Loading...
HomeMy WebLinkAbout0021 ALISON CIRCLE - Health ostelr llle., #E LOCATION ' 4-0 T 3� SEW&C-xE PERMIT UO. VILLAGE . — ���Co C�4-o — lWSTQLLER 5 W&ME ADDRESS.' BUILDE 5 Q / VAF- t, ADDRES Lfl-.Q LD-L Dtl►TE PERNA T ISSUED D ATE COMPLI W.4CE ISSUED : Y. as�- Commonwealth of Massachusetts Title 5 Official Inspection Form X t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments c 14 Alison Circle Property Address Gary&Janet Norwood Owner Owner's Name information is required for every Osteryille !/ Ma. 02655 7I26/201$ w .` �.- �.�.. page. City/Town State Zip code Date of Inspection r 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. Genera! Information / filling out forms ,SIj / 31 on the computer; use only the tab 1 Inspector: key to move your cursor-do not Sean M. Jones use the return Name of Inspector key. - . S.M.Jones Title V Septic Inspection � Company Name. 74 Beldan Lane Company Address rears Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5i gmail.com SI4522 Telephone Number License Number B. Certification 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 16.346'of Title 5(310 CMR 16.000).The system'. ® Passes 0 Conditionally Passes ❑ Fails Q Needs Further Evaluation,by t e Local Approving Authority 7/26/2018, Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system 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. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does hot address how the system will perform in the future under the same ov different conditions of use. t3ins,doc rev,6116 Tiife s oMetai lnspecllort Forih,,Subsurface Sewage bispossi System Page i of 17 Commonwealth of Massachusetts Tithe 5 Official inspection Form - ts' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t �rr1 �.� 14 Alison Circle Property Address Gar&Janet Norwood Owner Owners Name information is Osterville Maw M,µy 02655 required for every 7/26I2018 page. Cltylfown State Zip Code Date of Inspection B. Certification (cant.) 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 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The dwelling located at 14 Alison Circle Osterville is served by a Title V septic system consisting of a 1000 gallon septic tank,and a 1000 gallon precast leach pit. The system was found to be in proper working condition at the time of inspection. 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 over20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration,or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. ".A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available: Y N. E ND (Explain below). OlnsAoc-rev;WIG Time 5 Official inspec4on Form;.Subsurface Sewage D sposat System-Page 2 of 7 Commonwealth of Massachusetts Title 5 Official Inspection Form " Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Alison Circle Property Address Gary&Janet Norwood Owner Owner's Name information is Osterville Ma. 02655 7126/2018 required for every page. City/Town State Zip Code Date of inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms 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): ❑ broken pipe(s)are replaced ❑ Y 0 N ❑ NO(Explain below): obstruction is removed ❑ Y ❑ N NO(Explain below): distribution box is leveled or.replaced ❑ Y ❑ N ❑ NO (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); ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND.(Explain below): ❑ obstruction is removed ❑ Y ❑. N ❑ NO(Explain below) C) Further Evaluation is Required by the Board of Health: - El 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 16.303(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 151ns.doc ree.6/16 Title 5 Official Inspection Form!Suosudeee Sewage Disposal System•Page 3 of't7 Commonwealth of Massachusetts = = 1 Title 5 Official Inspection. Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Alison Circle Property Address Gary& Janet Norwood Owner Owners Name information is required for every Osterville Ma. . 02655. - 7/26/2018 _........,__.._......_...�. ...�:.. �. - page. City/Town State �.�.�.�Zip Code Date of Inspection B. Certification (cont.) 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, (I 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 1,00 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 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: D) System Failure Criteria Applicable to.All 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 0 Static liquid level in the distribution box above outlet invert'due to an overloaded or clogged SAS or cesspool Q Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow i5ins:doc•rev,6H6. Title 5 Offioal Inspection Form-Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal.System form-Not for Voluntary Assessments 14 Alison Circle Property Address Gary&Janet Norwood Owner Owner's Name ' information Is required for every Osterville Ma. 02655 7/26/2018 �.....�. ..._. ' page. Cityrrown State Zip Code Date of Inspection B. Certification (cont) Yes No ElRequired pumping more than 4 times in the last year NOT.due to clogged or ED 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. ❑ 9 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.] ❑ © The system is a cesspool serving a facility with a design flow of 2000gpd- 10,0009pd. ® The system fails. I have determined that one or more of the,above failure criteria exist as described in 310 CMR 15.303, therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design Now 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 ❑ ❑ 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 li of a public water supply well If you have answered"yes"to any question in Section Ethe 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. 15ins.goc.-rev 6116 Title 5 0(tdot Inspection Form,Subsurface Sewage Disposal System-Page 5 or 17 Commonwealth of Massachusetts Title 5 Official Inspection Form tl) Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t. 14 Alison Circle Property Address Gar&Janet Norwood Owner �,�.��..�..�,.W:,�., -_„„-•�,,,.,.�.,.��,:..�.....-.,�.,..»....,.o...._.�...�..,......W.,,.—.._•.�..,.;..r_...�..._...�....:»,..�:�. ,___-_._ Owner's Name Information is required for every Osterville Ma: 02655 -7/26/2018 - - - page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes or"no"as to each of the following: Yes No ❑; Q 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? © 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) Q ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site inspected for signs of break out? Were al[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? Q ❑ 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 determinedbased on: ® ❑ 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(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 - Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example 110 gpd x#of bedrooms),- 330 gpd; _ i5ins doc•rev,6116 Title 5 O(faal inspedion FormSkibsur(ace Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �r 14 Alison Circle Property Address Gang&Janet Norwood Owner Owner's Name information is required for every Osterville Ma. 02655' 7/26/2018 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2. W-- Does residence have a garbage grinder? ❑ Yes © No Is laundry on a separate sewage system? (Include laundry system inspection 0 yes No information in this report:) Laundry system inspected? ❑ Yes Z No Seasonaluse? Z. Yes ❑ No Water meter readings, if available(last 2 years usage(gpd)): Detail Sump pump? ❑ Yes 63I No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: --�- �- Design flow(based on 310 CMR 15.203); Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system?' ❑ Yes ❑ No Water meter readings, if available: 15 ilsdoc•iev,W 6 Title 5 OKNal Inspection Forma Subsurfaro Sewage Disposal System•Page 7 or 1) Commonwealth of Massachusetts Title 5 Official Inspection Form ;'j Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Alison Circle Property Address Gary&Janet Norwood Owner Owner's Name information is required for every Osteryille Ma. 02655 7/26/2018 - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): .General information Pumping Records: Source of information: tank pumped at inspection Was system pumped as part of the inspection? Yes ❑ -No If yes, volume pumped: 1000 gallons How was quantity pumped determined? size of tank routine Reason for pumping: maintenance Type 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)and a copy of latest inspection of the I/A system by system operator under contract Tight tank, Attach a copy of the DEP approval: [) Other(describe): t6ins,doe•rov,611,E Title 5 Official Inspection Fo m.Suosuiface Sewage Disposal System Page Sor 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments 14 Alison Circle Property Address Gary&Janet Norwood Owner Owner's Name information is required for every Osterville Ma 026 7126I2018 page. City/Town State Zip Code Date of inspection D. System Information (cost.) Approximate age of all components, date installed (if known) and source of information: original system 9/21/1976 Were sewage odors detected when arriving at the site? ❑ Yes 0 No Building Sewer(locate on site plan): 1 Depth below grade: 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.): Joints ok, no leaks,vented through roof Septic Tank(locate on site plan), 5 Depth below grade: teen Material of construction: concrete ❑-metal ❑ fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000�2110f1S Sludge depth: 61' t5ins.doc-rev.6116 Title 5 Offioal Inspection Form-Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts tDot Title 5 official Inspection Form - Subsurface Sewage Disposal System form-Not for Voluntary Assessments F 14 Alison Circle Property Address Gary&Janet Norwood Owner Owner's Name information is required for every Osterville Ma. 02655 7/26/2018 �,. .....,.�,�.�., page. City/Town 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 3 Scum thickness X Distance from top of scum to top of outlet tee or baffle 6 101, Distance from bottom of scum to bottom of outlet tee or,baffle How were dimensions determined? opened covers and took measurements 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 was pumped at time of inspection and should be done again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Grease Trap(locate on site plan); Depth below grade: feet Material of construction: concrete ❑ metal Q fiberglass M polyethylene M 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: Date Mns-doc rev,6m Tit e 6 Offloa!Inspection Form;.Subsurface Sa wage Oisp©sai System Page j o or 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form 4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 14 Alison Circle Property Address Gary&Janet Norwood Owner Owner's Name information is Osterville Ma. 02656 7/26/2018. required for every . �•--,•. �. - --- page. Cityrrown 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 []fibergiass Q polyethylene other(explain) Dimensions: - Capacity gallons Design Flow: gallons per day Alarm present; ❑ Yes [] No Alarm level: Alarm in working order.. ❑ Yes [] No Date of last pumping: Date Comments(condition of alarm and float switches, etc): *Attach copy of current pumping contract(required). is copy attached? ❑' Yes . ❑ No t51gs.doc•reu,.61;6 Title 5 OfWel Inspeciiop Fpfm:$uhsllrfne Sewage 0ispo"[System Page 11.of 17 Commonwealth of Massachusetts >r - s Title 5 Official -Inspection Form r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments !� 14 Alison Circle Property Address Gary&Janet Norwood Owner Owner's Name information is Osterville Ma. 02655 7/26/2018 required for every .-..- . page. CitylTown State Zip Code Date of Inspection D. System Information (coat:) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert NIA Comments(note ifbox is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.)- Pump Chamber(locate on site plan); Pumps in working order: ❑ Yes ❑ No* Alarms in working order. ❑ Yes [] No* Comments(note condition. of pumpchamber, condition of pumps and appurtenances,-etc.): If pumps or alarms are not in working order,system IS a conditional pass. Soil.Abso.rption:System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: 15ins doc•rev,61f 6 Title 5:Official Inspa^ction Form,Subsurface Sewage Disposal System Page 12 of 17 Commonwealth of Massachusetts y - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 14 Alison Circle Property Address Gary&Janet.Norwood Owner Owner's Name information is Osterville Ma 02655 7/26/2018 required for every � ,.�.. ,. _.,,..........,.�..._,..,,.. ,�,...�.�...._».�..�-:�..�,...w.:.__..�... page. CityfTown State Zip Code Date of Inspection D. System Information (cont.) Type: leaching pits number: ❑ leaching chambers number: leaching galleries number: leaching trenches number, length: ---�-- leaching fields number, dimensions: ❑ overflow cesspool number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,-level of ponding,damp soil; condition of vegetation, etc.): s.a.s. consists of a 1000 gallon precast leach pit. Pit was found with approx 3'of standing water with no stain lines higher. 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 i5ins.doc-rev.5116 title 5 Official Inspection tomi;Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form t - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .� 14 Alison Circle Property Address Ga &Janet.Norwood Owner Owner's Name information is Osterville Ma. 02655 7/2612018 required for every .. _.�..�...�. ,.�.�.,.�.,.. _. .,.�..W;�:.....�,...,�.�.r..,_ page. C1tyfTown 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 doe-rev-WIS Title 5 Official Inspection Form-Subsurface Se:rage Disposet system•Page 14 of f7 Commonwealth of Massachusetts Title 5 Official inspection Farm Subsurface Sewage Disposal System Form Not for Voluntary Assessments �- 14 Alison Circle Property Address Gary&Janet Norwood Owner Owner's Name information is Osterviile Ma 02655 7/26/2018 required for every - ��-- — page. CitylTown 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 he boxes below: Q hand-sketch in the area below, ❑ drawing attached separately t 3 6 t5ins.doc-rev>6ft6 7nle 5 official Inspection Form Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts � # Title 5 Official Inspection Form g p y - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 14 Alison Circle Property Address Gary&Janet Norwood Owner Owner's Name information is Osterville Ma 02655 7126/2018 required for every -- page. City[Town 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: 12+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: at ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: Checked with local excavators, installers (attach`documentation) ❑ Accessed USGS database-explain: You must.describe how you established the high ground water elevation: Groundwater elevation.was determined by accessing Town of Barnstable groundwater contour map•. Before filing this Inspection Report, please see Report Completeness Checklist on next page. 150s:ooc•rev,6116 Tille 5 Official Inspection Form:Subsurface Sewage Discosal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ae� ,✓, 14 Alison Circle Property Address Gary&Janet Norwood Owner Owner's Name information is required for every Osterville Ma. 02655 7/26/2018 _.._.,_..- page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist 9 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 Q Sketch of Sewage Disposal System either drawn on page 15 or attached in separate rile t5ins doe•rev..6f16 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 17 of.17 40RWo01 °SfolvL �,E ' MA OUS-5 7 gent r� Parcels R. Town Boundary Yk + Railroad Tracks Buildings Painted Lines ­114* 9 Parking Lots Paved ...: Unpaved Driveways 41�130 Paved Unpaved Roads 146 • � - i"=. Paved Road #t2 ve Unp- Road 1 � Unpaved ® ridge P`x aveMedian -, � r Streams Marsh �Q Water Bodies Qo� qb c ' N r 14C,004 Iwo 4 i4- Ift L ^ .Q }^ � v i ' rp3 }46:.44 as�E TIM ° mxa as #' � � x € , ' z� r � � , 146041. 01 VN Map printed on: 6/15/2018 - This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic Town of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street;Hyannis,MA.026oi 0 42 83 an on-the-ground survey.It maybe generalized,may not accurate relationships to physical objects on the map 508-862-4624 reflect current conditions,and may contain such as building locations. Approx.Scale: I inch= 42 feet cartographic errors or omissions. gis@town.barnstable.ma.us i THE COMMONWEALTH OF MASSACHUSETTS BOARD O HIEA -_ �l lira ivi or Dispoiial Workii CnonMrurtion Prrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal Sys -���� � C�------. ...................................... Location- ess or Lot No. - ----------- - - -- - Owner 1 A dress Installer Address U Type of Building Size Lot��}__k_�__7_Sq. feet Dwelling—No. of Bedrooms._....................................Expansion Attic (. ) Garbage Grinder ( ) 44 Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures .... .. .. ..... d ------ -----•---•-•-_------- --------------------- --------------------------Design Flow_..____.___4 o---....._..-•-•--... Mons per person per day. Total daily flow............. �' ® ____-.-.--.__.gallons. ----- --••--- WSeptic Tank—Liquid capacity/_r?4 allons Length................ Width................ Diameter................ Depth.._--._--..._- xDisposal Trench—No_ ____________________ NNJ '................... To tih__...._....___._.... Total achin ,rea..._:._.__...__._._.sq. ft. Seepage Pit No•----z/,a.GVDi --- ` - .._ area------------------sq. it. z Other Distribution box ( ) Dosing tank ( ) B/� �e_ "2 G- 7 C W Percolation Test Results Performed by________ ________________________________________________________•__-_--•- Date----_-___-•---------_-------•---••----- ,� Test Pit No. 1----------------minutes per inch Depth of "Pest Pit_.-_-_-___-__.____-. Depth to ground water.-.__-_. --__._.__.-. - 44 Test Pit No. 2......_.........minutes per inch Depth of Test Pit.................... Depptt'h to ground water-_.------_-.._-._--_.._. O o2 Description of Soil____ ____________ _ _ �•.__.... k.. ---------- - cxj _.-------- 9----------- -------------------------------------------------------------------- W V 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 Article XI 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 bar f healt II. P f Signe . ._ i.......� Date ApplicationApproved By------------------------------------ _-------------------- ---------------------------------- Date Application Disapproved for the following reasons:................................................................................-............................... ....................................•-----•---------••-----------._.__..-•-------------•-•-•--------•-----------•---------...----._....._.....-----•-----------•---------._...--------------.......•---- Date PermitNo........................................................ Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HIEA .......OF............ ...�� ...... , pphration -fur DioVuiitt1 Workii Tonitrurtion Permit Application is herby`made for a Permit to Construct (')or Repair ( ) an Individual Sewage Disposal System at: -----------------------------`_..------------------•-----......----•----•-_._._.._...._-••- �Location-Address f or Lot No. ...........................--.._...:........-• --'•---- .........------ -•--------------.._-------"------•• --- ...................... Owner Address t%!� Installer f ~ Address as / c Q Type of Building �- Size Lot_ �_/.__c .. .ZSq. feet U Dwelling—No. of Bedrooms------".--•--- ______________Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) QOther fixtures ___. ?'.'�-�� ----------•--_--_-•-.................... ----•-----------------•-- -----------------------------_________------ Rw', Septic Tank—Liquid c�city������lions peL person gth per day.• Total daily flow lliameter�__��.. ................. Deptil-- -gallons. w Disposal Trench—No"____________________ Wi.•tht_____...__________ Total 6ength.__._ Total eachin rea...-_.__--._._____-_sq. ft. � Seepage Pit No------ D e tnle=`___._----_------- 'dotal 1•e.-lIE—FI g area------------------sq. ft. z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.___-_.--._..__________________________________________________ _.____ Date---------------------------------- Test Pit No. 1----------------minutes per inch Depth of Pest Pit-------------------- Depth to ground water...____--____-____--.._. f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...____.____________.._. Ix •--•------------------_ -------------•--•------------------•---•---••••------------------..._-----•......................................................... 0 Description of Soil---------- --------------------------------------------------------•---------------------------------------------------------------------------------------------------- x c., 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 Article XI 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, rSigned:,_: - '.fit f x`-� --------------- --•--S--- / --- Date ApplicationApproved BY ___-------•----•------ ---------------------------------- ...............---_-- ---------------- Date Application Disapproved for the following reasons:---------------------------------------------------------------------------------•••-••••----••----------------- --•---•••---•-----------------•..--•--•--•••••-_._..•----------------•....•-••---•---•----••--------•-------------------•--•----••-•-----•------------------•-._.-"---------•---------•-•----•-•----•--- Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT_ .G " � 7 f ..�...�-'.-'� "y`' ....OF...... :...:_... ............. QIrrtifirate of 101.1"untpiiana THIS ISjZO CERTIFY, That the I �dividual Sewage Disposal System constructed �(�/) o/Repaired ( ) "--•-�------- - ----- --- Installer ✓' at........... � Cam/ /,/- �' ( ------------•--•---------------- has been installed in accordance with the provisions of Article XI of The State Sanitary C as described 1 the application for Disposal Works Construction Permit No.___-_.•................................. dated...-____ _____._.._� �_..__ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G ARANITEE THAT THE SYSTEM WILL FUNCTION SATIStARTORY. DATE---------- ............ ---------- .......... Inspector--- --- ---- ................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTHf`-- .6�' ' .....................• FEE__ ................ �i��u��t� urk� �un�tr�rtiutt �rrmit Permission is hereby granted_. L� 1 `._... _ -------- ----------------------------•-----••-------- to Construct (' )-or Repair ( ) an Individual-Sewage.Disposal System vU. _ - -•- --._ ............................................*. Street _ C/ iC / as shown on the application for Disposal Works Construction Pt No.__ ._.._ __ ated_._.__l._.._.__ _'7/.._.__.. _ Board of Health DATE------------------ ---------- --------(�..................:.................. FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS � J t �y —°.� z�•,�.+tom �t1A.1 Via- t t rr Y Wt T/ OT AFL AA! SGq.L E !" - y47' DF-7TG'•. �G --!C�-iC� '.,.�^�.. :��.% -,..` �-�,c.14, EFE e,--AA E: k �Z /-1E.eEBy CEeT/FY 7NFaT THE B(J/LD/�/G _�•��_ S�ON/l/ OV TN/S PLAi.V /S LOG,, TEa OA/ THE sy CF I 4 BOv.VD .,95 .SNO PVA.✓ FiA/D TNgT /7- {7U�= CO.VFO eiV! TO TNE• 4''O.-//1t/G BY- L g1n/5 O.� THE 7Z7N/N OF` G.t.'. Yl. <� ARNE Gs� v y✓UE.V CO,t/ST2C�C TE D. (V t N. "_`� I� i11r".tA cn awn cam en ineerir� o L A�•/a SC/.BVE YO BS 2oc/TE GA^`/AeMOt/Ts-i, MFa55. 'aATE eEG. Lo4ti/D SC/2VEYO.E