The URL can be used to link to this page

Home My WebLink About0021 BATES STREET - Health ti 140-143 Ostervi lle 1 i Agostinelli, Joan From: McKean,.Thomas Sent: Monday, November 28, 2005 8:46 AM �Jj To: Agostinelli, Joan Subject: FW:Address change map 140 parcel 143 ^ "J Please make folder change. -----Original Message----- From: Schlegel, Frank ✓ Sent: Wednesday, November 23, 2005 4 :33 PM To: Barrows, Debi Cc: McKean, Thomas Subject: Address change map 140 parcel 143 Hi Deb, I got a request from COMM Fire Dept. to correct a bad address on the above parcel. I changed it from #28 Bates Street to #21 Bates Street/ I fixed Pentamation but you may need to update any hard copy files. Apparently, we had an even number assigned to the odd side of the street. THANX i 1 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Bates Street Property Address Maureen&John Falconi Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. Cityrrown 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. i Important:when A. General Information filling out forms `��quuuuupu� on the computer, (N OF I<Zgs use only the tab `````�� ` , No key to move your 1. Inspector: o�' • c cursor-do not �: JAMES use the return James D.Sears I _FAQ key. Name of Inspector CapewideEnterprises, *�c� \�o.�� Y Company Name F 5 I N SP'�;' `��`` 153 Commercial Street �� Company Address Mashpee MA 02649 Cityrrown State Zip Code 508-477-8877 S1623 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 1-28-14 pec tor'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 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. ****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. t5ins•3/13 Title 5 Official :Subsi !ML•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Bates Street I Property Address Maureen&John Falconi Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. City/Town 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 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: i 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 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 ❑ ND(Explain below): t t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System;Page 2 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Bates Street Property Address Maureen&John Falconi Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. Cityrrown 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 ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ 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 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Pap 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Bates Street Property Address tv Maureen&John Falconi Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. Cltyrrown 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. ❑ 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 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. r D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No".to each of the following for all inspections: Yes No El ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in a is less than 6"below invert or available volume is less than %day flow k£A Ch IAI47 t5ins-3113 Title 5 Official 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 21 Bates Street Property Address Maureen&John Falconi Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. Cityrrown State Zip Code Date of inspection B. Certification (cont.) Yes No ❑ Z 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.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health,to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Bates Street Property Address Maureen&John Falconi Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. City/Town 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 ❑ ® 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 N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of breakout? ® ❑ 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: ® ❑ 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): 5 Number of bedrooms(actual): 5 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 550 t5ins-3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a 21 Bates Street Property Address Maureen&John Falconi Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: The system is a 1500 Gal.tank, D Box and 14 high cap chambers. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundryon a separate sewage system? Include laundry system inspection P 9 Y ( rY Y p� information in this report.) El Yes [D No Laundry system inspected? ❑ Yes ® No Seasonal use? ® Yes ❑ No Water meter readings, if available last 2 ears usage 2012-211,000Gal g ( Y g (gPd))' 2013-383,000Gais Detail: Sump pump? ❑ Yes ® No Last date of occupancy: NA Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/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: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Bates Street Property Address Maureen&John Fak oni Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. Citylrown 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: NA _ 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: I ® 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) l ❑ 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): t5ins•3113 Tale 5 Official Inspection Forth:Subwrface Sewage Disposal System Page 8 of 17 k r Commonwealth of Massachusetts Title 5 official Inspection form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Bates Street Property Address Maureen&John Falconi Owner owner's Name information is required for every Osterville MA 02655 1-25-14 page. Cityl-rown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 1995-Permit#95-223 Tank&Leaching 1999-Permit#99- 185 Add 4 infiltrators Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): - Depth below grade: 2'feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: P P P Y feet Comments(on condition of joints,venting,evidence of leakage, etc.): Pipeing is 4 PVC SCH 40 Septic Tank-(locate on site plan): 1' Depth below grade: feet 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: 1500 Gal.Precast Sludge depth: 1" t5ins•3113 Title 5 Official in spection Form:Subsurface Sewage Disposal System•Page 9 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments °< 21 Bates Street Property Address Maureen &John Falconi Owner Owners Name information is required for every Osterville MA 02655 1-25-14 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 0" Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 18" How were dimensions determined? Asbuilt-TapeSludge 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 at 1'below grade,w/both cover's at grade. Inlet tee,out let.baffle. No sign of leakage or over loading. Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•W13 ride 5 official inspection Forth.Subsurface sewage Disposal System•Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments `< 21 Bates Street Property Address Maureen &John Falconi Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. City/Town 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 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 t5ins-3/13 True 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 l I • a Commonwealth of Massachusetts Title 5 Official Inspection I=orm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Bates Street Property Address Maureen&John Falconi Owner Owner's Name information is Osterville MA 02655 1-25-14 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 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.): D Box is 16x21"-23"below grade. Box is clean and solid w/five lines 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.): *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: t5ins-3113 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17 I' Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Bates Street Property Address Maureen&John Falconi Owner Owners Name information is required for every Osterville MA 02655 1-25-14 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Type: ❑ leaching pits number: ® leaching chambers number: 14 ❑ 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.): Leaching is 14 high cap infiltrators w/4'stone. One set of ten and one set of four. Ck D Box and camera outlines. No sign of over or solid carry over. No sign of 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 4 t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 or 17 V Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Bates Street Property Address Maureen&John Falconi Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) F 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 21 Bates Street Property Address Maureen&John Falconi Owner Owner's Name information is required for every Osterville MA 02655 1-25 A4 page. City/Town State Zip Code Date of Inspection D. System In (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 attache&separately 1. �E� R ' FF El t t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments " 21 Bates Street Property Address Maureen &John Falconi Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells NO Estimated depth tofh- 10'+igh ground water: 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 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: Bottom of Leaching at 5'below grade. Hand Auger Hole at 10' no G.W. T.H. at 5' below bottom of leaching. Before filing this Inspection Report,please see Report Completeness Checklist on next page.. t5ins•3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 21 Bates Street Property Address Maureen&John Falconi t Owner Owner's Name information is required for every Osterville MA 02655 1-25-14 page. Cityrrown 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 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file r t5ins•3M 3 Title 5 Official Utspedion Form:Subsurface Sewage Disposal System•.Page 17 of 17 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUB C HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS n pplication for MiopozaY 6pgtem Com5truction Verna Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System [Kndividual Components Location Address or�Lo No. � —�f� 5 r Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No."1 Designer's Name,Address and Tel.No. �G ig Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures p— Design Flow ��J gallons per day. Calculated daily flow J gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank V-,ec Y 3L'V*va I SM .Sc l i Type of S.A.S. c Description of Soil l/i6cZ�5�4 wJ Nature of Repairs or Alterations(Answer when applicable) �'��G 9 j✓L su_.s� LTIc�R��S i� u 1:ST7a�_.��—��,� � f �%U�� /J �i 1L��, _NVT04 d� 1 d S 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 t Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has>P 11111 1 hds3rdard,of fle Signed Date Application Approved by Date — Application Disapproved for the'MIlowiiq reasons Permit No. Date Date Issued / i-#!. ma's Fee }% - Entered in computer: THE COMMONWEALTH OF MASSACHUSETTS E Yes 't _ PUB IC HEALTH DIVISION -.TOWN OF BARNSTABLES MASSACHUSETTS n u ppri ratio n for ;Digpogar *pgmem Congtruction Verlhit Application fora Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System )Kdndividual Components Location Address or Lot No. --BATc: 5T' Owner's Name,Address and Tel.No. Assessor's Map/Parcel� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. �(J-6tjfie_ Type of Building: ~'Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures /111 Design Flow ' gallons=per day. Calculated daily flow _ 7- gallons. Plan Date, Number of sheets Revision Date r _Title Size of Septic Tank '2F'Y !-_4 CA l 1 Type of S.A.S. V__kn Description of Soil ' 0&l 10 Nature of Repairs or Alterations(Answer when applica le) l'.0/J! i%✓L rm=e I-T/'-_1 n JA (1 SZ I,v-1 gnvL= C 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 • Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has bee a by t ' far of He Signed I Date 045 Application Approved by X644Date t _ - Application Disapproved for the'Wllowihk reasons , Permit No. r-f�9 - 1 � Date'Issued -------=--'----------------- - ---------THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance s /' THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(V) Abandoned( )by 't --c P V: s, - 1 at c. -5( n Sw has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. IA-:5— dated ^/: -- 0 '. Installer &",.f 7 / _ Designer The issuance otitis permit shall not be construed as a guarantee that the cysts ill function as designed. Date Inspectorz"`pr' - 4F I/L� Y--------------------------------------- NO. Fee — 8,5 Fee ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS 'Wi0o5ar *p! tem Congtruction Permit Permission is hereby granted to Construct )Repair( Upgrade'e-"')Abandon( ) System located at h c ?< .t-), and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this permit. Date: - 1 a3 9 Approved by� t 1 TOWN OF BARNSTABLE i _ATIONL—C /f SEWAGE # `/ ,:$� LAGS_ ASSESSOR'S MAP& LOTT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILM: (type)osr/y�i C rp s+ (size)__ T NO.OF BEDROOMS B' R OR OWNER . PERMTTDATE: t COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) Furnished by��$�� .-j��e� Feet A i r I 3 i i i f x/&l 13 lad A ?3LI J3 3 c 116/99 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) f hereby certify that the application for disposal works construction permit signed by me dated `} A-3 921 , concerning the property located at Q97-9�4-(C-S meets all of the following criteria: V The failed system is connected to a residential dwelling only. There are no commercial or business uses 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. (/• There are no wetlands within 100.feet of the proposed septic system /There 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 maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method 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, s Please complete the following: A) Top of Ground Surface Elevation(using GIS information) t B) G.W.Elevation ,'O +the MAX.High G.W. Adjustment,-), 6 = 7 - ` DIF E BETWEEN A and B �b SIGNED : DATE: [Sketch proposed plan of system on back]. q:health folder:cert Ci � �.. �, • .,�J1 ' .� O O O .;� - / TOWN OF BARNSTABLE 6001- Ltx-xnON tL= SEWAGE # VILLAGE_ < [� 5��7 ,^�/7 J��, ASSESSOR'S MAP&LOTS . INSTALLER'S NAME&PHONE NO. /V J b C' ,d C SEPTIC TANK CAPACITY /1--b o Ir LEACHIINIG FACILITY: (type) or/5�i L?�i�Tol�.�' (size). `f NO.OF BEDROOMS ' ,.B' R OR OWNER PERMITDATE: 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 i • a J "A 2`��' 4 .2 /f TOWN OF BARNSTABLE 4V LOCATION �3 ��4-i�-S' SEWAGE # VILLAGE S ASSESSOR'S MAP & LOT -3' INSTALLER'S NAME & PHONE NO. . SEPTIC TANK CAPACITY /57J0 LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OIQ:UBLIC ATER BUILDER O O WNEI( DATE PERMIT ISSUED: sF�� DATE COMPLIANCE ISSUED:.t VARIANCE GRANTED: Yes LNo r �� T .��' r. � � � ., �� 1 �7 j'a d ��. t t ..�a S"�. •,4 /Fim..... p .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Applirativia for Di-nVotial Workii Tnntrnrtinn Frrmit Application is hereby made for a Permit to Construct ( ) or Repair (DC} an Individual Sewage Disposal System at: I, /� ocaho \dd ress ✓ or Lot Ua7 � � No �- � ............................ ........�-----•........................... ..........................uf-----firv�----------- - � ......... �Ownner '�- 1 /�.m �/Address `s �- a •-......-.. .....s`w-U ....� .--w.......�iA°1� .....W--d......_ __._�...I -d Installer Address Type of Building Size Lot............................Sq. feet U Dwelling— No. of Bedrooms------------------------------------- ------ 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---------------7--Q.__._..........__gallons. WSeptic Tank—Liquid capacitv/-�.WA__gallons i Length---------------- Width_.-.--.-..-_-_-- Diameter._______..__..- Depth................ x Disposal Trench—No. ......1........... Width.....�o............. Total Length......:?1�S Total leaching area....................sq. ft. Seepage Pit No...................... Diameter...........--------- Depth below inlet...../�� Total leaching area..................sq. ft. Z Other Distribution box (-,� Dosing tank ( ) aPercolation Test Results Performed by------------ ............................................................. Date--------------------------------------- Test Pit No. 1----------------minutes per inch Depth of 'Test Pit--------------------- Depth to ground water......................... �14 Test Pit No. 2................minutes per inch Depth of Test Pit.-_-_--_-._--___-_- Depth to ground water........................ 1:4 ------------------ -----•----------••••-•---•-••-•••-•••-•-••--•--------•---••-•----•..........-----...............-......................................... 0 Description of Soil..............................•--.--••--------------------------------•--------------------------------....----------................................................. x U ------ w .................. -------------------------------------------- ------------------------------------------------------------------------------ ------------ --- - x /SZ1 U Nature of Repairs or Alterations—Answer when applicable._.___l_l : .tom._.----.4_.................... .:.....:...5 .._. �..t--.._..p tS�►._.r.._.. .._�..7........10........�d.� .��.__.i!_��i't�-•---•--iial a-7b4•UCl i...__. t� ........... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmen 1 Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliant as een iss d b e board of health. - -- sue Signed ` Dace q� Application Approved By -------------- ..,�.�..� ,�..` ._. ..... ....-----.----... - - .. ---- Application Disapproved for the following reasons: ................................ . -- .... ................. .---..._...... Da- --------------------------------------------------------------_... ----- _..._....---- ............_...__.......- -- ---------------------------------------- .....---------- PermitNo. .......75...�.... .. ----------------- Issued .....................:...........-------------..__...... ------- Daze No... VFEim THE COMMONWEALTH OF MASSACHUSETTS . BOARD OF HEALTH TOWN OF BARNSTABLE AVVftratilan for Uhi-p t Sal WorkB Towitrnrthin (unfit Application is hereby made for a Permit to Construct ( ) or Repair (>e—). an Individual Sewage Disposal System at: ...... -•-----•-- •-•- -._....•---•-•-•-----•••-•..................•-:------ .............................•--- ----- - - �'/ ��. o�� Address p G,�a 7O O Cam•'l V w 1 �1.+ or Lot No.�------_.. ---------•-----------•- ............................................... ••----•----•------••••••---•--------:-----------------...-------.._..------ ................... owner Address a = c�,„ C,a _..s'! �v c.t_-cup.► 7 _._w f�s6 ' .ti► r t_c_S Installer Address UType of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms--------------- ----------------------------Expansion JAttic ( ) Garbage Grinder aOther—Type of Building ---------------------------- No. of personsn---------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ------------------------------------------------------------------------- '-----------. ------------.._.--------------------------------------------• -71 W Design Flow.............. -_-.--_____-___..gallons per person per day. Total daily flow--------------------- Q.................gallons. WSeptic Tank—Liquid capacity/�o__gallons Length-----------._...-Width.--------------- Diameter................ Depth................ x Disposal Trench—No. -.-..-`__...._._.. Width.....6..-... .--. Total Length...--! Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter-..---------- ...... Depth below inlet----- -____ Total leaching area..................sq. ft. Z Other Distribution box (--/) Dosing tank ( ) f-I Percolation Test Results Performed by..................................................................t........ Date........................................ W Test Pit No. 1-_---.----_--.minutes per Inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth fto ground water........................ DDescription of Soil---------------------------------•-•----------•--------------------•-----------------------------------.---............................................................. x „ ,_ , W x ••--••-----•--------------- -------------------------------------------------------------------------------- ---- ------------------------------------------------------------ •-••--•----•------•--- U Nature of Repairs or Alterations—Answer when applicable ....f-..fv_ "--..�=._--..-/.�?�U_�-* ----rEpy— ••. G la �ti7T--r ---------E,.1 ,77�1---- ....... ------•-•-•----------- 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 has ee�n is `s d by the board of health. Signed ------1.�`} -------- .... ...... .._ Dare Application,Approved BY ------- / ..-qJ Date Application Disapproved for the following reasons: .......................................................:........... .............. . .......... ..................... R .............. . ............................. ...... .................................... ---- ........... ............ . .......... . ............ Date Permit No. .........I ..'_.. ..?� Issued ~ _ Dace ____--_—, _ -- .—>—._ --_,—®®—<..,...,<n-_...�.r�.�..�... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (11,1ortiftrate of Trimpitttlnce THIS IS TO CERTIFY, ThAhe Individual Sewage Disposal System constructed ( ) or Repaired (.o<') by ..... ......................... ....................-------------..s•""&10 G_�-u irl LA�.57`X-j 4:;:1 �.-t J -- ---...-------...--------- -------------------------------------------------------------------- �......_......... Installer at -----------------------------.--------------------------------------o l..._... .>_v--S-.-----4 4 t ......_.. tJl ---------------------------------------- has been installed in accordance with the'provisions of TITLE 5 of The rate Environmental Code as described in the application for Disposal Works Construction Permit No. ------- .�.... dated .. ... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE ...... "..._ .. ...- '..., � - Inspectors: �r /d '•'.R..._( ` ��-- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No.... ._.2a2) FEE.---`•76-•......... Difivnitt1 rrmit Permission is Hereby grantedef��W.1�7 CUB to Construct ( ) or Repair O an Individual Sewage Disposal System at No. `J`-�T-- Street C� as shown on the application for Disposal Works Construction Permit No.. Dated_._.-_-- _c-�. .l..J�^_____..__ v Board of Health DATE....................7*1_1 ................................... FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS �J TOWN OF BARNSTABLE LOCATION ��`�j�t{-i�-S ��- SEWAGE # VILLAGE _/ :�l 0, ASSESSOR'S MAP LOT D- INSTALLER'S NAME & PHONE NO. yo/ 7_&lvpl7 SEPTIC TANK CAPACITY LEACHING FACILITY:(type) size) NO. OF BEDROOMS -PRIVATE WELL O UBLIC A� TERM BUILDER O OW E l/YJ L/L L DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No (� p �Lb 1: �h TOWN OF BARNSTABLE LOCATION_�z �L>(" /j SEWAGE # VILLAGE_ ASSESSOR'S MAP & LOTS INSTALLER'S NAME&PHONE NO. ;��, ,tee S 2 SEPTIC TANK CAPACITY �. _00 LEACHING FACILITY: (type) -- > (size) NO. OF BEDROOMS OR OWNER PERMTTDATE:_ .6/ti�S%"��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 ��, � V