i Tltle 5 Official Uspedon Form:Subsurface Sewage Disposal System• Jun 2714 09:50a p.6 Commonwealth of Massachusetts. Title 5 Official- Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments i 306 Straightway Pruperty Address Richard and Brenda Smith Owner Owner's Name information is required for every Hyannis MA 02601 6-23-14 page City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"nog as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® were any of the system components pumped out in the previous two weeks? ❑ Has the,system received normal flows in the previous two week period? t 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 NIA) 0 ❑ 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 E, ; inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth,of sludge and depth of scum? 0 ® 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: I ® Q Existing information. For example, a plan at the Board of Health. i Determined in the field(if any of the failure criteria related to Part C is at issue ® approximation of distance is unacceptable)[310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms desi n 3 Number of bedrooms(actual): 2 DESIGN flow based on.310 CMR 15.2,03 (for example: 110 gpd x#of bedrooms): 330 t51ns'•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17 i Jun 27.14 09:51 a p.7 Commonwealth of Massachusetts Title 5 Official Inspection Form r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information is Hyannis MA 02601 6-23=14 required for every y page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. tank D Box and four inflltrator's. 0 Number of current residents: . Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes I No information in this report.) Laundry system inspected? [] Yes No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d NA g ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No NA Last date of occupancy: Date CommercialiIndustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/personstsclA., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No pl Non-sanitary waste discharged to the Title 5 system? ❑ Yes El No Water meter readings,if available: t5i'is.•3113 Title 5 Official kupection Form:SubsuAace,Sewage Disposal System Page 7 of 17 .y Jun 2714 09:51 a p.8 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name -- information is required for every Hyannis MA 02601 6-23-14 page- Citylrown State Zip Code Date of Inspection D. System Information (cons.) Last date of occupancy/use:., date Other(describe below): t - General Information Pumping Records: Source of information: 2013 Was system pumped as part.of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: -- ---; --— — Type of System: ® Septic tank,distribution box, soil absorption system ❑ Single cesspool i ❑ Overflow cesspool ❑ Priyy ❑ 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)and a copy of latest inspection of the UA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): 15int-31`13 Title 5 Official Inspection Form;Subsurf000 Sowago Disposal Systom-Pogo 8 of 17 I 1 Jun 2714 09:51 a p.9 Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information is Hyannis MA 02601 6-23-14 required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1999 Permit # 99-695. Were sewage odors detected'when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 3' feet Material of construction: ❑cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipeing is 4" PVC SCH 40.' Septic Tank(locate on site plan): Depth below grade: 2811feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes El No Dimensions: 1500 Gal. Precast 1„ Sludge depth: 95ins•,3113 Title 5 Official Inspection ForTw Subsurface Sewage Disposal System•Pape 9 of 17' Jun 2714 09:52a p.10 Commonwealth of Massachusetts •i Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner owner's Name information is required for every Hyannis MA 02601 6-23-14 page. Cityrrown state Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 29" Scum thickness � Distance from top of scum to'top of outlet tee or baffle 8„ s Distance from bottom of scum to bottom of outlet tee or baffle 18" f ' How were dimensions determined? Asbuilt-Tape $ Sludge Judge Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc_): Tank at working level.Tank and outlet cover at 28" below grade w/'inlet cover at 1'. In and outlet tee. No sign of.leakage or overloading. Grease Trap(locate on site,plan): 1 Depth below grade: feet -- i 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: Hate t5dns 3r13 - Title 5 official Inspection Form:Subsurface sewage Disposal system•Page 10 of 17. Jun 2714 09:52a p.11 Commonwealth of Massachusetts, Title 5 Official. Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information required for every Hyannis MA 02601 6-23-14 page. Citylrown State Zip Code Date of inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day i Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in woricing order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No- Sins•.3113 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System r Page It of 17 Jun 271409:52a p.12 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments -- 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information is required for every �H annis MA 02601 6-23-14 i ipage_ cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): i D Box is Wx16r'-3' below grade. Box is clean and solid w/one line out. No sign of over loading or solid carry over. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.): i * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System(SAS) (locate on site plan, excavation not required): If SAS not located, explain why: mini-31 3 We 5 Olfidal h5petllai Form:Subsurface Sewage Disposal System-Page 12 or 17 f Jun 2714 09:53a p.13 Commonwealth of Massachusetts Title 5 Official. Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information required for every Hyannis MA 02601 6-23-14 page. C4rrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 4 ❑ leaching,galleries number: ❑ leaching trenches number,length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/altemative system Type/name of.technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leaching is four infiltrators w/4'stone. Chambers are under black top drive. Ck D Box and camera,out to chamers. Clean and wet bottom. No sign of over loading, solid carry over or holding water. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert - Depth of solids layer Depth of scum layer -- — Dimensions of cesspool Materials of construction — Indication of groundwater inflow ❑ Yes ❑ No t5ins•3113 Tile 5 Officia!Inspection Forth:Subs_rfare Sewage Disposal System-Page 13 of 17 i. } Jun 2714 09:53a p.14 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information is required for every (Hyannis MA 02601 6-23-14 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions - Depth of solids - Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3n3 - Tine 5 Official Inspection Fam Subsuri CO Sewage-040sdSystern-Page 14 01.17 Jun 2714 09:53a p.15 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information is required for every Hyannis MA 02601 6-23-14 page. CityrTown State Zip Code Date of inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area:below ❑ drawing attached separately C --/ _Z ECK = 3, l� �3 = 3 A z r , ftlsA 3113 Titla 5 Official Inspection Fofm Subsurface sewage,Disposal Syslem•Page 15 of 1 T Jun 2714 09:54a p.16 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information is required for every Hyannis MA . 02601 6-23-14 page. City/To" - State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water 23+ feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date.of design plan reviewed: Date ® Observed site(abutting propertylobservation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: Off ccnst.permit G.W.work sheet. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database,-explain: You must describe how you established the high ground water elevation: Const.Permit G.W. work sheet 23+. Bottom of leaching at around 4'_ Bottom of leaching at 19'+ above work sheet G.W. Depth. { r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•,31 13 { Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Jun 2714 09:54a p.17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 306 Straightway Property Address Richard and Brenda Smith Owner Owner's Name information is required for every Hyannis MA 02601 6-23-14 page. Cityrrown j State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or'E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)`completed ® System Information Estimated depth to high groundwater a ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file i i S 15ins-3l13 Title 5 Otficied Inspection Form;Subsurface Sewage Disposal System•Page 17 of 17 TOWN OF BARNSTABLE LOCATION C/ SEWAGE # ??f V LAGE �/�/.4`e!/.f/�r, ASSESSOR'S MAP & LOTS INSTALLER'S NAME&PHONE NO. /fZ/a Qit/>� 411 SEPTIC TANK CAPACITY ffs LEACHING FACILITY: (type) /ii/7C��1�.¢��/r S (size) � 5- NO.OF BEDROOMS BUILDER OR OWNER PERMIT DATE:Z COMPLIANCE DATE: 40'— 9.W ` Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist._ .` within 300 feet of leaching facility) Feet Furnished by � � , 4 f.r F hz, cw t� wti � No. Fee s s ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Ve 01ppYication for Migogaf *p!tem Construction Verrait Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) <Complete System ❑Individual Components Location Address or Lot No. �a �`f(��b`lam(�eQ(/L Owner's Name,Address and Tel.No. S Assessor's Map/Parcel �(Ql" 1 3� +1G� i V 10:Spl; � V Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. OAt ID —C'A(ve_.S�pT�C k'S` dQN S S• yatwwl S Type of Building: Dwelling No.of Bedrooms -_-2, Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow E73 o gallons per day. Calculated daily flow 3 1--kc1 gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank � vcA Type of S.A.S. kJ +SV\_C,Ole 1_( = L, Description of Soil Nature of Repairs or Alterations(Answer when applicable) r STD(L 1 SST• �-Q Fove 0 I,S C c�tic? y= zcA C ,z v t U 2 S l ti.� Ut ST(J—�. l>W— S li7 e t 7� l L/ LX NC_4� 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 En ' nmental Code and not to place the system in operation until a Certifi- cate of Compliance has n issue y d h. Signed Q 1=� Date Application Approved by Application Disapproved for the following reasons Permit No. Date Issued No. Fee S� ' THE COMMONWEALTH�OF MASSACHUSETTS Entered in computer: ✓ ` es PUBLIC-HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS r, � • 1(ppfication for Mi!5pogar *p5tem Con.5tructfon- Permit Applicatio for a Permit to Construct / epair( )Upgrade( )Abandon( ) Complete System El Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor'sMap/Parcel Z(pci_ s Installer' Name,Address,and Tel.No. Designer's Name,Address and Tel.No. .:- ��� {'UPS S, VA,�w� 5 _ , f-• , Type of Building: r" Dwelling No.of Bedrooms -1, Lot Size sq...ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow `-3 U gallons per day. Calculated daily flow 'I'A Cl gallons. r r Plan Date Number of sheets Revision Date Title Size of Septic Tank I S(SU C v l\ov J Type of S.A.S. l�� �� C, 6! Description of Soil rz_-Q S✓1K�} Nature of Repairs or Alterations(Answer when applicable) t.1/f C 1-�y_7'l/�L t 1.��1' �..-AU fl S (A..\ k- 1. ..SAC(J--�-..• C�u�— S (Q-E ( T-/ 7 / li tt ✓ /�J��1'ah ` 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 En�dr-o7h. ental Code and not to place the system in operation until a Certifi- cate of Compliance has n Issue d of Signed Date /4/�c 'S Application Approved by Date /U—Z/-�, Application Disapproved for the following reasons Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(►i)✓ Abandoned( )by %p'G (- c E C at O(0 5 t 6Zr4�s, �T ►.v1f+ya-- C,,-o V'A has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 9?-i�9f_ dated 16'' 2- Installer Designer The issuance of this permit shall not be co hued as a guarantee that the ill function as srgn Date ;/ �✓" o�� Inspec� �- �a+'i -- — ----------------- --------- — clkll —�..� No. [� Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS Zi5po5al *pgtem Construction Permit u Permission is hereby gianted to Construct( )Repair( )Upgrade( Abandon( ) System located at f 7 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 completedwithin three years of the date of this t. Date: Z�// / Approved by I 1/6/99 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 DESIGNED PLANS) hereby certify that the application for disposal works construction permit signed by me dated ta=92 concerning the property located at 006 s ( r� w�9�— , y meets all of the following criteria: `�• The failed system is connected to a residential dwelling only. There are no commercial or business /rises associated with the dwelling. �// The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. ere are no wetlands within 100 feet of the proposed septic system • ere are no private wells within 150 feet of the proposed septic system • There is no increase in flow and/or change in use proposed /There are no variances requested or needed. ,/The bottom of the proposed leaching facility will not be located less than five feet above the ma�dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor ethod when applicable] • If the S.A.S.,will be located with 250 feet of any vegetated wetlands, the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) VR B) G.W. Elevation 40 +the MAX. High G.W. Adjustment J, DIFFERENCE BETWEEN A and B SIGNED : A DATE: (Sketch propos plan of system on back]. q:health folder.cert --� -` n'o Ul ,� '� �l �� �. ,. _j TOWN OF BARNSTABLE LOCATION 361, s7 ', Gi.�(� SEWAGE # ??f VILLAGE 4t1-4,f1124<-- T ASSESSOR'S MAP & LOTS •- / 7' INSTALLER'S NAME&PHONE NO. /1'I1 a c,:<ae— SEPTIC TANK CAPACITY %fs c) LEACHING FACILITY: (type) (size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by TOWN OF BA.RNSTABLE LOCATION S1f'���`V�� SEWAGE # Q VILLAGE yc� w�l s ASSESSOR'S MAP & LOT .�If INSTALLER'S NAME & PHONE SEPTIC TANK CAPACITY 1 (: 00 LEACHING FACILITY:(type) PRT---CK1�;i- P% (size) ,3 / NO. OF BEDROOMS PRIVATE WELL OR BLIC-fi k BUILDER OR.OWNER �'�-- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes,.; No 4. s No................_...... Fr�s...✓�........ . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for 3 iipmml Work.6 Tomitrurtinrt rrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: .-----...... .......... ....... ------------------------- • . ,tom.a ....................................... Location•�\d ress or Lot No.` • ................ -------------------------- ........ . .......-•-•--.........................._--- Owner ddrt s W .................... -'� 1-��',D---...._..... .............. -------------------- U. Installer Address I UType of Building Size Lot............................Sq. feet ..a Dwelling—No. of Bedrooms.......................................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a Other fixtures ....................................... . W Design Flow................ ..............gallons per person per day. Total daily flow.----- ....................gallons. WSeptic Tank A Liquid capacitv\o .gallons Length---r_-____ Width.___-_._- Diameter................ Depth................ x Disposal Trench—No- ------------------- Width.................... Total Length.................... Total leaching area--------------------sq. ft. Seepage Pit No-------/------------ Diameter-----Q, .......... Depth below inlet_.-_'I............ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 1­4 Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.----............... Depth to ground water........................ fZ Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ 9 ..............................................................•--...•••••--•-•-------•.......----_........................................................... ODescription of Soil........................................................................................................................................................................ W U ....•----------•--••--•--••----••••••-•----•----•-----•-•---------•-••......--•-------•••••-••----•----•-•-•-------••--•--•------••---•--•............................................................ x ............................................................. --•--•--------------•------•----•---••-- ----------------------------- U Nature of Repairs or Alterations—Answ r en applicable. u-_� _.�Q. _.� AP� ..� Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance ha bee e bo d of health. _ Signed ...... .---- ............................. Due Application Approved B ..........:...... . 7�� Application Disapproved for the following reasons- ----------- -------------- ---..........--------------------------.-.......------------------------------- . ... . . ........................ .... ............. ..... ............................... � C Dace Permit No. ......................... Issued .. --- �' Date ------------ �C� - 1 No.._.. ....... ���. Fxs.......�..........1..�..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Allp1utttiun for Uhipuiittl Wurtai Cnunutrnr#iun rumit Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at: - .'� .,. _Y�T IrS `�------- --•--------------------- .... -...... (J ` Loc tion-i1d ress f 1 or Lot No. \�_1 fn_1Ml - ............ ..... ------.....---......t-....-----------------•-•------..................^-•--••--- 1^ Owner i (� Address Installer Address d Type of Building Size Lot............................Sq. feet - DwellingNo. of Bedrooms_ _. Expansion Attic ( ) Garbage Grinder ( ) — ------------------------------------- '14 Other—Type of Building No. of persons---------------------------- Showers — Cafeteria Q' Other fixtures _______________________________ _ _ W Design Flow.................... ----------------gallons per person per day. Total daily flow..... ....................gallons. WSeptic Tank—V Liquid capacitvX_Q gallons Length--- --------- Width-- ----------- Diameter.-..-.---._-__- Depth................ Disposal Trench—No -------------------- Width_-_---__-_.-.--_-_._ Total Length.....___..._........ Total leaching area___.............__..sq. ft. x - Seepage Pit No..._.../.....-...... Diameter-_---17........_. Depth below inlet..__�1(.......... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water-.___-.---_-_-_--_----.. f� Test Pit No. 2----------------minutes per inch Depth of Test Pit--..__.-.--_..__-___ Depth to ground water........................ --------------------------- ------------------------------------------------•-•-•-------------.-----......................................................... 0 Description of Soil........................................................................................................................................................................ x U ----•---••••-•------•---------•-----------•-•---•--•---••-------•-----•--------------•-...----•-----------•----------•••----------•--•••-------------•---•--•------•-------------•-•-•----•-------•----- W ••• -•--------------- ---------------------------------------------------------------------------------------------------- ---------- UNature of Repairs or Alterations—Answer when applicable. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate off Compliance has beerr'ssued by_he boa-d of health. _ Signed .......... .......`t .... ........ J ... .... --�Q----------- Application Approved B ..- .... ..........%�.... -- -��.......... ............................................. ...,< %..'!'' Dace `----'- Application Disapproved for the following reasons: --------------------------------------------- ...... ........... .................... ... ............. ................................. ...............------------------------------------------- ---------------------------------------- Permit No. ..... ------------tom. ---------------------------- - Issued ------------ Da ce THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (NEVdifi ate of CIlumplialttcE THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired b C----- -------------------.......................---------._....------------------------------------- has been installed in accordance with the provisions of TILE o�he�e Environmental Code as describe In the application for Disposal Works Construction Permit No. f,?j�,------....._.__------_---------- dated .___.��:.._. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFAC,DORY. DATE..... ... - _... - ---- Inspect<--...._..�'c-•f`. .'�° . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE -�� No.................•-- FEE---�............---••--- Rupuunl Workii Tum#riun rrrntit Permission is hereby granted-------------------_------ ---.&c.�Q 57-f .............................................................. to Construct ( ) or Repair ( C)_arfTndividual Sewage Disposal System atNo.--- ...�5 0_' ----------------------------------------------------------------------•-- S[reet as shown on the application for Disposal Works Construction Permit ✓^ //�^ Board of Health / DATE........ s. f FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS